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introduction the development of the digital era has bring lots challenge for journalists and mass media conventional media caused by the development of the internet and new media before development internet technology and network mass media no can update news in a manner fast or update it in realtime in mass media such as radio mail newspapers and television news usually only got an update the next day day because limitations technology for transmit information this no like day this where technology advanced possible spread genre information with fast possible content news keep going updated in minute or seconds outside that another challenge faced journalists and conventional media in this digital era is emergence of new media in various forms particularly social media social media as the platform used for socialize through internet technology social media users can each other discuss exchange ideas and opinions and participate in form interaction social with social media users other related with journalism social media often used as means for spread news to public product news broadcast in a manner direct or stream online direct through various features available on social media social media content like photos videos infographics and video graphics served through content content social media presence as new media form facilitate the communication process two direction between user and participate create room for user for share content there are also opportunities big for all user for use media for share events and information in real time via social media contribution inhabitant through social media has give birth to practice journalism normal new known with journalism citizen events and information communicated by the public general through social media processed and consumed by conventional media become product news transformation journalism into the digital age has been bring development new in technique reporting and reporting in the field journalism that can practiced by residents normal or public general except journalist professional in phenomenon moment this is mass media load snippets snippets and results news incident big catastrophic or incident unique which is results post from social media users result of later report become product from news spawned term journalism citizens development sustainable technology make it easy social media users for role as journalist citizen with fast share information and events important with audience broad one product journalism inhabitant first in indonesia then later impact in the mass media industry amateur videotape inhabitant about earthquake earthquake and the tsunami that hit the ramjame area nanggroe aceh darussalam and so on 12 since 26 march 2004 amateur video recorder capturing moment moment after earthquake so strong so that triggering a minute tsunami after earthquake in the video family can hear conversation related new earthquake just happened only a number of minute then the video footage shows atmosphere tense with scream hysterical and gurgling water in the background back after that amateur video tsunami events broadcast in a manner broad by through channel television no only in indonesia but also around the world recording amateur this then produce product mainstream and triggering news discussion journalism citizen according to allan the news about the aceh tsunami was carried out by the local community using the video recording method clear understanding of the reasons this situation preferably carried out routinely by mass media journalists journalism practice citizens in current events the aceh tsunami is currently the majority of the news comes from warrelated documentation as a result privileged access for professional journalists to look for location serious damage to infrastructure in the tsunami event in aceh is now happening paralysis in the communication network and unreliable transportation access that makes it dangerous in difficult coverage that is being carried out by professional and insightful journalism information provided to local audiences this phenomenon must noticed and practice citizen journalism can be interpreted as a lift production and dissemination of certain information by ordinary citizens or the general public more specifically lasica defines journalism citizen as a form of journalism ie including the general public apart from journalists professionals to provide information utilize the most appropriate media for events or events to a wide audience through certain media practice journalism the more increase especially remember trend technology information and communication it provides various feature for increase growth journalism citizen smartphones and laptops that can used for open and send picture in a manner secret so that audiences general can involved problem in the collection process information news moment this everyone only use device electronics and internet connection and able communicate results report to audience with easy besides it for give results report regardless from documentation that can accessed public unum with easy and anywhere kindly special with utilise electronic with internet access development journalism inhabitant make practice the the more interested society because every inhabitant now own chance for can lift a topic or issue warm as product news not only enjoyed public in general the mass media industry is also one of them the exploiting party potency journalism inhabitant with method produce payload news through content journalism citizens shared on social media in matter this presence journalism inhabitant naturally help with the work process a journalist taking content journalism inhabitant for broadcast in the mass media naturally make it easy work professional and enabling journalist company for produce news with costs more research methods study this done with use approach qualitative through technique studies literature data collection obtained from results studies earlier on the topic journalism inhabitant as well as documents related practice journalism citizens on social media researcher gather a number of uplifting article theme journalism citizens and take a number content news results production journalism uploaded citizens via social media data that has been obtained then analyzed use literature review technique or study literature method study literature used researchers so that a number document references related theme study can studied in a manner systematic with objective for synthesize information important that can concluded literature review aim for describe method study from studies beforehand collect data and information important as well do analysis on the data that has been obtained writer especially formerly gather research and study related journalism citizens in indonesia method research used and techniques data collection for then analyzed and obtained synthesis related development trend journalism citizens in indonesia result and discussion journalism inhabitant now be one alternative for public for contribute in serve information warm and eventful important which is not reported in conventional media in development activities journalism residents are very helpful with sophistication new media technologies particularly social media sophistication instagram from features found on social media instagram can accommodate activity journalism inhabitant through ability upload photos and videos allows interaction two direction between users and social media users and save upload it and can shared with user other activity journalism citizens on social media possible public access content information and discuss various recent hot things and events kindly general journalism citizens on social media are also heterogeneous because no only function as source information for user but it is also possible exchange information between users activity journalism residents also provide a number benefit for public broad like as with the tsunami in aceh in 2004 the information provided through amateur videos inhabitant become initial primary documentation start incident theand speed deployment information then make results reportage inhabitant can seen by the international world so speed up coming help from neighboring countries this is one excess main from journalism citizens that is ability for can spread information in a manner fast and broad journalist residents too often was the first to get access for cover something incident important like disaster nature accidents as well phenomenon unique which is not entirely can covered journalist because that moment this is conventional media has utilise results reportage from journalists citizens because mark news or high news value besides from facet news value activity journalism residents also benefit internal media company expenditure cost production cause content shared by journalists citizens on social media is free media company only need provide source original from document and no need pay publisher content for conventional media companies results coverage journalist inhabitant can complete product the news you want they broadcast for example if suddenly broke no possible journalist international journal of humanities education and social sciences eissn 28081765volume 3 number 1 august 2023 page 219 223 email has deployed to location this before fire at the moment information about incident fire has circulating journalists new placed in place incident however journalists field often experience a number of constraints among others in a remote location or difficult accessible already late for perpetuate moment event key here journalist inhabitant play role key and through amateur videos media companies can use document for fulfil peoples visual needs in fact temporarily lots literature mention use journalism inhabitant for profitable conventional media there are also some challenge in develop journalism citizen challenge biggest in develop activity journalism inhabitant is reality that journalist inhabitant are ordinary people who do not own skill or training journalism because of them is inhabitant normal them no own knowledge about management or production news so generated content often violate rule journalism for example journalists inhabitant can distribute photos and videos of the perpetrators and victims below age as well as the program that contains content violence this usually no found in product news which is results report journalist professional because there is code necessary ethics obeyed besides thats it journalist professional bound with institution place work and law profession journalist in produce news reporter no can disseminate or publish information a product news made journalist professional must fulfil lots criteria accurate and factual information relevant sources and coverage two side journalist citizens on the other hand are ordinary people who are free spread information and results the recording no as well as immediately based on principle journalism conclusion the mount batur area offers natural potential that substantially encourages the growth of sports tourism in the region the growth of sports tourism is intended to give economic benefits to the local population as well as environmental protection in the mount batur area tourist destination based on the results of the research and analysis 11 strategies for the development of trail running as a sport tourist activity in the mount batur area were developed the qspm matrix analysis results suggest that the priority strategy that can be used is the allocation of ticket distribution to attending this tourist attraction with a tas value of 837 as a result of the regions tourism development the adoption of this approach is projected to assist boost the income and welfare of local communities furthermore relevant stakeholders are expected to examine ten other alternative strategies in promoting the growth of trail running as a sport tourist activity in the mount batur area

this digital age the latest media advances already give birth to order journalism latest aim journalism residents informed by residents general no journalist reliable various type category means the latest exclusively social media already open chance for public normal follow and deep procedure submission of data as origin suggestion information to public broad journalism inhabitant grow fast in fame as well as hinted with consuming content journalism inhabitant as product news broadcast in the mass media conventional product journalism inhabitant can present missing data from information conventional media news that distributed to the crowd as information items this writing mean to view method utilise social media to use support business journalism inhabitant as well as consequence utilization journalism residents on the means conventional study that used ie method qualitative utilise method review literature from the results review means conventional mass media a number of big liked as effect from reportage correspondence resident at least famous for inhabitant to use looking for linked data information journalism citizen but growth journalism inhabitant instead without problem application ethics journalism often no practiced because journalism inhabitant lived by ordinary people who do not background behind journalism

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introduction the field of computermediated communication studies communication that occurs between human beings via the instrumentality of computers with the goal to enhance communication by spanning spatial and temporal distances 1 cmc can be considered as an extension for human beings to maintain persontoperson relationships without being limited in geographical location the term global village describes the concept in which technology diminishes spatial distance because information can flow instantaneously from one location to another when this phrase was coined by media philosopher mcluhan 2 the world was on the verge of globalization currently globalization is here many multinational companies have increased the deployment of expatriates 3 and the number of international student enrolments are higher than ever 4 the leading actors in globalization are sojourners betweensociety culture travelers eg exchange students and business expatriates a sojourn is a voluntary temporary stay as most sojourners expect to return home after the completion of their assignment contract or studies 5 transitioning between cultural environments can have consequences for the wellbeing of the sojourner for example culture shock can cause anxiety that results from losing all our familiar signs and symbols of social intercourse 6 p 1 one of the important coping mechanisms for preventing a cultural shock is social support 7 social support can come from various sources hostcountry nationals homecountry nationals or homecountry relatives 5 social support from homecountry relatives is important for the sojourner because it can help to maintain ethnic loyalty and provide tangible and emotional support 8 simultaneously it is likely that existing relationships with relatives will be put under pressure when the sojourner is distressed 5 it is even possible that being immersed in a different culture can have an effect on ones own cultural identity 9 the aim of this paper is to investigate how novel cmc tools can facilitate social support between the homecountry relative and the sojourner by identifying the challenges caused by the cultural distance between the sojourner and the relative in the home country investigating the consequences of new interactive communication tools on the communication practices for the sojourner and the relative and providing a set of recommendations to design specifically for facilitating social support and presenting an design of an interactive communication tool based on these recommendations these three research phases are visualized together with the research scope which converged during the process in fig 1 we focus our analysis on chinese dyads composed of young chinese sojourners living in the netherlands and the communication with their parents we selected this target group because chinese sojourners face a large cultural distance when moving to the netherlands in addition the relationship of chinese children with their parents is complicated these children have to show filial piety based on cultural normative expectations 10 in the following section we present the theoretical background regarding these two cultures and their communication practices related work we are interested in the design lessons we can draw based on the theory of several disciplines anthropology can provide insights in the theory behind cultural values and the resulting consequences for communication and cmc tools social sciences studied the communication practices of family members living separated from each other finally we will analyze several applications and studies of family communication and awareness systems from the fields of humancomputer interaction and interaction design cultural differences hofstede describes culture as the collective programming of the mind that distinguishes the members of one group or category of people from another 11 p 9 one of the important visible manifestations of culture are rituals 11 rituals are collective activities that are technically unnecessary to the achievement of desired ends but that within a culture are considered socially essential cultural individualism or collectivism has a direct influence on behavior of people through norms and rules used in daily life individualistic cultures emphasize the goals of the individual over group goals whereas collectivistic cultures stress group goals over individual goals 12 hofstede discovered that the netherlands has a high individualism index meaning it is a highly individualistic culture china on the other hand has a relatively low idv score 11 indicating china to be a highly collectivist culture even though schwartz 13 used a different set of cultural values he confirms hofstedes these differences in cultural ic between china and the netherlands could be the potential cause of culture shock for a chinese sojourner in the netherlands another difference between the dutch and chinese culture lies in their communication styles 14 one way to explain variations in styles across and within cultures is halls 15 differentiation between highcontext and lowcontext communication in general cultures that favor lc communication will pay more attention to the literal meanings of words than to the context surrounding them on the other hand hc cultures pay more attention to nonverbal and paraverbal cues for example body language intonation in voice and other knowledge which one has in common with the communication partner lc communication is used mostly in individualistic cultures whereas hc communication is used mostly in collectivistic cultures 16 the netherlands is considered an lc culture this means that the speaker or writer is responsible for communicating the message in a direct loudandclear way that does not rely on previous external or unstated information in hc cultures like china it is up to the listener or reader to figure out what the speaker or writer is trying to say hc listeners and readers need to have additional background knowledge that most members of the culture or group are expected to already know culture and computermediated communication in recent years there has been a growing interest in studies examining cultural issues in cmc 101718 an analysis of this field concluded that it is hard to identify explanatory themes or frameworks and often contrary results are yielded 19 the studies are often focused on collaboration in the work context and therefore aim for the least amount of collaborative effort however for chinese communication partners their culture dictates the building and maintenance of relationships in addition to completing the communication task at hand 20 this desire has been recognized and allowing the user to promote or minimize emotional information is now considered as an additional goal for cmc collaboration 19 media richness refers to the extent to which a communication tool provides contextual support for interaction for example by communicating body language facial expressions and tone of voice 21 richer media such as video conferencing have more of these features than leaner media such as instant messaging in a study comparing the effects of media richness for the interpersonal communication between highcontext chinese dyads and lowcontext american dyads there were few cultural differences found 17 but it was concluded that for the chinese pairs visual awareness was significantly more socially fulfilling than for the lowcontext pairs because of the availability of highcontext information chinese cmc users make very deliberate choices about how to use media qualities to both convey and mitigate emotional information depending on which is most appropriate to the situation and the relationships 17 chinese exchange students and their family perceive phone communication as a more suitable medium to convey emotional information than email because it is easier to express personal views and feelings using additional audio information 10 family communication communication tools should help families to fulfill social obligations in a way that does not create new obligations it is important to maintain the family interactions that people find special 22 for families who encounter cross timezone communication timedistance poses more challenges than geographical distance members of separated familys rely mostly on synchronous communication because asynchronous communication is perceived as a method to exchange formal information and messages 23 routines and rituals are powerful organizers of family life which support its stability during times of stress and transition 24 in cross timezone family situations communication is still based on implicit routines which means that a regular time window is informally recognized by both parties as a time to communicate 23 another important element of longdistance communication is the facilitation of emotion and problem sharing this should be facilitated in a subtle way while also giving the opportunity to comfort the remote partner 25 awareness systems support individuals to maintain with low effort a peripheral awareness of each others activities 26 p 1351 awareness systems in the home and personal setting can benefit from affective awareness 26 good examples of using peripheral awareness to support emotional relationships are gavers wellknown feather scent and shaker concepts 27 the astra system is an awareness system which addresses a need of families currently unmet by other systems serendipitous sharing of moments through the day 28 summarizing the abovementioned insights provide a theoretical understanding of cultural differences and communication practices there are distinct cultural differences between china and the netherlands as well as in their communication styles the studies about cmc tools and cultural backgrounds show that emotional awareness is important for the target group and that richer media lead to a greater social fulfillment the studies about communication between separated family members show that there are interesting design opportunities for new communication tools based on the literature we identified the challenges and opportunities of communication across cultures through user studies we aim to gather more understanding in the influences of the new cultural environment on communication practices between the sojourner and relatives in china we will present the results of a questionnaire study and a qualitative interview study conducted with chinese sojourners in the netherlands questionnaire study the goal of the questionnaire study is to investigate whether there are correlations between the degree of culture shock and the amount of affective awareness the participants are currently experiencing we aimed the questionnaire at current voice communication experiences of the sojourners with their parents in china we chose to design an online questionnaire assuming we would have easier access to our chinese target group we used 30 questions from the affective benefits and costs of communication questionnaire to quantify the affective awareness 26 to measure the degree of culture shock we used the seven questions of the culture shock questionnaire 29 we directed the questionnaire to chinese people living in the netherlands with parents in china the questionnaire was distributed by a chinese organization in the netherlands and an online discussion group for chinese people in the netherlands fiftyfour people filled in the questionnaire from which we eliminated 22 results because of missing data from the resulting 32 participants the largest amount of people was between 20 and 30 years old exactly 50 was male and 50 was female 469 of the participants were students 344 was working 125 was searching for a job and the remaining 62 had a different occupation the durations of the sojourn of the participants were diverse the largest groups were 12 years in the netherlands and 35 years in the netherlands the female participants reported a higher level in the sharing experiences theme of the questionnaire 039 p 005 this theme includes the notion that experiences can be shared mutually from both sides the expectations theme includes the feeling that the parent should contact the participant regularly and the disappointment if the parent does not contact the participant the participants have increasing expectations of their parents contacting them when they are longer in the netherlands 036 p 005 an examination of the degree of culture shock and the themes of affective awareness resulted in the observation that the theme thinking about each other negatively relates to culture shock 045 p 001 this means that when the participants experience a higher degree of culture shock they will think less about their parents discussion female participants report a higher value in the sharing experiences theme which would indicate that the male participants from this study have more difficulties to share experiences with their parents the result that participants expect their parents to contact them more the longer they live abroad is surprising a possible explanation could be that the role of the person who initiates the communication session changes parents are getting used to the fact that their child is living away from them and are less active in communicating with their child the child still has the expectation that the parent initiate the contact with him or her but this expectation is not addressed to the parent the result of the negative correlation of culture shock with the thinking about each other theme seems to contradict with these expectations because the study shows that the participants will think less about their parents when they have a higher degree of culture shock it could be the case that the participants do expect more contact from their parents but will not show this due to the unease caused by culture shock parents could fail to recognize this symptom and as a result the communication between parent and child cannot provide the social support necessary to cope with culture shock if this is true there could be an opportunity in providing a better communication channel between parent and child so that it becomes more apparent for the parent that the child is in need of contact based on the issues that were raised by the questionnaire study it is clear that there are still unanswered questions regarding the influence of culture shock on communication and the problems this is causing interview study to gain a better explanation from the insights of the questionnaire study we decided to conduct an interview study we used a semistructured interview technique with prepared questions on the topics of communication with the participants parents communication content cultural differences and communication and routines participants for the interviews were approached with the help of a chinese organization in the netherlands the sample existed from four participants three females and one male the age varied from 23 to 27 one participant lived in the netherlands for 7 months one for 15 year the two other participants for 5 and 6 years three of the participants were working and one participant was a student the participants received a voucher of 750 euro for their effort to analyze the interviews we applied the affinity diagram technique 30 we transcribed the audio recordings of the interviews and wrote down relevant quotes on postit notes these postit notes were regrouped into themes finally we used the contents of the themes to draw conclusions for every theme all the participants described that the communication window was based on the available time communication moments during weekdays were short and inbetween activities in the weekends the participants had more time to communicate with their parents time difference was not perceived as a problem but as something they could plan around p4 explained thats not a very big issue i know the time difference very well because of my job the frequency of communication and amount of involvement is personal and not the same for every participant these rituals seem to vary depending on how long the participant is living in the netherlands p3 called every evening with her mother p4 calls short during weekdays while having long communications sessions in every weekend p1 and p2 both report that after 2 years they called less frequent with their parents the ritual was lost because of other activities in the netherlands but both started their communication ritual again in which they call once a 2 weeks during the weekends the participants described different methods of how their parents used contextual information to create highcontext communication styles p3 described for example how their onlineoffline status on internet was noticed by their parents i go online on msn and then my mother asks why are you at home today why dont you go to school or go to work and i say it is holiday here other methods that the participants mentioned during the interviews were the sound of the voice or the kind of questions their parents asked them information was also transferred through other people the family of p1 in the netherlands gave information to the parents in china which was then discussed in direct conversations the feeling of being connected is more important than the topic of conversation the conversations are often started with very mundane questions as p4 puts it how is your health did you eat well recently these are very typical chinese questions being positive in the communication between the participants and parents is something which came up in every interview it is important for the participants that they give an impression that everything is going well and that their parents do not have to be worried p1 mentions i also talk to them but most of the time i say positive things if i say a lot of negative things they will probably worry about me more in some of the interviews the influence of cultural differences on the behavior of the participants was mentioned p1 specifically mentions the effect of culture shock and the reason why she would not share her feelings with her parents the first 2 years for me were really hard because i had to get used to the culture also i was busy with my study when i had a problem i never told my parents only the positive things p3 talked about the effects of a different cultural environment on her behavior when she went back to china she had problems with buying things because she was not used to a farmers market anymore she recalls a conversation with her friends about this they asked me can you buy this at the market and i was so sure of course i can can you check the price or can you check if it is fresh and then i started thinking i cannot indeed in the interviews the participants mentioned that their parents were aware of the cultural differences between the netherlands and china the parents of p3 supported her specifically for this reason she thinks it is good for me because i can understand different cultures and differences between asia and europe p4 tells about his difficulties of explaining cultural differences to his parents from time to time i will try to explain something to my mother or my father i will tell them that this is just the culture i cannot do anything about it except getting used to it from all these different statements it becomes clear that cultural differences are an important element in the communication between the participants and their parents and they all have different methods of coping with these differences summary and discussion of findings in this section we will summarize our five most important findings regarding the communication practices of chinese sojourners in the netherlands parents need of hc communication in collectivist cultures such as china a highcontext communication style is preferred chinese parents found opportunities to maintain elements of this highcontext communication style however their children did not we assume there are various explanations firstly the child may not have the right tools to be able to engage in such communication style secondly the preferred communication style of the child could have changed because of living in a culture with a different communication style and finally there is also the possibility that the child is not interested enough in the life of the parents to engage in a form of highcontext communication which costs more effort than lowcontext communication failing of routines and expectations connectedness is very important for both the parent and the sojourner the participants indicated that they communicate frequently and regularly using direct synchronous communication these communication sessions can be seen as routines for the sojourner and parent because they take place on a fixed day and time in the week if this routine cannot be followed for example because of other obligations the other party will be worried the two participants who were living in the netherlands for 5 and 6 years both described that they have had a communication dip because of a more active lifestyle later their lives became more stable and they formed new communication routines the questionnaire study showed that over time the childrens expectations of the parents contacting them increased this could be contributed to the absence of communication routines during the communication dip the parents lost the awareness of when to call their children because they were not uptodate about their daily lives desire for connectedness on opportune moments the participants indicated that they could adapt well to the timewindows available for communication for most of the participants this meant that they called during lunch breaks for short updates and used the mornings in the weekend for longer conversations however these communication routines are a result of the time difference and limit both the parent and the child in communication opportunities some participants mentioned during the interviews that they had to make efforts to give an update to their parents when they could not follow the communication routine as normal because of different activities the cause behind these routines is the use of synchronous communication means by all the participants participants indicated that they like these means the children mentioned during the interviews that hearing their parents voice made them feel more connected and the direct synchronous communication made them feel like they were really together explicit and implicit communication of culture one of the goals of the studies was to find out more about how the parents and children deal with differences in culture in communication and if this is an important topic of communication cultural exchanges through communication between parent and child occurred this happened mostly when there were special events which the children experienced for example queens day or christmas the participants also mentioned during the interviews that the parents noticed cultural events in the netherlands through their communication routines for example during the weeks in may and june the children communicate more during weekdays because of national holiday days being positive and culture shock an unexpected insight from the study has to do with the experiences which the children decide to not share with their parents all participants mentioned that they do not share problems and bad experiences with their parents it is important for the participants to remain positive in the communication and to show that they are doing well the children do not want to make their parents worried but show instead the good things and their ability to live an independent life this can be linked to the result of the questionnaire in this study it was shown that the sojourners thought less about their parents when they experienced a higher degree of culture shock a reason could be that because of the difficulty to talk about problems in daily life their parents cannot provide enough social support during the times when culture shock is highest in normal chinese life these signals will be conveyed implicitly using highcontext communication but with the lack of hc information it is difficult for the parents to be aware of the problems of their child technology probe videomail to help transferring the knowledge gathered through the user studies into a set of design recommendations we decided to apply the technology probe approach 31 this approach is suitable for gathering information about the users and use of technology in the real context to trigger users to think about new uses of technology and to reflect on their communication practices the technology probe named videomail is a device which can be used to record short video messages for the communication partner who fig 2 the videomail device is located on the cupboard next to the television in the home of one of the participants also has a videomail device design the goal of the design of the technology probe was to build further upon the results of the questionnaire and interview studies which were described in sect 33 we will first explain how these five findings were translated in the technology probe during the interviews we noticed that both the parents and the children had different requirements of context within their communication parents used many sources to acquire highcontext information while the children relied less on highcontext during communication the related work about culture and computermediated communication indicated that media richness and context are closely related and context is an important factor to enable socially fulfilling communication between chinese dyads with the technology probe we aimed at discovering how the two communication partners will use context when they both have the availability of richer media we decided to use video messages since these afford both lowand highcontext communication the activities and schedule of the sojourner can change rapidly and are dependent on the phase within the sojourn when the life of the sojourner becomes more filled with activities it is difficult for the sojourner and the communication partner to initiate and maintain communication routines with the technology probe we wanted to test whether an interactive communication tool will be able to convey an awareness of each others daily lives and will influence the communication routines of the communication partners we decided to base the interface on a timeline to test how important time is for the communication partners awareness of each others daily life routines video messages are placed on the corresponding location on the timeline we added a rotating disk on top of the object which the user can manipulate to scroll through the timeline recording a video message is an activity which can be executed quickly without paying too much attention to the interface or the controls the webcam on the side of the videomail device starts recording when the switch in the middle of the front panel is pushed when the switch is pushed again the webcam stops recording the video messages appear on the timeline of the communication partner who can view the messages on a moment suitable for him or her viewing the messages can be done by scrolling the timeline left or right when the video is located in the vertical bar and the user pushes the switch the message will play we choose to combine the playback and the recording of video messages at one location in order to offer the user one communication channel which couples both perception and action at the same location the interview study participants mainly use synchronous communication tools to communicate with each other the sojourners indicated that they like to hear each others voices have the direct connection and feel being close together on the other hand the sojourners reported that this did not leave much room for flexibility which is required to be connected on more opportune moments asynchronous communication tools are often lean in media qualities which could be a reason they are not favored by sojourners for videomail we chose to use asynchronous video messages because we want to trigger the sojourners to think about this type of communication in relation to their current communication tools we also wanted to investigate the responses from the sojourner and an interesting observation from the user studies was that much information about the new culture was communicated explicitly through the communication of daily routines and rituals one of the goals of videomail was to build in opportunities for more of such explicit communication of culture through daily routines we created a kioskshaped communication device which affords to be placed on a fixed location within the homeenvironment because the device cannot be easily moved we expected that the routines related to the location of the object are going to be reflected in the communication routines the timeline with the recorded messages will be the representation of these routines because they combine location time and rich media qualities the sojourners who participated in the questionnaires and interviews were aware about the information they filtered and what they communicated to their parents it is for example important for them to show a positive image about their experiences from this we can conclude that it is important that both communication partners can control what is communicated and how they communicate it because of this we chose for clear affordances of the device the device would not automatically record messages but the communication partners can choose themselves when to record something and send it testing videomail after a 1week pilot run we resolved some stability issues added the option to display multiple messages and we prepared the technology probes for deployment the goal of the test was to approach the reallife situation as much as possible including the target group chinese sojourners in the netherlands with parents in china because it was not possible to deploy the technology probes in china we chose for participants both located in the netherlands however they do share a similar kinship as the intended target group our participants were a chinese dyad composed from a chinese woman in the netherlands who is living and working in eindhoven and her aunt who is living in nijmegen the netherlands they do not meet regularly but keep in touch through voice communication we deployed the two technology probes in both households the participants chose a place for the videomail device after connecting the prototype to the wireless network of the participant the functionality of the device was explained we did not brief the participants about the background of the technology probe or the type of video messages they could send both participants understood the functionality of the device quickly and made a first test message directly figure 2 shows the videomail device in one of the participants living rooms after 1 week of using the system we fig 5 digital form for consent and message description collected the technology probes in both locations we debriefed the participants by interviewing them about their experiences of using the videomail device we also gave both participants the opportunity to complete a digital consent form on which they could approve individual video messages to be reviewed later by the researchers the other video messages were deleted immediately after the test p8 has sent a total of 45 messages and gave consent over 711 of the messages p9 has sent 23 messages in total and gave consent over 261 of the video messages a possible reason for this low percentage could be that the partner of p9 also used the videomail to send messages but rather not participated in the experiment results and conclusions videomail deployment one assumption that led to the design of this system was that the communication of daily routines will enable a sense of awareness of each others daily life messages were sent when coming back from work when having dinner or when going to sleep the debriefing interviews with the participants confirmed the finding that this created an awareness of daily life p9 mentioned i know when they come back home sometimes when they are going to eat and when they go to sleep if they send a message more about their daily life also which clothes they are wearing an analysis of the messages that were sent during this experiment showed that many messages indeed communicated mundane daily information three types of messages could be distinguished short greetings status updates and questions the short greetings did not contain much information for example just a good morning or good night the status updates contained more information for example about an activity which was done that day or was planned the questions were messages in which information was asked of the other person we assumed that the ability to create asynchronous messages would be valuable when having a small communication window because of time differences this situation was difficult to simulate in the experiment a critique on an asynchronous communication system could be that the communication window becomes spreadout and people have to pay more attention to see whether there are new messages related to this p8 describes the following experience i looked to see if there are new messages or not when there was a new message i always wanted to see it immediately on the other hand the asynchronous communication can help to feel more connected but also to consider and respect the others personal life p8 mentioned you feel the distance with the person is a lot smaller if you call you are never sure is the other person happy maybe they do not want to talk to you at that moment but with this one you can click and it does not matter even without a time difference the participants experienced the asynchronous messages to be pleasant because it lowered the threshold to communicate more regularly with each other the participants both in the pilot test as in the deployment loved to see each other it gave additional information which could enable highcontext communication there were some examples in the debriefing interviews which gave the idea that the participants noticed the potential of asynchronous messaging p8 recalled sometimes when i felt i wanted to say something i could just do it you can decide to contact somebody on your own terms and that is very practical she also reflected on how this could help communication between her and her parents and was enthusiastic about this possibility the timeline interface was created based on the recommendation from theory that it is important to provide a temporal context to enable people to have a better idea of each others daily activities this interface did not cause any problems and was clear for the participants however certain aspects could be improved eg the ability to view back earlier movies should be easier and we should add notifications of new messages also the layout and the colors could be adapted more to the physical design of the object and the domestic environment another decision was to design videomail as a kioskshaped object the interaction was open for everybody who wanted to interact with the object we chose for this approach because of the goal to create an interaction style which would trigger short daily messages we do think that in the long run this openness can cause some privacy issues during the experiment it happened that visitors came into the house and started to interact with the object p8 explained during the debriefing interview that many of her friends were interested in the product because of the large form factor people could not miss the product that was standing on a prominent place in the living room p8 explained people were very curious oh what is this did you buy this p9 explained that she did not know most of the people who visited her aunt and sent messages but meeting those people gave her a peek in her aunts life she normally would not get in this case this caused no problems because the messages were not intimate for future designs the messages themselves could be more hidden in the object and require clear permission by the owner for playback design recommendations the following design recommendations are meant for designers who are developing an interactive communication tool for family members who are living separated from each other in different cultures social support can be facilitated by enabling communication styles more suitable for the cultural background of the sojourner and by conveying details about a culture which normally would not be communicated intentionally by the individual sojourners the following five recommendations will be explained in more detail how to describe the target group how to use context in communication why routines should be communicated which aspects for the interaction with such a tool to consider and implications of the design recommendations when implemented in an interactive communication tool target group it is necessary to have the right tools to describe and specify the target group theories provide an abstract level of understanding while qualitative studies can give detailed insight in the life of the target group hofstedes theory of cultural dimensions 11 can be used to assess the cultural distance is between the home country and the new country the dimension individualism versus collectivism can be an important factor this determines whether a person favors group goals over individual goals or vice versa it is important to consider that these theories describe a countrys national culture it is always possible that values of an individual are very different the experience of the sojourner can be described by using the theory of culture shock 5 this phenomenon can be measured by using the culture shock questionnaire 29 to empathize and understand the people from the target group qualitative studies such as focus groups and interviews on location are especially valuable to generate insights it is important to have an idea of which target group to approach beforehand if possible try to investigate both parties of the target group the sojourner and the communication partner in the home country some aspects to keep in mind are the difference in cultural values between the home culture and host culture of the sojourner the time difference between the two countries the sojourning experience of the sojourner the expected duration of the sojourn experience of the sojourner with different cultural values and previous life experience of the sojourner context an important element in communication is the availability of context for the sojourner and communication partner context can be provided using a communication tool but this is influenced by the preferred communication style of the sojourner the methods a sojourner is already using and the different types of context which are available the amount of context which needs to be shared depends on the communication style people in collectivistic cultures will generally favor highcontext communication styles while people from individualistic cultures will favor lowcontext communication styles it is important to realize that people always try to adapt their communication tool to the communication style they prefer from the interview study we discovered for example that parents who send money to their children can see their spending patterns also monitoring the onor offline status on an instant messaging program can give valuable information based on the interview studies and insights from theory we propose some examples of context which could be considered for communication the interactive communication tool should allow the sojourner to compare his or her routines with the routines of the family member in the home country and vice versa for example by comparing the moments on which routines took place or messages were sent a possible implementation is to use a timeline which shows the day of the communication partner with activities and communication events interaction it should be well considered how much control the user has about what is shared by balancing between what is shared actively and passively the object should be discrete enough to respect the privacy of the users for example by hiding personal information from direct visibility to enable the sojourner to communicate routines and context it is necessary that the interaction with the communication tool is integrated into daily activities by requiring conscious interaction from the user the object will trigger reflection about new cultural routines and home routines the behavior of the object should trigger the owner of the tool to engage in an interaction with the product to find out more about the daily life of the other by leaving the interaction open enough for interpretation it can become possible for the sojourner to create his or her own language which can be used to communicate in a more ambiguous context implications when designing a new interactive communication tool it is important to consider the implications on the behavior of the users for example because of new obligations and privacy issues these design recommendations aim at communicating details from a culture by sharing and comparing routines between the sojourner and the communication partner instead of the acculturation to routines in the new culture it could happen that the sojourner tries to maintain his or her home routines the interactive communication tool needs to be designed in such a way that it strikes a balance between the delight of recognizing home routines while also being triggered to explore new routines by using asynchronous communication the pressure of timezone differences is limited however asynchronous communication requires attention to be divided between multiple communication moments for the sojourner and the communication partner it is important to limit the new pressure created by this tool and to anticipate on the use of synchronous communication tools as well when developing new interactive communication tools for people who favor highcontext communication styles it is important to consider that it might not be desired to share certain context information especially when designing for people from different cultures it is important to remember that the perception of privacy might be different from our own above all it should be clear which contextual information is shared and the user should have control over it 6 circadian an interactive communication tool based on recommendations the abovementioned design recommendations led to the final design of the interactive communication tool named circadian similar to the videomail object this communication device is based on asynchronous videomessaging the object can be used in two different modes a decorative mode in which the object blends in the living room environment and the usage mode with which video messages can be viewed and recorded fig 6 the circadian prototype shown as decoration fig 7 browsing through the day representation using the touch interface we will describe the object based on the design recommendations the target group circadian was designed for consists of chinese sojourners who moved to the netherlands and their close relatives it specifically supports the phase when the sojourner has recently moved and finds it valuable to maintain close family relations the design is inspired by a chinese puzzle the kong ming suo based on an architectural principle for attaching beams together this device exists from three separate parts that combined form the device the materials chosen for the object symbolize the distance between the two different cultures mahogany wood for china based on traditional redwood and beech wood to symbolize northern european culture the materials meet in the middle of the object where the messages are hidden and cannot be seen when the object is in decorative mode when the parts are separated a touch display becomes visible which has a camera on the rearside aimed for sojourners who prefer highcontext communication styles we embedded context using two aspects a visualization of the days of the two communication partners and video as medium for the messages the overview of the day was built up by pieces representing timeintervals the interface displays two of these day overviews both in the local time of the user we chose for the localtime perspective to make it easier for the users to compare each others rituals and activities video messages are displayed on the moments they were recorded using a small icon which can be clicked the communication partners can compare the video messages in the context of their day which will give them extra input for hc communication to give an overview of communication routines we used the color intensity of the timeinterval to represent the usage of the object during the interval moving the object interacting with the interface viewing a movie or recording a movie are all actions that will intensify the color of the timeinterval this visualization provides an overview of the routines of the interaction with the product which creates opportunities for the communication partners to discover each others routines and make it easier to create new communication routines the interaction and appearance of the product affords to be placed in the domestic environment our assumption is that this will result in a better integration of communication routines into daily life movements with the object will result in intensified colors in the interface which functions both for communicating context and can be used to send ambiguous messages to change from the decorative mode to the usage mode the user has to open the product this action can be considered as a routine itself this is both to protect the privacy of the users and also to transform the act of communication in a clear routine we considered implications of privacy by choosing for a dedicated object the object does not register the environment autonomously but requires an active interaction from the user we chose an interface which will objectively show the usage of the local object and the remote object by mapping these on a synchronized timescale we aimed at triggering reflection about the different lifestyles and the influence of culture concluding remarks in this paper we studied how we can design for communication across cultures in particular bridging chinesedutch differences we generated a set of design recommendations regarding target group context routines fig 8 circadian in docked mode for example for recording a video message fig 9 the red disk represents the day of the chinese family member white of the sojourner interaction and implications based on literature a questionnaire study interviews and a technology probe to validate these design recommendations we created a final design facilitating communication across cultures called circadian of course the studies we conducted have been mostly qualitative and with a limited amount of participants still during the design of circadian we experienced the design recommendations to be abstract enough to leave space for creativity while providing a set of clear requirements which we used to base design decisions upon

in our global village distance is not a barrier anymore for traveling people experience new cultures and face accompanying difficulties in order to live anywhere social support can help these sojourners to cope with difficulties such as culture shock in this paper we investigate how computermediated communication cmc tools can facilitate social support when living physically separated from lovedones in different cultures the goal is to understand the design considerations necessary to design new cmc tools we studied communication practices of chinese sojourners living in the netherlands and the use of a technology probe with a novel video communication system these results led to recommendations which can help designers to design interactive communication tools that facilitate communication across cultures we conclude the paper with an interactive communication device called circadian which was designed based on these recommendations we experienced the design recommendations to be abstract enough to leave space for creativity while providing a set of clear requirements which we used to base design decisions upon

19802_0

volume 19 nomor 2 desember 2022 233248 death china experienced an increase in cases the government of china immediately provided policies to carry out quarantine social distancing and isolation of residents or areas affected by the epidemic this policy was considered adequate because the covid19 case in china began to subside and activities in the country returned to normal in addition the united kingdom urged quarantine territories independent isolation closed schools or universities and prohibited physical contact with humans covid indonesia is one of the countries affected by the covid19 outbreak the first case was discovered in february 2020 and announced 913 were in care 46 recovered and 87 died the governments policy of handling the pandemic allowed pros and cons in public and social media which is crucial for information policies many problems related to the response to covid19 are presented on twitter so the government will eventually provide a better and faster response many cities in indonesia ran into economic stagnant trading stopped from current conditions until normal conditions now the situation is called the new normal or collaboration with coronavirus new normal issues are vital for everyday life on social media many are critical of jokowis policy on the new normal because there is no government operational standard in the new normal thus other issues besides the movement stopped the new normal according to two strategies may reduce covid19 transmission first mitigation focuses on slowing but does not have to stop the spread of the epidemic reducing peak health demand while protecting those at risk of severe disease from infection second suppression aims to reverse the growth of a pandemic reduce the number of cases to a low level and maintain an unlimited situation each country made various efforts to suppress the spread of covid19 including indonesia in many countries such as china the united states france netherlands belgium iran saudi arabia malaysia singapore thailand and south korea the governments response to covid19 is quite varied and rapid meanwhile in indonesia twitter users perceived that the indonesian governments response was lack of speed so victims continuously grew therefore twitter users harshly criticized the central governments readiness the indonesian government confirmed the first case of covid19 on march 2 2020 where two cases of covid19 affirmed currently the number of covid19 cases in indonesia has reached 1986 and is the highest in southeast asia if referring to the picture below there is always an increase in confirmed daily cases the number can also be quite significant therefore a more strict government policy to reduce the rate of transmission of covid19 is required at the beginning of the covid19 case the indonesian government immediately provided a policy to conduct social restrictions or social distancing this policy tried to ask people to minimize social this study shows that there are complications when the government enforces a stayathome policy some citizens disobey government policies and there is a view that the covid19 outbreak is an international conspiracy by the indonesian government which does not agree with indonesian muslims the views come from some muslims and indonesia scientists regarding the largescale social restrictions policy the community hoped that the government would seriously prevent the increased number of patients and victims of covid19 due to the indecisive nature of government those are great numbers for a country with a middleclass population reaching 52 million out of 267 million inhabitants twitter has given massive coverage of covid19 around the world twitter help for preventing massive outbreaks of epidemics throughout indonesia social media users in however social media has positively impacted the government in dealing with covid19 since public criticism has made the government responsive to the outbreak however the massive twitter news could also negatively impact some people panic to carry out social activities such as meeting healthy people and even going to a funeral during the covid19 pandemic in other cases there is a rejection of a community health worker who died because he had struggled to save patients infected with covid19 in semarang regency there was also a rejection of people who came from outside to return to their hometowns some people tend to ignore to checking and rechecking the news received the middle class in indonesia pays attention on twitter news many twitter users often even upload sensational news by shorten news in the field twitter users do not hesitate to upload unreliable information they do not heed the ethics of reporting so the communitys extensive social impact is struggling with covid19 therefore the government policy in providing news to the public must also be clear firm and unchanging from day to day people are waiting for what is happening in indonesia related to covid19 the indonesian people may not be willing to believe the government if they dont provide firm and complete news which also tends to change indonesia certainly is not alone in facing difficulties in handling covid19 indonesia with a population of 2642 million cannot simply copy the policies of small countries such as singapore malaysia brunei darussalam philippines and thailand however indonesia can imitate some countries like australia britain and france in handling the outbreak they successfully suppressed so the number of patients and victims doesnt increase the government pays attention to twitter users criticism through dirumahaja even this hashtag became the most popular and adopted by all citizens when the covid19 outbreak continued to concern the world the hashtag invited the community to reduce activities outside unless urgent matters such as buying daily needs seeking treatment or going to the hospital the npf can identify actors who play a role in three levels namely micro mezzo and macro at the micro level the actors who play a role are individuals at the mezzo level it is a coalition of combined individuals and at the macro level by involving institutions or culture at this level the policymaking actor is the government through the ministry of health which confirms or instructs the public to limit traveling outside the home and engaging in activities that involved many people the government expected that their policy will be obeyed by the public so the spread of the covid19 virus does not increase

the central and local governments must continue synergizing to reduce the spread of covid19 policies that the indonesian government implemented are social distancing and selfquarantine the dirumahaja movement emerged on various social media platforms including twitter this paper analyzes the use of twiter as a platform for dirumahaja movement to understands peoples attitude in dealing with covid19 the findings show that becomes a public space through hashtags on twitter the public communicate and support government policies related to social distancing and selfquarantine

19803_0

background in common with indigenous populations in the us canada and new zealand indigenous australians have higher incidence of endstage kidney disease but lower transplantation rates than their nonindigenous counterparts 1 2 3 4 for example in 2005 454 of nonindigenous treated eskd patients in australia had a functioning transplant compared with only 127 of treated indigenous patients corresponding figures for 2009 were 459 and 120 1 reasons for these disparities are not completely understood but clinical factors alone do not explain them most indigenous australian eskd patients attend incentre hemodialysis 1 generally in large urban centres many patients from regionalremote areas must leave homeoften suddenly and indefinitelyto access treatment the hemodialysis regimen is extremely demanding with ongoing dialysis attendance tight dietary restrictions and multiple medications much of a dialysis patients life is spent travelling tofrom dialysis sessions having treatment and recovering afterwards time and resource constraints in clinical settings mean that healthcare providers make decisions about patients often with limited understanding of their individual circumstances 5 for eskd patients the impact of such decisions can be profound and potentially lifechanging determining for example whether a patient is assessed as suitable for homebased dialysis or transplantation many indigenous eskd patients share social and situational circumstances likely to affect their responses to the demands of dialysis including remote regional residence low income and education and a first language other than english 6 7 8 these factorstaken togethersignificantly increase the challenges of dialysis 910 this may explain at least in part characterisations of some indigenous patients as noncompliant with treatment a label with negative impacts on patients access to the full range of renal replacement modalities 1112 given the vulnerability of this patient group it is important to understand how dialysis treatments impact on and in turn are impacted by the lives of indigenous patients this paper presents the views and experiences of indigenous australian eskd patients undergoing dialysis comparing them with those of nonindigenous patients it draws on material from a large indepth interview study involving patients from around australia methods data presented here were collected as part of impakt an integrated mixedmethods program of work investigating barriers faced by indigenous eskd patients in accessing kidney transplants brief methodological details relating to the present analysis are described below a more detailed account of impakts aims methodology ethical issues recruitment sampling and data analysis is available elsewhere 13 data collection semistructured interviews were conducted in 200506 with 146 indigenous and 95 nonindigenous patients from nine hospital renal wards and 17 associated dialysis centres which together treat the majority of indigenous australian eskd patients all participants provided informed consent a maximum diversity sampling strategy helped select patients based on ethnicity location age sex treatment type and illness duration the interview structure aimed to elicit a lifestory narrative that made sense to the patient 14 topics included personal history of illness social and psychosocial context attitudes to treatments including transplantation adequacy of information and communication and satisfaction with services almost all interviews were conducted individually and facetoface by one of three investigators and digitally recorded and transcribed most interviews were conducted in english in order to elicit more nuanced perceptions and attitudes from some patients for whom english was not their first language seven interviews were conducted entirely in an indigenous language by fluent nonindigenous contract interviewers analysis thematic analysis was performed using qsr nvivo 7 the analytical methods used were evolutionary and iterative in nature 1516 the research team met regularly throughout the study to propose debate and negotiate the major thematic groups arising from the interview material one investigator coded all the interviews for themes relating to patients experience of dialysis and engagement with treatment participant demographics were selfreported descriptive statistics were generated using spss 150 for windows ethical approval the study was approved by 14 results participant characteristics compared with nonindigenous participants indigenous participants were more likely to be female younger and have dependents and less likely to speak english as their first language be employed or have completed secondary school the majority of indigenous patients lived in a remote area at the time of diagnosis compared with 15 of nonindigenous participants patients experiences of dialysis patient interviews suggested several factors shaped their treatment experience including the impacts of late diagnosis the consequences of family separations necessitated by moving to treatment centres the physical and psychosocial demands of dialysis and ineffective communication between patients and their care providers none of these factors were unique to indigenous patients some nonindigenous patients also had communication difficulties some were also diagnosed at a late acute stage some endured family separations and so on but in stark contrast to indigenous patients none were likely to experience the combined interactive and continuing effects of all these factors the conjunction of treatmentrelated circumstances with a profile of disadvantage and social marginalisation posed a substantial challenge for indigenous patients to engage with their treatments late unplanned start on dialysis many indigenous participants described an abrupt unplanned commencement of dialysis this was often accompanied by immediate relocation to a distant town city with no time to mentally or physically prepare in many cases patients were unaware of the severity of their kidney problems the following example hints at the profound impact of late diagnosis interviewer okay so you were there with your kids and just got sick one day and then what happened participant thats when they fly me down to major city i was there for three and a half years yes might be more recalling their first experiences of dialysis indigenous patients described shock fear and bewilderment p i was shocked first yeah shocked because nobody had ever said anything to me about kidney disease i went to the hospital and when i got there it was late late at night in the hospital and the next day the doctor came and had a look at me and they were looking at my you know which side theyre gonna put the fistula i didnt say anything i was wondering what they was doing you know i thought somebody might come up and tell me about it then when it was time for them to do it thats when the doctor said that they was gonna put a tube down here pointing to site of vascath access in neck and they didnt say anything to explain that they was getting me ready for dialysis i had to find out myself they put that thing on and then i was wondering what thats for you know they put me in a wheelchair to this part of the hospital where they had dialysis i looked and i see this thing one side of me and then i said i was thinking to myself so this is what its like to be on the machine by contrast most nonindigenous patients were aware of and being monitored for loss of kidney function well before commencing dialysis this tended to lessen the shock of starting treatment p i mean i was expecting it you know for some time and so i was very prepared yeah well if its an acute thing i can understand its probably a huge shock to people and things like that but i was quite prepared even though when they said oh look youve got to go on dialysis next week it was sort of that i knew it was going to happen but it was something i would sort of rather not heard i just didnt want it to interrupt my lifestyle and things like that mainly family separation through relocating for treatment most indigenous participants had had to leave home permanently to access dialysis treatment thrice weekly dialysis sessions severely limit opportunities to visit distant home communities indigenous participants spoke of the sometimes overwhelming difficulties of constant separation from their families communities and land indigenous patients were on the whole younger than nonindigenous patients as well as more likely to be caring for dependent family members including children although some nonindigenous participants were also caring for children they were less likely to have relocated for treatment indigenous parents faced a grim choice between bringing their children with them to an unfamiliar towncity life or leaving them behind in the care of others finding housing social networks and support services for families and children all present difficulties many patients expressed concerns about exposing their families to alcohol and drugs andor the likelihood of homelessness the alternative was a life undergoing a difficult treatment in virtual exile from their families communities and support networks in addition to family responsibilities dialysis requirements may cut across or conflict with patients family community andor cultural responsibilities patients described the dilemma of having their personal health needs set against their social and cultural responsibilities this patient was a senior community member with ceremonial obligations to younger kin he asks how can i put my own health above my responsibilities to my family and kin his fardistant relatives have no comparable experience to really understand his situationhe feels guilty and uncaring on the other hand travelling and thus missing treatments flies in the face of his health carers advice and the pleas of his wife physical and psychosocial demands of treatment all participants spoke of a range of physical andor psychosocial demands associated with the dialysis treatment itself including fear pain nausea fatigue faintness and a range of negative feelings such as deep sadness loneliness and homesickness p because of the time lying there on the dialysis machines four hours like that the back becomes really painful when its finished the sisters pull out the needles and get everything give us medicine and the patients feel paralysed they cant go walk they feel really tired the bus driver has to lift them up into the bus when they get off the bus they move slowly using walking frames so its because of all this that people are sad also the dialysis affects their eyesightafter the machine some cant see properly they recover later after going home and having a sleep the dialysis machine has some bad side effects while nonindigenous patients also noted some physical discomforts associated with dialysis their commentary did not reflect a similar experience of distress with its suggestions of alienation social isolation confusion and sadness ineffective communication communication difficulties associated variously with differences of language literacy conceptual frameworks values and preferred communication styles between patients and health providers were recurrent themes of indigenous commentary patients noted that medical jargon andor overly complex english made it difficult for them to understand information and instructions this was particularly so for specialists some participants reported apprehension and confusion as a result others spoke of feeling uncomfortable and uncertain in the hospital environment which reduced their willingness to engage with health professionals as an experienced indigenous interpreter observed people ie indigenous patients will go along and shake their head and agree to things just to get away from that person clinician thats firing all these big questions at them but theyre lost for answers they cant understand all that so the easiest way is to agree because you know youre out quickly then and the health providers are happy oh well at least they feel as if theyve done their job so they feel good about it but the full story hasnt been given perceiving clinicians as reluctant to provide information several indigenous participants expressed uncertainty andor scepticism about whether health staff wanted to give them the whole story this was keenly felt by some p when i ask the doctor i dont get anything clear information have i got something else wrong with me the doctors keep it a secret they hide it we want them to tell us plainly this is the problem they dont talk moreover the busyness of the daily dialysis routine can itself mask a lack of patient understanding and participation in their own care asked what he knew of his current situation a longer term indigenous patient replied p well we dont know we really only just go in and out and have the treatments we dont know where we stand with how were going so we dont know whether were getting a bit better or things are getting a bit worse they dont tell us whether were improving or getting worse were just going in and out of the sessions in contrast only a small proportion of nonindigenous patients did not speak english as their first language most reported few difficulties understanding their health providers those who did report difficulties focused primarily on language differences with little mention of medical jargon or overly complex language notably while most major treating units routinely used interpreter services for nonindigenous nonenglish languages only one unit involved in this study made regular use of indigenous language interpreter services maintaining the dialysis regimen despite the challenges most indigenous patients described themselves as following their health providers advice with its emphasis on attending dialysis and maintaining dietary and medication requirements those who reported being unable or unwilling to maintain the regimen gave a variety of reasons including transport problems not understanding what was expected difficulty in adjusting to dialysis needing to travel home for important events and feelings of mistrust anger or frustration although indigenous patients commonly noted that information from their care providers had been inadequate either in its comprehensiveness or more usually its appropriateness most also expressed a reticence about asking for clarification or additional information several indigenous patients recalled how anger and frustration at their vastly changed circumstances led to neglecting their treatment after the initial shock of starting dialysis and adjusting to its physical demands many indigenous participants described coming later to the full realisation that their need for treatment was permanentthat despite prolonged and aggressive medical intervention their illness could not be cured p it took me nearly two years to get used to it you know just worrying to go back home but i couldnt for many indigenous participants the eventual acceptance of dialysis was accompanied by a somewhat bleak sense of resignation described graphically by one indigenous patient p well a lot of them know theyre stuck here for life until they die you know and they know it and its really upsetting to them in essence these participants experienced their lives as being simultaneously savedand devastatedby dialysis i discussion as a group indigenous patients dialysis experiences were shaped by several factors including late referral and unplanned initiation of dialysis family separation associated with relocation to an urban centre for treatment barriers to meeting family and community responsibilities the physical and psychosocial demands of dialysis and ineffective communication between care providers and patients as noted none of these factors were only identified by indigenous patients some nonindigenous patients also experienced the effects of some factors some nonindigenous patients had communication problems some had a rushed and frightening start to dialysis some had to deal with family separation and so on however in contrast to other patient groups the majority of indigenous patients experienced all or most factors combining in varying levels of intensity throughout the period of their dialysis as a result centrebased hemodialysis presents distinct and particularly complex challenges for indigenous patients despite such challenges the majority of indigenous participants reported their endeavours to maintain the treatment regimen however there was also a sense that patients isolated from family and support networks became worn down and lost motivation over time in a setting of serious illness and limited understanding a range of responses including alienation isolation confusion frustration anger denial resentment andor mistrust led some patients to act against their own best interests often unknowingly they were also potentially reducing their chances of being deemed suitable for transplantation or for selfcare homebased dialysis modalities a key finding of this study concerns the extent and implications of social hardships on the experience of dialysis treatment for many indigenous patients indigenous participants narratives revealed how feelings of alienation and isolation substantially increased the challenge of coping with an already demanding treatment our findings also support those of similar studies undertaken with native canadian eskd patients which found that relocation for dialysis disrupts patients social support patterns and creates ongoing psychosocial problems for both patients and their families 1718 all these more recent findings extend those of an earlier qualitative study exploring the illness and treatment experiences of aboriginal eskd patients in a specific region central australia in which patients similarly reported the stress of reconciling family and cultural responsibilities with treatment requirements 10 devitt and mcmasters found markedly divergent views between medical staff and aboriginal patients about the meaning purpose and priority of adhering to dialysis treatment requirements describing the centrality of family and kin relationships in the social and cultural life of indigenous people they say nonaboriginal health carers rightly exhort patients to focus on their own health requirements but many are apparently unaware of the enormity of the patients own dilemma who seeks to have not only life rather than death but a life that has meaning in their terms 10 ps114 in constructing a life that has meaning in their terms indigenous dialysis patients draw on a cultural and social wellspring that differs greatly from that of their carers and importantly includes specific and different notions of illness causality as well as ideas of how health and wellbeing are achieved a second key finding of this study was the degree to which miscommunication andor ineffective communication accounted for patients treatmentrelated difficulties when combined with relocation and family separation social dislocation and unplanned treatment initiation communication difficulties often took patients to the breaking point language differences the failure to use interpreters routinely and staff particularly specialists using inaccessible medical language added further to dissatisfaction and potential disengagement among indigenous patients low levels of literacy and education also hampered effective communication and knowledge transfer patients confirmed their difficulties in understanding their situation treatment and options some even perceived this as evidence of staff reluctance to share the full story with patients these findings are in line with our previous research which found that many indigenous patients feel uninformed about their illness and eager for more information 19 there are also parallels in our findings with those of an earlier australian study investigating effectiveness of communication between aboriginal eskd patients and healthcare workers which found that the pervasive miscommunication between patients and providers often went unrecognised by both groups 20 cass and colleagues highlighted the importance of developing shared understandings incorporating perspectives of both medical staff and patients as well as the importance of understanding clinical communication within a broader social cultural and political context 20 as articulated by humphery and colleagues the efficacy of clinical communication is constrained by structural issues including poverty dispossession marginalisation limited education and racial discrimination 21 all of which are relevant to indigenous australians the findings of this study indicate that dialysis treatment is likely to be more challenging for indigenous patients than for other patients yet our findings also suggest that the large majority of indigenous participants see themselves as either managing a difficult situation or persevering under very onerous circumstances this may not add up to the compliance proposed by staff but neither could it be said to constitute noncompliance in contrast with views expressed by health professionals 12 we found little evidence of indigenous patients admitting to intentionally deviating from their dialysis regimen and any such deviations tended to represent either temporary rebellion or giving up after a long period on dialysis however it is also possible that indigenous patients who do not adequately understand their situation including their treatment requirements may be unaware how and why their behaviour deviates from expectations our findings suggest that most indigenous patients see themselves as engaging with their dialysis treatment as best they can under fraught circumstances nevertheless it also appears that there may be a gap between patients views of their own efforts and the assessments of compliance by health professionals using a range of clinical measures this is critical because despite recognising that it is both poorly conceptualised and poorly measured clinicians rely strongly on notions of compliance in determining access to transplantation 1112 this study which draws upon selfreported views attitudes and experiences of 241 indigenous and nonindigenous eskd patients has some potential limitations most importantly patients selfreports can only represent a partial account of the situation for example some patients may have overestimated the extent to which they followed the regimen particularly if they thought this could affect their chances of being waitlisted for transplantation others may not have been sufficiently wellinformed to assess whether their behaviour accorded with expectations these limitations aside the value in garnering the personal experiences and perspectives of a large number of dialysis patients is the rare insight it affords into challenges and obstacles faced by indigenous patients in maintaining their dialysis treatment conclusions the impact that social and situational circumstances have on the ability of australian indigenous dialysis patients to fully engage with treatment has important implications for health services while factors such as place of residence educational attainment and language are not easily modifiable treatment practices can be adjusted more readily earlier diagnosis could reduce some of the trauma associated with unplanned start to dialysis some progress has been made with late referral declining from 338 of indigenous patients starting treatment in 2005 to 212 in 2009 1 but delayed diagnosis remains an important concern improved linkages between specialist renal services and primary care in regional settings would support patients to better prepare and more effective communication and patient education would significantly strengthen patient understanding of their situation as well as reviewing the weight placed on patient compliance in decisionmaking transplant and home dialysis programs should establish more systematic transparent approaches to compliance in their guidelines competing interests the authors declare that they have no competing interests authors contributions jc participated in the overall management and design of the impakt study in data analysis and interpretation and in writing and editing the manuscript ka coordinated data management conducted interviews participated in the coding analysis and interpretation of data and drafted the manuscript jd participated in the design of the impakt interview study protocol and coordinated and participated in data collection management coding analysis and interpretation cp participated in study design coordinated the indigenous community engagement component and participated in data collection management analysis and interpretation ac conceived of the study participated in design and overall management and in data analysis and interpretation all authors participated in the drafting andor critical revision of the manuscript and read and approved the final version to be published

background in common with indigenous populations elsewhere indigenous australians have higher incidence of endstage kidney disease eskd but lower transplantation rates than their nonindigenous counterparts understanding how the demands of dialysis impact on and are impacted by the lives of indigenous patients may provide important insight into treatment pathways and decisionmaking methods we conducted semistructured interviews in 200506 with 146 indigenous and 95 nonindigenous patients from nine hospital renal wards and 17 associated dialysis centres which together treat the majority of indigenous australian eskd patients results factors influencing treatment experience included the impacts of late diagnosis family separations associated with relocating for treatment the physical and psychosocial demands of hemodialysis and ineffective communication between health care providers and patients although not unique to them indigenous patients were more likely to experience the combined effect of all factors conclusions socialsituational circumstances profoundly affect indigenous australian dialysis patients ability to fully engage with treatment this may ultimately affect their likelihood of receiving optimal treatment including transplantation areas for improvement include earlier diagnosis improved linkages between specialist renal services and primary care in regional settings more effective communication and patient education and more systematic transparent approaches to patient compliance in transplant and home dialysis guidelines

19804_0

introduction according to scholarly sources megaevents may be defined as expansive cultural events including both commercial and sports aspects that possess a remarkable level of popularity and global importance 1 megaevents has significant economic implications including substantial financial investments amounting to billions of dollars while simultaneously exerting a profound influence on a vast number of individuals potentially impacting millions of people moreover these events possess the capacity to strategically reposition cities and localities within the global landscape megaevents possess a temporal brevity yet their influence and importance for the host city extend well beyond the event itself 2 the preparatory phase the event execution and the subsequent legacy collectively impact various interconnected facets of urban revitalization including the economy society physical infrastructure city reputation and the environment 3 the observable effects of a megaevent such as the olympic games on the host city mostly pertain to the enhancement of the physical infrastructure however it is important to note that these improvements sometimes occur at the detriment of economic social and environmental fairness and impartiality 24 2 mega events improving the physical environment in urban regeneration the choice of a city to host a megaevent is driven by the possible beneficial outcomes it may bring with a primary focus on enhancing the economic growth of the city or area and facilitating urban regeneration via the cumulative investment stimulated by hosting such event 5 enhancements that are closely associated with the event are often seen in the development of venue amenities the refurbishment of transportation and service infrastructure and the upgrading of communications networks 6 infrastructure projects that are tangentially associated with the event including as recreational amenities business hubs and public areas often occur with the objective of enhancing the host citys surroundings and reputation hence enticing investment for further progress consequently there is a growing trend whereby significant athletic events are being used as catalysts for extensive enhancements to the urban landscape an exemplary case demonstrating successful urban development can be observed in the context of the 1992 barcelona olympics during this event significant investments were allocated towards the enhancement of transportation systems telecommunications infrastructure and the revitalization of a deteriorated coastal region consequently these efforts yielded positive outcomes such as the establishment of an improved public transport network the creation of new marinas and the development of various leisure amenities notably the transformation of the coastal area resulted in the creation of captivating sandy beaches which continue to serve as a beloved public space in the present day 7 the sydney olympics included the development and building of the olympic park the cleanup efforts undertaken in the homebush bay region provide a valuable chance to tackle the significant levels of brownfield pollution 8 this evidence illustrates that megaevents provide possibilities and facilitate enhancements to the host citys physical environment inequalities caused by mega events governments that host megaevents frequently justify their bids and budgets by emphasizing the increase in tourist activity and the resulting economic gains as well as the enhancements made to the urban environment 9 however this argument is based on the assumption that all local residents consistently reap the benefits of the citys economic growth and improvements in urban infrastructure nevertheless this assertion has encountered growing opposition in recent times as some scholars contend that evaluations of megaevents have to include an equitable standpoint about the allocation of advantages and disadvantages among the populace resulting from those occurrences 3 in theory it is expected that various socioeconomic groups would experience distinct economic advantages extensive research has demonstrated that the middle and upper classes tend to derive varying degrees of benefits from megaevents however existing studies offer limited evidence to support the notion that these events confer advantages upon the most economically disadvantaged groups this suggests that megaevents may contribute to the exacerbation of urban population polarization the following part sequentially examines the economic and social disparities and exclusions that may emerge from the three stages of megaevents namely the pre mid and post megaevent phases displacement as a direct result of eviction the word eviction is often used to describe the act of forcibly directly andor involuntarily displacing someone 10 megaevents are often orchestrated with the objective of urban redevelopment necessitating the removal of existing structures and displacement of disadvantaged communities residing in lowincome neighborhoods 11 nevertheless within the trio of the state community and capital it is evident that the communitys voice has the least amount of influence therefore they have a considerable disadvantage when it comes to protecting their position and community against the occurrence of forced evictions and demolitions the perception among privileged individuals is that community opposition to demolition or development is detrimental to economic interests consequently efforts are made to ignore minimize or even stigmatize such resistance in order to facilitate the process of eviction 12 the expropriation of families on a large scale at the pre stage often results in the immediate occurrence of mass evictions and a decrease in the availability of lowcost and social housing these outcomes ultimately lead to substantial decreases in affordability as shown by reference 13 one prominent instance may be seen in the context of the atlanta olympics during which about 15000 individuals were displaced from public housing developments resulting in the loss of 9500 affordable housing units this displacement was undertaken to facilitate the construction of the olympic project 14 disadvantaged inhabitants often experience displacement from their original neighborhoods resulting in their relocation to far urban peripheries characterized by restricted availability of public amenities and services this phenomenon exacerbates existing imbalances in their access to decaying urban infrastructure and contributes to heightened levels of social segregation furthermore it is worth noting that new disparities may emerge within the already marginalized groups of even this phenomenon is effectively demonstrated in the transformation initiative undertaken for the rio olympics even within slum communities and other lowincome populations which are identified by the exceptional city theory as the primary groups affected by urban transformation disparities in geographical location and policies give rise to varying outcomes for different individuals and communities involved in the demolition and relocation process 15 in the event that the government is unable in furnishing resettlement homes for the displaced individuals or if the cost of the alternative housing provided surpasses their financial means it would inevitably result in the emergence of a fresh cohort of individuals experiencing homelessness 16 the land acquisition and demolition phases of urban redevelopment projects have the potential to exacerbate existing inequalities in access to housing and the city this can lead to increased exclusion of disadvantaged and economically marginalized groups while residents in more affluent areas experience the advantages of improved infrastructure following redevelopment efforts employment and income inequality the rationale for investing in the organization of megaevents is often predicated on the notable augmentation of job prospects nevertheless the allocation of these emerging employment opportunities is often characterized by an uneven distribution mostly favoring those who are currently gainfully employed possess specialized skills and have the desired mindset 17 a significant proportion of those who experienced prolonged unemployment were not selected for a considerable number of the assured positions available during the olympic games instead their attention was directed towards employment opportunities that lacked union representation and exhibited substandard working conditions 12 during the preparations for the 1996 olympics a significant reliance on lowincome undocumented immigrants was seen resulting in a notable prevalence of labor exploitation within the construction sector 2 furthermore megaevents are seen as advantageous promotional prospects for cities and regions since they aid in the attraction of tourists and the augmentation of tourism income 16 nevertheless research indicates that the attendance and accessibility of megaevents are typically restricted and the exorbitant costs associated with these events can discourage potential tourists who would otherwise be inclined to visit this is particularly evident in cases where the host city is already a popular tourist destination as evidenced by the decline in tourist arrivals during the olympic games in beijing and london which experienced a decrease of 30 and 6 respectively this situation has disadvantages for some merchants who are often involved in private tourist activities nevertheless in the context of mega events wherein there is a substantial rise in both visitor influx and overall economic activity it is quite plausible that street sellers may see a decline in their revenue for the duration of the event the reason for this phenomenon might be attributed to the significant decrease in pedestrian activity inside the city during the event additionally it is observed that affluent visitors tend to reside in the more upscale areas of the city where a substantial police presence acts as a deterrent for street sellers 9 the orchestration of large events sometimes results in the relocation of a substantial amount of economic activity which in turn adversely affects local small enterprises however it is observed that prominent vendors or renowned brands situated in affluent regions tend to attract a significant influx of income and consumer spending 18 this implies that megaevents have the potential to amplify disparities and inequities between wellestablished authorized suppliers and smaller enterprises within the industry the uneven distribution of legacies infrastructure projects associated with megaevents particularly those pertaining to transportation often serve as a significant factor in the rationale provided by local and national governments when bidding to host such events these governments assert that hosting megaevents would enhance the quality of urban life for their population 19 nevertheless the distribution of advantages and expenditures resulting from the legacy is sometimes unevenly allocated among community members infrastructure investments and the establishment of public transportation networks often exhibit a concentration in the vicinity of the event location however as indicated by the preceding analysis it is observed that lowincome populations are more likely to have been displaced to the outskirts of urban areas during the preevent stage consequently these investments do not effectively enhance accessibility for lowincome groups who persistently experience lower levels of accessibility to the facilities in comparison to middleincome groups 15 furthermore empirical research has shown that the implementation of fresh transportation infrastructure mostly enhances the accessibility of regions that are already comparatively welllinked through metro and rail networks hence attracting middleand highincome demographics who prefer to concentrate in these locations changes to urban transport networks have been shown to have a negative impact on the capacity of lowincome groups that rely on transportation to access urban services and infrastructure this exacerbates existing sociospatial disparities in terms of access to opportunities 17 gentrificationrelated indirect displacement zheng and kahn 20 argue that when the government invests in enhancing the built environment it initiates a social multiplier effect in certain urban areas this impact occurs when the environmental improvements are incorporated into increased rental prices thus leading to the development of housing and amenities in such locations the substantial and concentrated investment resulting from megaevents serves as a significant catalyst for private investment that is strategically focused on certain areas leading to the growth of the middle class the aforementioned transformation serves as a tangible representation of urban revitalization facilitating the emergence of novel residential districts that will serve as vibrant hubs of economic expansion simultaneously it contradicts the previously stated goal of providing housing assistance to those with low incomes 21 the escalation of land and property values has resulted in a corresponding rise in rental expenses rendering homes perpetually inaccessible to those with lower incomes hence rendering it financially unfeasible for this demographic 12 the subsequent ripple effect will also result in the transformation of nearby restaurants shops and other amenities into higherend establishments catering to the uppermiddle class this process will involve the closure of support services and the replacement of old businesses or social centers that previously served lowerincome groups 22 consequently those residing in the host community will experience compelled relocation from their residential areas leading to an occurrence of indirect displacement the reconstruction initiatives aimed at enhancing the physical surroundings of a megaevent do not provide improvements in the quality of life for the people of the host area instead these efforts lead to the displacement of those locals due to the process of gentrification 10 the aforementioned phenomenon is supported by the transformations observed in the newham stratford region which served as the host for the london olympics it was observed that a significant number of individuals were compelled to relocate due to their inability to meet the financial demands associated with housing and expenses in the revitalized stratford area furthermore these individuals encountered difficulties in securing employment opportunities and experienced a loss of familiarity with their former neighborhood 21 gentrification not only impacts residential areas but also entails the removal or restriction of public spaces that are meant to be accessible to all citizens consequently developers gain control over these spaces limiting access to only certain privileged groups predominantly those with financial means this transformation effectively undermines the democratic nature of these spaces rendering them exclusive rather than inclusive as an illustration the establishment of the olympic golf course on the marapendi nature reserve and park during the preparations for the olympic games in rio de janeiro entails the transfer of ownership from the state to the developer subsequent to the event the developer assumes the responsibility of transforming the park into highend residential units thereby restricting access exclusively to individuals of higher economic means consequently this exclusion permanently deprives lowincome groups of their ability to utilize and appreciate these wetlands and parks thereby exacerbating existing social disparities in spatial utilization opportunity cost and encumbrance of cost as previously mentioned it is often observed that the advantages of megaevents tend to be concentrated among already privileged sectors of the community while the less advantaged individuals incur a disproportionate penalty 2 although it might be argued that tax monies can be allocated towards programs determined by the elected government the burden of repaying debts falls disproportionately on people via taxation the expenses associated with staging megaevents are often substantial characterized by significant cost overruns that indicate a financial burden according to research findings megaevents tend to surpass their original budgets by an average of 179 nagano saw significant economic repercussions as a result of hosting the winter olympics leading to a burden on taxpayers who were required to bear debts of almost £20000 per family in order to achieve fiscal equilibrium this financial strain was particularly challenging for lowincome populations who were already facing many adversities furthermore the allocation of these public funds may have been directed towards more expansive social objectives therefore fulfilling the collective welfare of a wide range of individuals the concept of public interest the diversion of cash resulting from the depletion of these budgets inevitably reallocates resources away from other crucial social and economic initiatives including education healthcare and infrastructure this reallocation hinders the implementation of programs that may effectively foster social justice and enhance the wellbeing of marginalized populations furthermore because to the substantial financial resources at stake similar to any enterprise encompassing billions of dollars the likelihood of corruption and embezzlement is heightened throughout the building and preparatory stages of largescale events 5 additionally the political aspect of megaevents sometimes leads to the use of political power by governments in order to fulfill their aims and engage in unethical commercial endeavors hence potentially fostering corrupt behavior 22 furthermore megaevents are characterized by their limited duration necessitating the implementation of special legislation that temporarily suspends regular rules in order to streamline event organization however the lack of comprehensive and transparent regulations surrounding this process can create favorable conditions for the proliferation of corrupt practices 23 this phenomenon might result in a higher susceptibility to corruption in largescale events compared to conventional building projects the disproportionate impact on disadvantaged individuals and marginalized communities arises when corrupt politicians or civil employees engage in the misuse of public money resulting in insufficient investment in social service initiatives in the context of organizing largescale events it is seen that prominent suppliers with extensive networks and abundant resources tend to establish monopolistic practices hence intensifying the marginalization and exploitation of small enterprises moreover it is imperative for any government and its affiliated institutions to garner public trust in order for their policies and programs to thrive the presence of corruption and embezzlement can undermine the confidence in the governments capacity to tackle issues of fairness thereby impeding effective governance in addressing social inequality and exacerbating the problem of polarized inequity 24 conclusion the phenomenon of urban regeneration through the coordination of megaevents has long been regarded as a reflection of the impact of neoliberalism on global politics and economics this influence has shaped the manner in which megaevents are planned and funded often involving the infusion of capital through publicprivate partnerships 25 megaevents often employ the neoliberal framework as a means to rationalize the necessary evictions and renovations associated with them while these events effectively revitalize specific urban areas stimulate economic development and enhance the physical infrastructure within a given region 26 their marketoriented nature can lead to the displacement of marginalized individuals through housing demolitions or indirectly through the process of middleclassification consequently these individuals may experience economic displacement or in some cases bear the burdens of these events without receiving equitable access to the associated benefits initially the primary purpose of governments was to assume a regulatory and facilitative function inside the marketplace with the aim of promoting the implementation of initiatives that alleviate economic and social disparities in the realm of megaevents the convergence of free market ideology with state institutions has led to governments assuming the role of capital agents rather than regulators as they want to attain political prestige and cultivate a favorable urban image 27 undoubtedly the aforementioned phenomenon is poised to intensify economic social and geographical polarization inside urban areas thereby giving rise to heightened disparities

the article focuses on the significant economic and social impacts that largescale events such as the olympic games have on the host city they involve large financial investments affect millions of people and can strategically transform cities while these events often improve physical infrastructure they can also exacerbate inequality and displacement disadvantaged communities are often forced to relocate to make way for urban redevelopment projects associated with largescale activities employment and income inequalities may also emerge with employment opportunities benefiting mainly the middle and upper classes legacies such as infrastructure improvements are often unevenly distributed further marginalising lowincome groups they may also lead to suburbanisation and higher costs of living resulting in the displacement of residents and the exclusion of disadvantaged groups in addition megaevents can place a huge financial burden on taxpayers and are prone to corruption in short the neoliberal framework behind megaevents can contribute to the economic social and geographical polarisation of urban areas

19805_0

introduction poverty drug use and stigma are often connected poverty involves stigmatising labels drug use attracts stigmatising labels and drug use in impoverished communities compounds that stigma the empirical reality that intersecting stigmas increase marginalisation has shaped the focus of criminological research with people from disadvantaged communities while there is some degree of universal stigma associated with illicit substance use substances that are more commonly injected tend to be associated with socioeconomic deprivation and harsher criminalisation research on the stigma and criminalisation of injection drug use has understandably focussed on those more 1 3 vulnerable to the harms of the labelling process people who inject drugs in disadvantaged areas and those who belong to marginalised groups such as ethnic minorities and diverse sexualities and genders while we know that stigma leads to marginalisation its effects are mediated by the contexts in which it is produced for instance less is known about the way stigma impacts the structurally advantaged or people from communities of relative affluence this paper seeks to deepen criminological understandings of the ways in which drugrelated stigma compounds harm among the marginalised by exploring other settings where we know little about how stigma is internalised and experienced taking injection drug use in an affluent community as our object of study this research provides an opportunity to generate insights into how drugrelated stigma and criminalisation is impacted by social position background foundational concepts stigma and labelling criminological scholarship has long grappled with the roles that stigma and labelling play in matters of crime irving goffmans classic 1963 text stigma notes on the management of a spoiled identity conceived of stigma as occurring when an attribute that is deeply discrediting transforms the person who holds this attribute from a whole and usual person to a tainted discounted one in conceptualising this goffman wrote that we need a language of relationships not attributes to indicate that stigma is not about the qualities of the people who are subject to it but about the social relationships that stigmatise since goffman research on stigma has proliferated well beyond the conceptual framework he outlined and often implicitly informing contemporary public discourse and policy processes building on the concept of stigma labelling theory was formative in developing the sociology of deviance and the tradition of critical criminology that emerged out of it for criminology labelling is stigma in action it takes stigma as its starting point and elaborates on the processes that spoil identity articulating how criminal legal institutions are essential in such processes labelling theory was also influential in shifting the epistemological and ontological frameworks utilised in criminology in howard beckers classic book outsiders studies in the sociology of deviance he makes the case that deviance and by extension crime is not a quality of the person who commits it or even of the act itself but rather a social process in which such labels are selectively applied this conceptualisation has had a significant impact on the field by highlighting the social construction of crime which has no underlying ontological reality for becker and the labelling theorists that followed the observation that stigmatising labels are applied unevenly in society was cause for a major shift in criminological theory away from matters of criminogenesis and towards social responses to crime this conceptual shift had a significant impact on the way social science scholarship approached drug use with qualitative traditions of the sociology of deviance entering an appreciative turn in drug research since the introduction of the labelling perspective social science scholarship on drug use has tended to start from the position that the criminalisation of drug use is unevenly applied across racial and class lines a classic example is the legal distinction between powder and crack cocaine in the 1 3 usa despite being chemically similar crack cocaine use is more prevalent in black and impoverished neighbourhoods and has historically attracted significantly harsher penalties infamously referred to as the 100to1 disparity the penalties for crackpowder cocaine have been criticised as unsound in theory and racially discriminatory in practice much drugs scholarship has since focussed on how the surveillance and thus concentrated labelling of disadvantaged communities produces harmful stigma notes on stigma labelling and power given the long history of the concepts of stigma and labelling in criminology there has been much commentary on the limitations of these concepts which has emphasised the importance of acknowledging the role of power for example early stigma scholarship was challenged on the grounds that it did not include the voices of those who experienced stigma and that the concept was deployed in a highly individualised way the analysis of individualised adaptations to stigma has become a bedded down feature of the more instrumental version of the concept used in contemporary criminological literature lived experience forms a growing part of qualitative traditions of drug research but remains sidelined in mainstream and positivist accounts of stigma related to issues like mental health disability and criminal selfconcept as tyler and slater have observed the conceptual understanding of stigma inherited from goffman along with the use of microsociological andor psychological research methods in stigma research often sidelines questions about where stigma is produced by whom and for what purposes in the case of drug use criminological research has broadly conceived of stigma as deriving from the attributes of individuals and has focussed on how communities respond to stigmabut fails to address the processes that produce drugrelated stigma such as the harms of prohibition the impacts of colonial violence and the carceral logic associated with it parker and aggleton have argued that research on stigma needs to ask social and political questions about how people are stigmatised and the uneven harms that this eventuates or as link and phelan have noted for stigmatisation to occur power must be exercised in responding to such questions fraser and colleagues have also argued that drugrelated stigma is a contingent biopolitically performative process rather than as a stable marker of some kind of anterior difference though labelling theory is appreciative of the position of those deemed deviant it rarely challenges the category of the deviant per se the theory questions the way institutions construct people as deviant but has not engaged in a robust assessment of whether that construction is ethical or justifiable in terms of people who inject drugs the labelling process has clearly demonstrated impacts in both marginalising people from mainstream society and in making them vulnerable to being targeted by the criminal legal system what this literature has not done is challenge the framing of the criminalisation of people who inject drugs as a legitimate response to drugrelated harm in short labelling theory tends not to articulate the ways in which the labelling process and the stigma it attracts can be violent and harm generating inandof itself nor does it provide a robust account of how political and power structures are implicated in the harms caused by social responses that construct drug use as crime research on stigma and labelling stigma and labelling have been influential in the development of a contemporary research agenda in criminology that has focussed on the impact of the degradation of the selfconcept of people on the margins this is especially so in drug research with the stigma and labelling of people who use drugs informing large bodies of research with implications for policing and criminal justice as well as relevant research in psychology public health and public policy for example healthoriented research on drug use has found that forms of shaming and associated internalised stigma social rejection and discrimination contribute to the compromised health status of people who inject drugs and impede the uptake of health and social services fears about bloodborne virus transmission by people who inject drugs can also further the criminalisation process and exacerbate stigma which feeds upon strengthens and reproduces existing inequalities of class race gender and sexuality however for the most part contemporary literature on drug use and criminal justice tends to address stigma in a more instrumental way seeing it as a general mark of disgrace that results in forms of social rejection or stereotyping in criminological research on drug use stigma is often presented as a less harsh alternative than formal sanctions or punishment by the state this includes studies that assess stigma as a control factor in drug use at the neighbourhood level and which conclude that the gain of social stigma could not be marked as negative unambiguously in crime policy literature stigma is assumed to act as a form of informal social control that reduces drug use and associated crime in policing scholarship stigma remains central to the supposed deterrent effect of an increased movement towards securitisation and surveillance although stigma tends to be treated as benign in the literature outlined above criminological research on drug use is consistent in finding that stigmatising already marginalised communities is unequivocally harmful our paper draws on observations from intersectional feminism critical race theory and critical drugs scholarship to respond to the limitations of stigma and labelling in contemporary criminological accounts methodology research design as part of this research the first author conducted 18 interviews with people who inject drugs in the affluent beachside suburban setting of the northern beaches of sydney known locally as the beaches fieldwork began in may 2020 and lasted for 6 months including being based one day a week at a local needle and syringe programme participants were recruited by responding to flyers posted on community message boards and at local transport hubs as well as warm approaches by nsp staff and snowballing from existing participants with one referral by a local mental health professional fieldwork was brought to a close once the data reached saturation and further interviews did not generate new information or insights related to the research questions participants were remunerated au 40 interviews were transcribed verbatim and transcripts were analysed by thematic content through a combination of preliminary and close readings ethical approval for the study was provided by the unsw human ethics research committee further details on the methodology are described in a previous publication entering a suburban drug scene located on the eastern coastline of sydney the northern beaches are north of the sydney cbd starting a short distance from the citys iconic harbour bridge the area covers approximately 30 kms of beach and coastal suburbs populated by an often insular largely white middleclass community doing research on injection drug use in this setting brought with it particular conditions that have implications for the findings there was a tension between the reputation of the area as wealthy and the research subject matter which is often associated with innercity and disadvantaged communities for example one interview took place on the beachfront of a popular nighttime entertainment district which at the time of interview was bustling from the foottraffic of local restaurants however during the interview the participant pointed to a spot only a few hundred metres away where he and others frequently slept rough outside an overcrowded social housing building findings and discussion this research involved a total of 18 participants 11 men and 7 women ranging between the ages of 26 and 67 with a median age of 485 years the vast majority of participants indicated that they grew up in families of relative wealth even if that did not quite translate to how they would characterise their adult life grew up with a silver spoon in my mouth but it ended up the nose participants came from a mix of uppermiddle and lowermiddleclass families some from european migrant aspirational families as well as two participants whose families struggled with money and periodically relied on social support payments wealth and the moral value that was ascribed to it played a central role in constituting the stigma that people who inject drugs in the area experience as well as the labels that stuck as a result i come from a good family stigma and injecting on the beaches the first interview was with darko a middleaged man in his midfifties whose parents had migrated from the former yugoslavia to sydney when he was very young darko was mild mannered and articulate if not a little nervous during the interview darko began by explaining what the beaches was like then saying growing up you know especially in the 80s you know life was quite free you know and it was abundant… and as a teenager… you experiment he went on to explain that while experimentation with drugs was decidedly normal on the beaches experimentation with heroin was much less accepted but powder heroin was always i guess looked upon as voodoo in explaining his drug use darko drew a figurative line between the beaches and the innercity which also functioned as an explanation for the lines he felt he crossed when he was using drugs in kings cross i had crossed a thin red line his move to kings cross and initiation to injection drug use were intimately intertwined it was when i started injecting thats when things changed you know… i wanted to get over the bridge i wanted to experience kings cross darkos description of how he began injecting drugs was also contextualised by discussion of his family background which he said was not consistent with the common stereotype of people who inject drugs i grew up you know in a good family i grew up with morals and values… and with addictionslowly but surely those morals and values get stripped away you know ive become morally bankrupt addiction it took me into the gutter in emphasising that he had access to the freedoms that the northern beaches afforded and was part of a respectable family darko felt that by injecting drugs he had squandered the good life he was born into this is a life that his high school friends and others on the beaches also had access to and freely indulged in but they were able to control it darkos story illustrates how the stigma of injection drug use was framed by participants as a kind of fall from grace among the sample injection drug use was seen to undermine the respectability of the family and this was a strong source of selfdoubt and blame the events that stuck out in the minds of many participants as being associated with shame also involved family members finding out that they used drugs for example pam recalled the following i was pulled over and i had mum in the car and the police officer didnt know me as such id never met or seen that police officer before but as soon as as he said put your name in all these things come up and they police officers came back with my licence and said taken any drugs today and mum knew participants also explained that the beaches was a wealthy area and that the accumulation of wealth was seen as the primary way to define what a successful life looks like this was reinforced by the middleclass status of the families that many participants grew up in basically the beaches are driven by success and to use heroin means youre unsuccessful in most peoples eyes the high standard for financial success in the beaches was one that participants uniformly felt unable to meet and this became a source of stigma definitely a lot of guilt and a lot of shame around it our findings extend on research about how those who live otherwise conventional and lawabiding lives avoid stigmatising drugrelated labels by relying on structural factors to aid in concealing stigmatising attributes and protect against status loss acts of injecting visible markers or signs of injecting drug use and the social interactions to obtain drugs and injecting equipment may be concealed through use of private settings and other impression management strategies however our participants described neither fully conventional lives nor fully marginal lives when injecting on the beaches while participants experienced stigma from family members around injection drug use they continued to receive support from family including emotional support and most were able to maintain financial and housing stability though participants could all recall instances of stigmatising treatment at local health services this was not regarded as the norm nor seen as a barrier to accessing health services in short our participants were subject to stigma but not the kind of stigma that is 1 3 totalising in its degradation of selfconcept in the terminology of the sociology of deviance the internalised stigma that our participants experienced did not involve the kind of labels that necessitate an escalation or amplification of a criminal selfconcept im not even a fucking junkie how class protects against the labelling process as outlined above participants did experience harmful forms of stigma however stigma associated with crime was actively resisted by participants who rarely thought of themselves as junkies in fact most actively distanced themselves from the label for example seb a 30yearold selfdescribed surfer dude whose parents used to inject drugs fiercely contested the label of junkie i had some old guy just step on me… i was like oh help and he was like fucking junkie and just stepped on me and i was like im not even a fucking junkie other participants were less forthright but still made efforts to distance themselves from the popular image of the junkie in describing themselves i dont look like you know the walking dead you know how you see real hardcore users and theyre skin and bone and theyve got scabs that they pick… fucking talking to themselves in public and that you know like im not like that so people that dont know me they dont know unless i tell them ive never been a junkie ive been a drug addict but ive never been a junkie participants often made distinctions between themselves and other people who use drugs by describing practices they did not engage in as junkie behaviour while many participants felt as though they had crossed a line by injecting drugs and this was a source of stigma they also qualified that injecting drugs only caused harm to themselves rather than directly harming others in their family or community im not acting crazy or just rushing too hard each participant drew the line differently some saying they would not for example sell drugs engage in any nondrugrelated crime would not steal would not engage in sex work and so on while people who inject drugs often distance themselves from terms like junkie and draw lines that they would not cross many of the distinctions made by our participants explicitly invoked their class position participants described how being from good neighbourhoods and families protected them from crossing lines that they saw as characterising the worst kind of drug user some participants even made explicit mention of the beaches itself in making such distinctions saying that the area is not seen as home to that kind of drug user like around here its not as rough as it can be out west and shit where junkies are looked at as scum and people who smoke ice are also junkie scum… the junkie places are out west other participants described drug use on the beaches as more civilised even for the three participants who did identify as junkies this was qualified for example sean explained that he only saw himself in this way when he injected drugs actually i think of myself as a junkie if im just using a needle… every time ive ever used one i do think that word comes into my mind in another example john made a point of showing his son that there are people who are worse than him ive shown him really bad junkies for sean his status as junkie was temporary and fleeting and while john left open the question of his status as a junkie he did so by placing the question in comparison to other people who are more far gone than he as a physical location the beaches provides proximity to mainstream society and a respectable selfconcept in participant accounts movement away from the beaches was almost exclusively associated with a deterioration in selfconceptinitiation to injecting in kings cross police harassment in the innercity and accessing the more visible drug markets in the outer suburbs of sydney however movement towards the beaches was almost exclusively associated with a restoration of positive selfconceptderived from external factors such as low levels of police contact uptake of services more stable housing less exposure to crime and being near family proximity to the beaches informs the distance participants place between themselves and those who occupied the worst elements of the stereotypical world in which injection drug use is part of a nexus involving crime and other stigmatised behaviours ive been offered decent money to have sex on being a woman who injects drugs on the beaches despite the way the classed status of the beaches was used to resist stigmatising labels and protected against the loss of family as a form of economic safetynet and housing stability the stigma and labelling participants experienced also depended on other elements of social position for instance the women in our sample had to contend with a range of gendered forms of stigma including the way women who inject drugs are viewed by people on the northern beaches pams story illustrates the tension between the affluence of the area and the gendered precarity of women who inject drugs pam was a 46yearold former professional athlete who had a successful career travelling the world until she experienced a back injury that derailed her participation in the sport for several years as someone who could claim to have at one point in her life lived up to the professional and financial success that defines the cultural milieu of the beaches pam was particularly conscious of how her status as a person who injects drugs was a topic of gossip on the beaches in discussing her experiences of stigma pam spoke a lot about how members of the beaches community viewed her things get around even without you knowing the people even sometimes for women in our sample including pam their class status was used to resist the compounding stigma experienced by women who inject drugs for example having a good credit rating from her previous career and investments meant pam had more options than most for navigating the precarious circumstances that women who inject drugs often experience ive been offered decent money to have sex with somebody no chance… no ill be alright ill get some money from somewhere despite being decriminalised for nearly thirty years in nsw sex work is still subject to stigma and often conflated with drug use particularly for women the ability to avoid sex work and property crime had a profound impact on her sense of self i still have a little bit of respect for myself… i kind of try to keep a little bit of selfesteem and respect 1 3 otherwise i cant really look in the mirror with too much respect this was a common refrain among women in the study these findings are consistent with previous research on women who inject drugs and the way they emphasise personal agency in resisting drugrelated stigma in our sample women were conscious of the class status that accompanied living on the beaches and the licence it provided them to make choices that free them from narrowly deviant or criminal selfconcepts and spoke about this as useful in resisting stigmatising ideas around drug use and femininity its just about colour on not being white on the beaches according to the most recent census the northern beaches is predominantly white with the most common ancestries being english nonindigenous australian irish and scottish despite this there was very little discussion of the racial profile of the area among participants this is consistent with classic accounts of critical whiteness studies which articulate how whiteness is normalised to the point that it is invisible to white subjects and those who benefit from whiteness as a system of power this was generally reflected in the sample which was predominately white there are also ways to analyse the performativity of whiteness in participant accounts for example a third of the participants had european migrant backgrounds though most presented visually as white and seemed practiced at performing proximity or deference to whitenessthis included boasting about attending largely white private schools with excellent reputations wearing collared shirts to casual occasions such as an interview with the researcher and so on participant narratives also involved ubiquitous references to being aussie when referencing white and european culture references to good families and civilised drug use can also be read as coded references to middleclass whiteness there were only two participants who did not present visually or in their accounts as white the first was darko introduced earlier who was clear about the whiteness of the area and the ways in which he stood out im a brown nonblueeyed nonblondehaired you know they look at me as though im ethnic sort of thing and they are probably thinking why isnt he out west with the rest of the brownies you know what i mean indeed the two nonwhite participants in our study tended to find themselves using the protective elements of the northern beaches bubble to contend with the compounding stigma associated with the outsider status that comes with not being white in an area of white affluence as outlined below the nonwhite participants used the status of the beaches as a good place to develop strategies to blend in however it was the ways in which gender race and class intersected that provided the most significant examples of stigma in our sample the other participant who identified as nonwhite was a 43yearold woman named moran the only koori or aboriginal woman in the study moran was a warm and welcoming person with a curious analytical mind and a subdued laugh unlike the vast majority of participants moran had been arrested many times over while living on the beaches contact ive had with them cops on the beaches whenever i get out of prison they are straight on to me they want me off the street this involved many known tactics of police that target aboriginal people for example the overzealous policing of petty offences like offensive language is notorious among aboriginal communities this often produces confrontations about the legitimacy of the charge resulting in further charges such as resisting arrest and assaulting police referred to as trifecta charges and charge stacking i think they do it lay charges knowing that the judge will look at it like im koori and that i will get locked up and they know that i think thats why when i get one charge they throw 10 like backup charges and justreally theres no need but there is a need because they know theyll get me off the street and thats what they want moran went on to observe that the capacity for her to be visually identified as an indigenous woman was what most targeted her its just about colour they dont have that many kooris over here to deal with were still treated as second class citizens to a point other than being targeted by police the greatest source of stigma for moran came from when her children were removed by the state child removal is a key marker of ongoing colonial violence in australia and a common source of stigma among women who inject drugs in recalling her history of drug use moran reflected i stopped for 12 years i was still on methadone but i stopped all illicit drugs and had my family had my kids and then yes after they were taken i just couldnt deal with it and i got into ice and that was daily she also went on to articulate the removal of her children as something that she experienced as compromising her femininity i have four children but i dont have access to them theyre with docs family services department and thats extremely punishing because theyre my children and being a woman thats what youre supposed to do in life procreate and have your own children and having that taken from you is definitely a hit below the belt so thats where a lot of my drug use has stemmed from here is it worth noting that child removal involves overlapping and compounding forms of stigma for moran having her children taken away was experienced as a mark of shame on her credentials as a mother but also on her capacity to control her drug use the criminalisation of her blakness and a continuation of intergenerational trauma emblematic of colonial violence from historical child removal policies to contemporary issues in the outofhomecare system importantly moran noted that moving to the beaches was one way she attempted to control her drug use and to therefore place herself in a better position to get access to her children again and then i moved away from mount druitt back over to my mums on the northern beaches sensing that the topics of being targeted by police and having her children taken away are emotionally taxing to discuss at this point the first author suggested pausing the interview but moran insisted there was no need reflecting thats ok… unfortunately ive had the privilege of talking about my life story over and over and over and over only because of going into custody every time you go they want to know your life story for moran explaining her move to the beaches to state authorities as a conscious and active choice to move away from stigmatised categories such as being a westie and being aboriginal was a survival mechanism she sought to perform proximity to the white middleclass culture of the beaches as a way to appear redeemed in the eyes of institutions that continue to exact intersecting forms of violence on her indigeneity and her status as a mother and a drug user in fact she was so used to rehearsing her story as someone who had escaped western sydney and apparent indigenous dysfunction that she is numb to it ive become very numb to that now to my story it doesnt even feel like mine sometimes morans example is illustrative of sociological stigma work which has articulated how race and ethnicity are not just individual attributes but cultural categories that shape the distribution of stigma and the institutional consequences that flow from it as boyd and colleagues note gendered classed and racialized stratifications… influence and are influenced by drug policies and practices that subject women to formal and informal regulation our analysis here articulates how injectingrelated stigma is constituted in intersectional ways even in the context of people who ostensibly occupy at least one element of structural advantage he was a nice bloke that cop how white masculinity protects against the labelling process unlike the way in which women and nonwhite participants tended to use the protective elements of the northern beaches culture to contend with compounding stigma for white male participants middleclass masculinity acted as protective many of their accounts were inflected by a blokey sense of being well connected among other white males with the clearest example of this in descriptions of their interactions with police it is well established that the stigma associated with the criminalisation of people who inject drugs can damage positive selfconcept act as a barrier to accessing health services and result in violence by police yet in detailed conversations about police interactions with male participants it was clear that they were often able to leverage notions of white and middleclass masculinity to appear familiar and less threatening to police on the beaches in one instance shane a 65yearold participant recalled negotiating his way out of being charged and arrested for stalking and harassing his exgirlfriend by striking up an impromptu connection with a young male police officer after shane heard that his expartner had started a new relationship he went to her apartment to find out if this was true explaining that i hadnt spoken to her for about 20 days or something and that silent treatment was killing me it was sending me nuts as the situation escalated the police were called on arrival a young male officer struck up a friendly exchange with shane he pulled me aside and said look mate he said what the fuck are you taking he said we all like to party a bit mate… you look like youve overdone it a wee bit how many days have you been awake they went on to have conversations about mutual friends and even bonded over the perceived plight of having girlfriends not speak to them hes just gone mate i can understand he said its the silent treatment… i know people doing life because of the silent treatment the officer then took the step of advocating that shane not be charged by attempting to convince his expartner to not make a statement he went to bat he was great… went in there and said… look if you make a statement hes going to get arrested if you dont make a statement hell get medical care like ill sect 20 him and take him up to the hospital rather than being arrested shane was sent up to the hospital and just blood tests and what have you despite a generally combative relationship with police white male participants also recalled instances when they have found common ground with officers hes a pretty good bloke actually these accounts of fleeting but friendly bonding with officers often involved some degree of redemption of the police in the minds of male participants having been mistreated by police when living in the innercity several white male participants indicated that the police on the beaches were different here all the cops know you so they know what kind of nature you are and stuff… while maybe elsewhere they might be more threatened by you in another example devon noted that i used to have some cops that really had it in for me but went on to explain that he had been able to renegotiate his relationship with police by bonding over the music he played as a busker at a popular beachside wharf recalling i think they actually like the music… i sort of rely on them now you know to keep people away from me when im trying to busk in these examples we see how the small world or bubble of the beaches was amplified by moments of masculine bonding in ways that often transcended the harsh edges of stigma and in particular the labelling process while women and nonwhite participants in our study were able to leverage the status on the northern beaches for better relations with the police this was especially so in interactions between white male participants and male police officers in the area conclusion our paper has demonstrated how structural advantage in one element of social positionality interacts with and augments the production of stigma and the forms of power that constitute labels applied to people who inject drugs our findings indicate that class status is constitutive of injecting stigma in affluent communities the sense of guilt and shame that participants associated with injecting drugs was largely based on the perception that injecting brought the good family name into question and that they were not living up to familial and cultural expectations of financial success yet for our participants the class status of the beaches is both the benchmark by which stigma was enacted and a possible source of redemption participants positioned their drug use as civilised expressed pride in not relying on crime including theft from their families to manage their drug use and pointed to the western suburbs of sydney as exemplars of the link between drug use and crime our findings extend criminological research about how the capacity to resist criminal labels among people who use drugs is structured by intersections between gender race and class critical criminology has always engaged with the way race structures processes of criminalisation and in australia the discipline has only recently begun to conceptualise the role of the settler colonial state in the criminalisation process the accounts presented here extend these arguments by demonstrating how injectingrelated stigma and labelling compounds harm when it is applied for example to women of colour in affluentas well as in economically disadvantaged communities lastly our research found that intersectional positionality can act as cumulative in the protective status it provides to the structurally advantaged our study found that white male participants experienced their status and that of the area they lived in as protective of publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

criminological scholarship has long grappled with the roles that stigma and labelling play in drug use in disadvantaged communities while stigma leads to marginalisation less is known about the way stigma impacts the structurally advantaged or those from communities of relative affluence our research involved fieldwork and 18 qualitative interviews with people who inject drugs in the affluent coastal community of sydneys northern beaches we find that even when people occupy the ideal class position internalised stigma was present but did not readily translate into labels involving a criminal selfconcept we also found that while the capacity to resist crimerelated labelling processes and other forms of state intervention were limited by social positionality some participants still had to contend with intersecting forms of gendered and racialized stigma however for white male participants their status and that of the area were experienced as protective of their criminalisation actively limiting criminal labelling processes

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introduction university students are regarded as a readily available market segment for public transport riding buses allows students to travel on a budget while engaging in some physical exercise in the form of walking or cycling at the start andor or end of their trips among planners the hope if not the expectation is that students reliance on public transport will keep campus environments clean and green it will reduce parking demand and congestion around campuses and finally it will help young people form lifelong sustainable travel habits 3 in hanoi as elsewhere students constitute a large portion of bus users most use discounted monthly passes which are quite affordable 1 while the overall bus modal share in the vietnamese capital is only 79 percent student passengers account for more than a third of bus trips their contribution to public transport patronage became clearer in 2020 at the outset of the covid19 pandemic when university closures were mandated at the start of the year bus ridership fell from 27 million in january to 19 in february and 16 in march once the national lockdown ended and students returned to facetoface classes in may bus ridership spiked to 19 million it kept growing but never returned to prepandemic levels in october 2020 it had just reached 25 millionnearly 2 million short of january 2020 levels that suggests that one portion of student riders did not came back at least not yet through a survey of more than 800 students in seven higher education institutions this study aims to find out why some hanoi students resumed bus ridership after the covid19 lockdown while others were lost to this mode is the fear of infection a key factor here or have there been other reasons leading to particular choices with regard to public transport use are there gender differences in travel behaviours and preferences among students and what drives those differences might service improvements persuade some students to return to public transport these questions are important not only for hanoiwhere the local peoples committee has made it a priority to attract and retain students among public transport usersbut also for other cities in southeast asia and beyond students use of public transport is fig 1 bus ridership along the pandemic timeline poorly understood elsewhere too in particular we know little about the reasons why students might stop using bus services studies focused on university campuses tend to combine data for students and staff or they take a snapshot of the modal split at one point in time rather than considering modal shifts over timefor example from public buses to private motorcycles or cars some studies only examine students stated preferences and intentions around public transport which may not translate into actual behaviour no existing studies on the modal choices of students have estimated the gender differences in the effects of variables given these research gaps the findings from this study will be useful outside hanoi and vietnam by way of context hanoi is a typical global south megacity in terms of transport and landuse issues as a higher education hub it attracts numerous students from all over vietnam out of 8 million inhabitants nearly 600000 are students attending 78 universities and colleges most of these are located in urban districts where access is relatively easy daily travel in hanoi is largely based on motorcycles with ownership estimated at 776 motorcycles1000 inhabitants automobile ownership is low but on the rise it currently stands at 60 cars per 1000 inhabitants 2 cycling is a marginal mode mainly used by children adults mostly consider it as recreation the public transport system comprises more than 100 formal bus routes which are subsidised by the public sector while this number sounds high it is inadequate for a megacity like hanoi most bus vehicles are conventional cng buses operate only along four routes one brt corridor was built in 2017 and two urban rail lines are currently under construction andor testing another major improvement comes in the form of a pilot program which added electric buses along ten routes this program was officially launched in the second half of 2021 the electric busesproduced and operated by vinbus a newly established local companyare new and comfortable and emit no noise or air pollution free wifi is provided on board buses are equipped with cameras which allow drivers to better control the interior and exterior of the vehicle drivers themselves are under camera surveillance as well in order to avoid risky driving and ensure courteous behaviour towards passengers however the electric buses run along the existing road infrastructure which is shared with cars and motorcycles no segregated busways have been planned so far the study was conducted in this changing environment on the one hand the risk of catching covid19 in crowded buses may have pushed some students away from public transport perhaps forever on the other hand the prospect of riding on modern and clean electric buses may lure some students back to public transport or keep them from leaving prior to discussing the empirical portion of the study we set forth the theoretical framework that guided the research theoretical framework students tend to use public transport more than other population segments however car use is quite popular among this group too for example the car vs transit modal split is 4131 percent at the university of california at los angeles us 2533 percent at iowa state university us 2024 percent at mcmaster university canada and 3928 percent in various british and irish universities the car offers both practical and symbolic advantages many north american cities are set up so that drivingas opposed to riding a bus or a trainprovides more independence flexibility speed protection from crime weather and prying eyes to some motorists driving also equates with freedom excitement identity and social status in the global north the rise of the urbane and environmentally conscious millennial generation has kindled hope that automobilebased travel will be reduced and a shift to pt will occur some studies have even reported the emergence of the carfree a class of people who choose to give up car ownership altogether cities have sought to facilitate these transitions by expanding transit coverage and adopting a range of other sustainable transport policies and tools including reduced transit fares for students congestion charging in inner cities parking caps in new developments and maas apps some cities have experimented with free public transport yet cars have remained a favourite choice among millennials based in the global north car travel dominates even more in global south cities for example in beirut lebanon a city of 2 million the overall share of formal public transport use among students is only 10 percent it is less than 3 percent in danang vietnam a city of 1 million 3 among youth in less developed cities car ownership is a key life aspiration the rest of the population uses cars or motorcycles for urban travel this is unsurprising considering the poor quality and erratic nature of public transport services in much of asia africa and latin america it is only in cities with superior brt systems such as curitiba or bogotá that the share of transit use surpasses 50 percent among students but even here car use is popular besides the quality of public transport and the attachment to automobility what other variables determine bus ridership among university students a review of the relevant literature reveals the following three groups of variables which can push students to or pull students from public transport sociodemographic variables findings from existing studies are highly contradictory evidence from norway and mexico suggests that female students are more inclined to use public transport in contrast a study set in lebanon shows that male students are more likely to use public transport studies set in the us vietnam thailand and the philippines find that gender is unrelated to public transport use among students similar contradictions are evident with respect to income in lebanon the us and mexico higherincome students are less likely to travel by bus whereas in vietnam income is irrelevant the role of living arrangements is not clear either in one study these are not significant whereas other studies find that students who live with their families as opposed to living alone or with housemates are more likely to use public transport a clearer finding is that bus use decreases over the years spent at university freshers are more likely to rely on public transport compared to seniors who gradually shift to the car or motorcycle in fact vehicle ownership either of a motorcycle or a car is associated with lower public transport use having a parttime job while studying may also affect ones travel modes for a variety of reasons but this variable has not been tested until now environmental variables the term environment is used here to denote the natural built and policy environment climate and weather conditions are known to affect travel mode choices in cities with very cold winters andor very hot summers carless students may limit their bus ridership to the season with increment weather and switch to cycling scootering and even walking the rest of the time an urban setting with a high street density appears to be more conducive to public transport use among students however where the inner cities are derelict and bus vehicles are poor students shun those more so than in suburban and rural areas the homeuniversity commute distance leads to more bus ridership among students in brazil and colombia some parts of the us but is not a significant variable in vietnam and other parts of the us procar transport policies such as free parking at university campuses lead to more driving whereas carrot measures such as free or discounted transit passes for students lead to more bus use in addition variables such as low population densities and excessive urban roads widths may disincentivise public transport use but these have not been examined in the existing literature on student mode choice psychological variables these comprise a wide array of perceptions around public transport including safety convenience comfort access cost environmental friendliness and utility typically measured on a likert scale perceptions can determine both students choice and intention to use public transport as with sociodemographic and environmental factors the significant variables vary by research setting and design a study set in thailand vietnam and indonesia finds that environmental friendliness and safety are crucial here vietnamese students in particular care about travel convenience and speed similarly studies from qatar belgium and norway highlight the importance of bus reliability frequency and access as well as drivers behaviour and security onboard and at bus stops a common crime in public transport is pickpocketing sexual harassment is prevalent too albeit underreported women are more concerned with security and sexual harassment and consequently tend to avoid taking buses alone after dark or quit using public transport altogether 3 in addition to the variables above which play a role under normal circumstances public transport use is also affected by major disruptions which impact entire cities and societies rather than select individuals or population subgroups these disruptions can be positive or negative natural disasters including epidemics are negative disruptors that tend to reduce public transport use on the other hand technological innovations such as maas apps or brt can be positive disruptors that spur transit ridership in the case of hanoi recent disruptors have included the covid19 pandemic and the launch of electric buses on select routes we combined these two disruptors with most of the sociodemographic environmental and psychological variables reported as significant in the literature to formulate our theoretical framework 4 while our analysis is based on data reduction and regression this framework paves the way for more powerful statistical tools in future studies such as structural equation modelling based on existing models such as goaldirected behaviour or theory of planned behaviour plus habit data and analysis this study employs primary data collected in may 2021 via a structured survey designed to examine students behaviours and attitudes around public transport to provide some context hanoi universities shifted to online learning in april 2020 as the city went into its first lockdown due to the covid19 pandemic thereafter infection rates fell considerably in hanoi university activities returned to normal and proceeded as such until may 2021 when the capital of vietnam experienced a resurge of covid19 cases at that point university activities shifted online once again the survey was conducted during that time the first part of the survey collected sociodemographic and environmental data including gender age year of studies employment status residential district living fig 2 theoretical framework arrangements homeuniversity distance and vehicle ownership 5 the second part collected travel behaviour data including the main commute mode to university and the frequency of bus use respondents who did not commute by bus were asked whether they had shifted from the bus to another mode during the year preceding the survey the third part of the survey contained a series of attitudinal statements measured on a 7point likert scale which explored the potential reasons for choosing or quitting bus transport these statements were derived from the literature and constituted the psychological variables in our theoretical framework 6 the effects on bus use of the two disruptorscovid19 and the launch of electric buses were measured through several attitudinal statements around the fear of infection and a binary question on the intention to return to riding buses once electric vehicles became available the survey was administered online through google forms with all the questions marked as mandatory the questionnaire was pretested with twenty students and upon validation a link was sent to the students of six universities and one college hanoi university of mining and geology national university of civil engineering university of transport and communications hanoi architectural university phuong dong university hanoi university of industry and hanoi college of commerce and tourism all but pdu are public hau humg and haui are located near the urban edge whereas the rest are in rather central locations these institutions were selected in order to achieve an even distribution of campuses across the urban districts however this choice has a shortcoming excluding students in certain fig 3 research area disciplines such as health and law for example may introduce a bias in the sample in total 862 responses were received which constituted a representative sample of these responses 29 were eliminated as unreliable thus the sample was reduced to 833 responses of these 249 respondents had always used a commute mode other than the bus and were therefore set aside the final sample consisted of 584 responses eligible for inclusion in the study these responses were provided by students who either used buses currently or had used them in the past but quit in the year preceding the survey it is difficult to determine whether this sample is representative because the populations of students who are current bus users and former bus users are unknown to combine the observable variables and unobservable variables we employed a hybrid method in a first step we identified the latent variables by reducing the 23 attitudinal statements into 7 constructs then single factor scores were estimated for each construct which could be used in a model given that the attitudinal statements we used were derived from different studies rather than a standardised questionnaire we applied exploratory factor analysis instead of confirmatory factor analysis the results of the bartletts test of sphericity and the kaisermeyerolkin measure of sampling adequacy confirmed that the use of efa was appropriate subsequently two binary logit models were fitted to evaluate the effects of sociodemographic environmental and psychological variables and the two disruptors on bus ridership model 1 included the entire sample female students were expected to experience a different set of issues to male students therefore interactions between gender and the remaining variables were added model 1 model 2 considered only former bus users because all interactions were not significant in model 2 they were removed to diagnose the risk of multicollinearity we estimated pairwise correlations between the independent variables all the coefficients were either not significant or weakie with values smaller than 04 the pseudo r 2 value of the first model which focused on past and current behaviour fell within the recommend range 0204 model 2 which measured future intentions had a lower but still acceptable pseudo r 2 of 01304 all the statistical analyses were carried out in stata 150 findings and discussion the findings are reported in three parts descriptive statistics factor analysis and regression analysis table 1 presents the key characteristics of the study sample as seen the distributions by gender and year of study were balanced overall incomes were relatively low with more than three fourths of respondents coming from households earning less than us 550 per month 7 more than half of the students in particular women 1 3 worked parttime to support themselves while studying the vast majority of respondents lived in urban districts 25 km away from their university and shared rental accommodations with roommates 8overall 52 percent of the respondents had stopped riding buses in the previous year those tended to be male and older students they had parttime jobs and were more likely to own motorcycles on the positive side more than half of the quitters intended to return to bus transport once electrical buses were introduced this finding supports the view that youth have more proenvironmental attitudes than older adults other the other disruptor the launch of electric buses was measured through a binary question and therefore is not included here 1 3 studies have similarly found that where public transport is regarded as more environmentally friendly it is more likely to be patronised the application of exploratory factor analysis to the survey responses generated seven constructs or factors convenience theft risk sexual harassment risk bus staff behaviour reliability and health image and status and covid19 risk these factors accounted for 74 percent of the total variance underlying the 23 attitudinal items in the survey women were much more concerned about sexual harassment risk as well as and image and status compared to men conversely women did not care as much as men about reliability and health the first model confirmed that gender was irrelevant in the decision to stop using buses this result contradicts previous reports that women including students are the most loyal bus users despite their more complex travel needs and the risk of harassment they face on public transport similar to peers in other developing cities hanoi freshers and sophomores were more likely to rely on buses relative to juniors and seniors there are a few plausible explanations for this finding students who come from rural areas and smaller towns are accustomed to lowerquality public transport services at home hanois bus system while not at the level of tokyos or seouls is considered the best in vietnam surpassing even ho chi minh citys hence its attraction among younger students as the novelty wears off and students start getting jobs and internships in their last few years of study public transport no longer caters to their needs and wants and they shift to other travel modes also once students are more familiar with hanoi some move choosing to live farther from the university but in betterequipped and cheaper accommodation in this study students who lived the closest to their university were the most likely bus users this finding can be interpreted in several ways for one female students who are the most frequent bus users tend to live closer to their university than male students bus reliability decreases over longer distances while the time spent on board increases the score of each psychological variable was estimated by summing the product the factor scores and the standardized values of the indicators which belonged to that psychological variable this score was then used in models 1 and 2 † usd1 22500 vnd ‡factor extracted through efa p 005 p 01 ns not significant na not applicable variables in model 2 all the interactions between gender and other variables were not significant and therefore were removed given that men value convenience more highly these factors may lead them to give up bus ridership at the same time travelling by motorcycle or even by car over long distances in hanoi is tiring risky and enervating it may be that male students are more prepared to battle the congestion pollution and noise in the city living arrangements were not a predictor of the shift from buses to other modes this may be because in either case hanoi students have access to the same modes they can take the bus or borrow a motorcycle from their roommates siblings or parents if needed studies set in north america have found that students who live with their families are more likely to ride buses than those who live with roommates this may be simply due to lower spending power among students who have chosen to attend university in their hometown returning to our findings higher household incomes private motorcycle ownership and parttime employment all increased the odds of students quitting public transport other studies set in vietnam have pointed to the same issue an increase in motorcycle ownership is associated with a decrease in bus use among students students purchase motorcycles not only for their own transport but also as a means of earning some income by joining appbased mototaxi services conversely those students who work while attending university tend to have more complex schedules throughout the day which cannot be followed using unreliable lowfrequency trunkline bus services studies set in other countries have found that students who come from higherincome families are more likely to own private vehicles and less likely to ride buses regardless of employment status as for psychological factors fear of sexual harassment was a significant factor in womens decision to quit using buses women however remain the main public transport users as noted these findings are quite concerninggenerally but especially in the context of the pandemic during this time buses have been less crowded than usual and based on previous studies a lower bus load was expected to lessen concerns around the risk of harassment but we found that not to be the case it may be that sexual harassment on public transport has increased rather than decreased during the pandemic due to a higher level of anonymity afforded to perpetrators by the mandatory use of face masks or less crowded buses may have led to less frequent but more severe sexual harassment in addition to outright harassment female respondents were also more sensitive to the poor conduct of bus staff they were more likely to take notice if drivers and ticket conductors were distracted ununiformed or impolite note that the vast majority of hanoi buses are staffed by men and in some cases staff have been known to engage in the sexual or gender harassment of female passengers 9meanwhile male students cared much more about bus reliability and the fatigue associated with bus trips perhaps because they tended to live farther from their university than female students other genderbased differences were not statistically significant both genders were more likely to quit using the bus where they perceived it as a lower status and a less convenient mode this is understandable inconvenience is a known factor that makes public transport unattractive the risk of theft was not significant neither men nor women were particularly concerned about it while pickpocketing does occur in hanoi it may not be seen as a major problem by students who are regular or frequent bus users and know how to protect themselves from thieves also students often commute accompanied by their friends classmates or roommates and this perhaps makes them feel more secure on buses among former bus riders those who lived closer to their university did not own a motorcycle or did not hold a parttime job were more inclined to want to return to public transport after the advent of electric buses former bus users who disliked the image of conventional buses and the behaviour of existing drivers and conductors were also more likely to want to return to public transport once electric buses were introduced clearly young people entertain high hopes that the vehicle and service quality in the pilot program will be superior to what they have experienced so far it is crucial not to disappoint them and risk losing them forever as bus passengers the fear of covid19 infection was not a significant factor in the decision to quit riding buses note that until recently hanoi has been exemplary for managing to successfully control the pandemic on public transport face masks have been mandatory and this rule has been strictly enforced one study reported that the rate of mask wearing is 100 onboard with nearly 90 of passengers using masks correctly as a consequence no cases of infection have been detected on public transport and the perception of risk has been minimized given these special circumstances this finding may not be applicable elsewhere in other cities covid19 has decimated public transport ridership conclusion and recommendations this study set in the capital of vietnam sought to pinpoint the forces that push students to or pull students from public transport to this end we combined a series of sociodemographic environmental and psychological variables with two disruptors one negative and the other positive and modelled their effects we found that bus ridership was determined by first or second year of studies lower household income and a smaller homeuniversity distance motorcycle ownership parttime employment and fear of sexual harassment led students to quit riding buses women tended to value polite bus staff behaviour whereas men were more focused on reliability and health both genders were equally concerned about the inconvenience and the poor image and status of buses somewhat surprisingly the fear of covid19 infection had little influence on the decision to discontinue riding buses meanwhile the prospect of riding clean and green electric buses may well lead a portion of students to return to public transport from a practice perspective these findings point to a number of issues which policy makers should consider in order to make public transport more attractive for students in particular noncaptive users and women any strategies to sustain public transport ridership need to be comprehensive and involve gender mainstreaming all aspectsincluding service infrastructure vehicles and marketingneed to be targeted in order to challenge gender biases at each stage of public transport planning development and operation specific measures which are being tried across asia and farther afield include designating seats for women in buses 1 3 providing womenonly buses employing more women as bus drivers and ticket conductors and promoting more women in transport policymaking positions however note that genderbased segregation has not been successful everywhere and in some countries has even backfired as orozcofontalvo et al note one of the challenges is that groups of men now target these wagons and wait for female passengers to exit the vehicle to harass them gekoski et al provide a full summary of the evidence the challenge is major because in emerging economies such as vietnam young passengers are increasingly demanding and much less willing than their parents to put up with the poor bus services of yesteryear owing to more exposure to the wider world and the availability of other travel options they expect reliability safe driving frequency of service comfort on board clean vehicles courteous and professional behaviour from staff harassmentfree vehicles and stations and realtime information on digital platforms in sum they expect public transport to match the convenience status and image of private cars motorcycles and hidehailing under these circumstances carrot measures that make public transport more attractive may work better than stick measures that restrict vehicle ownership and use appendix appendix 1 summary of studies on university students bus use author contributions conceptualization mhn and dp methodology mhn and dp data collection mhn formal analysis mhn and dp writing mhn and dp all authors have read and agreed to the published version of the manuscript

university students are regarded as a readily available market segment for public transport in hanoi as elsewhere they constitute a large portion of bus passengers however one portion has been quitting buses and the reasons were so far unknown nor was it clear whether they planned on retuning through a survey of more than 800 students in seven higher education institutions this study aimed to find the answers to these questions the study revealed that bus ridership was determined by sociodemographic variables year of studies household income employment status motorcycle ownership environmental variables homeuniversity distance and psychological variables convenience bus staff behaviour risk of sexual harassment reliability and health image and status a negative disruptor such as the fear of covid19 infection had little effect on the decision to continue riding buses meanwhile the prospect of riding clean and green electric buses which were introduced in a pilot program was a positive disruptor that may lead a portion of students to return to public transport

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introduction the notion that there is a role for civil society organisations in formulating public policy has been recognised at the highest international level action research methodologies allow for the analysis of deliberative democratic processes with and within civil society organisations in ireland community engagement in social and economic development has been the subject of academic and activist debate since the irish government added a community and voluntary pillar to the system of social partnership in 1998 the cvp is a mechanism which provides for a degree of regulated access to government decisionmakers for those organisations that represent citizens who may be subject to labour market volatility political or social exclusion social partnership itself is a process of consensus policymaking whereby government agree pay levels and social and economic policy with four key pillars employers organisations trade unions farmers groups and community and voluntary organisations this research presented in this paper uses participatory action research to capture the experiences of civil society organisations who collectively constitute the cvp these csos actively campaigned for and bargained with government and other policymakers leading to a negotiated lifecycle framework as part of the national partnership agreement towards 2016 the lifecycle approach is an approach to institutional design and policy delivery affecting a number of at risk groups the approach works on the assumption that risk of social exclusion differs according to a persons life stage children or older people can be identified as having distinct needs according to their life stage people with disabilities are recognised as facing lifelong difficulties across lifecycle stages while csos and the cvp appear to have secured a new social policy framework within irelands national corporatist regime it has also been argued that the community sector has been compromised in favour of economic stability and the promotion of a neoliberal political agenda thus the issues surrounding social partnership and the lifecycle framework remain contentious absent from this debate has been a robust empirical study which captures the processes and dynamics of cso engagement in such governmentled decisionmaking apparatus especially from the perspective of community activists and cso members this article reviews how par was employed to paint a holistic picture of the lived experiences of csos in the cvp of social partnership the use of par created a trusting research environment ultimately the par process contributed to a new understanding of the cvp challenging existing literature on the experience of these csos in social partnership previous literature took a critical approach presenting the cvp as a willing victim in a stateled programme to civilise civil society in ireland taking a par approach allowed us to include more forms of evidence more participants and ultimately to produce a more complete and practical interpretation of the role of the cvp in irelands system of decisionmaking these insights offered as reflections in this paper lead to a further key contributionin demonstrating how par is a useful mode of inquiry where disagreement about what is truth and interpretation has depleted trust amongst participants in order to achieve this the article continually refers to the usefulness of various aspects of par throughout our analysis of the case we are open and transparent about both positive and negative aspects of the par journey which are used to enrich a conversation about one aspect of the action research agenda our par study can be viewed as the next step in building a more holistic interpretation of the experience of cso engagement with the state in ireland in advancing this contribution the article is structured as follows first a contextual background to the research project and irelands social partnership model is explained including the specific role for csos within its cvp next the importance of an actionresearch agenda is reviewed in particular the specific role of the par methodology two main sections form the bulk of the reflective analysis and contribution the first develops a reflective contextualisation of par in terms of recruiting active and willing participant organisations building trust and empathy and considering the utility of the research techniques and analytical tools deployed the next section integrates the reflective views of the participants themselves noting some important and practical limitations finally the conclusion summarises the main contribution of the paper and describes how it adds to an ongoing conversation in relation to par methodologies context and background to the research the larger study assessed the impact of the life cycle approach on policymaking for csos participating in the cvp of social partnership the broad aims for the larger research project included to engage csos as collaborators in the project to understand the processes of decisionmaking within the cvp of social partnership to explain the diffusion of power relations between cso members and state agencies both inside and outside the social partnership framework and to disseminate the research findings to policymakers nongovernmental organisations and academics at a national and international level a brief contextual background to ireland and the substantive policy role of csos within the social partnership arrangement is now presented ireland faced a unique and unprecedented set of circumstances in the 2008 to 2011 period when the research project took place this period was one of huge change for the irish economy as a whole prior to the global economic recession ireland was recognised as an economic miracle a success story of the expansion of global capitalism via the postwar political project for european economic cooperation social partnership was credited with this success as gdp rose the community sector began to argue against rising inequality the lifecycle was introduced as part of the developmental welfare state a blueprint for social development negotiated by all the social partners and led by the cvp by 2008 ireland had gone from having the highest rate of economic growth and prosperity for more than a decade in europe to suddenly requiring the direct assistance of the european central bank and international monetary fund within the global financial crisis ireland was particularly exposed to the vagaries of international capitalism largely because of its overreliance on cheap global finance to fuel a property boom along with minimal regulations to curb the activities of banks and other multinational organisations the basis of what became known as the celtic tiger rested on several factors easy access to cheap global finance low corporation tax to attract foreigndirect investment support from trade unions and cooperative institutions such as social partnership to legitimise wage rates welfare state reform and decisionmaking a founding pillar of economic growth was the concept of cooperation and engagement with a range of social partners to this end irelands tripartite model of bargaining was rebranded as social partnership this was first introduced in 1987 and ran consecutively for over 20 years with seven negotiated agreements and was premised on voluntary dialogue between the state and multiple stakeholders the latest agreement towards 2016 was negotiated in 2006 and included the lifecycle approach with the incorporation of cso members through the cvp i importantly cooperative engagement was premised on inclusion in decisionmaking that set wages taxation welfare and social policy change according to murphy social partnership was the only game in town in terms of policy planning at the time all changed amidst recession and financial crisis social partnership in ireland has become associated with an unhealthily close relationship between unions employers and the government faced with extensive austerity measures and the potential loss of sovereignty with ecb and imf bailouts the government officially walked away from social partnership in 2010 when they decided to impose cuts rather than negotiate reform through the institution of social partnership a new coalition government elected in early 2011 abandoned social partnership although elements of the lifecycle approach negotiated in the towards 2016 agreement remain active in relation to social policy objectives if not specific strategic plans it is with this background context and circumstances encountered by the researchers and cso participants that we reflect on the par method as a tool to advance a deeper and more refined understanding of social policy decisionmaking in action contribution of the study to the action research agenda the crucial balance to find in all research is that between the replication standard versus deeper epistemological questions such as what the study contributes to our knowledge of the social world par is seen to be stronger on reaching an approximation of the truth at the cost of methodological sophistication there may be a tradeoff between methodological sophistication and truth in the sense of timely evidence capable of giving participants critical purchase on a real situation in which they find themselves for this project action research was chosen as a methodology because of a political and ethical commitment to the participants as such the study builds on a body of work pioneered by lewin whose work on labourmanagement relations in england was later developed in a scandinavian context by emery and thorsrud as our study is conducted on a smaller scale it contributes to the later frankfurt school tradition of challenging positivist inquiry by looking at local and contextualized meanings the significance of context is increasingly recognised in research which aims to provide some basis on which an organisation can change or innovate for this study it was important to work with all cvp member organisations in order to generate a more holistic picture of the experience of csos working within social partnership and especially the new lifecycle policy direction the project aimed to contribute to what denzin calls our collective endeavor as qualitative methodologists by demonstrating how action research clearly and ethically conducted can offer a more complete picture of a complex ongoing policy process the par method deployed meets the three requisite conditions for pragmatic action research identified by greenwood and levin namely i construction of arenas for dialogue ii cogenerative research and iii the use of multiple methods and data sources in doing so the paper makes three substantive and related contributions to the broader action research literature firstly the paper is an example of a detailed and transparent account of how one type of action research namely the formative evaluation can be used to investigate an important policy initiative at the national level secondly this account is enriched and emboldened by the inclusion of critical reflections of participants and researchers identifying problems and opportunities in attempting to use par in this way thirdly while the paper offers a useful example of a formative evaluation the reflections shared demonstrate how par can be a useful mode of enquiry where trust has been lost in this case the wellmeaning work of many previous researchers of the cvp led to a combination of distrust of researchers and research fatigue amongst participants in line with kemmis and mctaggarts in contributing to this agenda the current research project had both a reflective and an action element what greenwood and levin consider as formative evaluation in which there is reflective evaluation while a programme is in active operation participant organisations are positioned as the leading experts on the lifecycle approach and negotiated the approach with government through the social partnership process our article is then broadly relevant to the major work conducted in scandinavian corporatist systems and extensively recorded in the work of gustavsen toulmin grootings and others this connects with what gouin cocq mcgavin identify as the important collective role of participatory action research reported in an ngo feminist environment elsewhere aziz shams khan argue that female empowerment shaped the outcomes and processes of research around health and womens rights within a muslim context ataöv et al drawing on migrant worker rights in norway refer to related debates concerning inclusion and exclusion status in decisionmaking the professionalisation of csos in democratic systems of governance are important issues according to fyfe in the irish context while some progress has been made in problematising the role of civil society in social partnership much of the empirical research has been conducted on an ad hoc basis the critical approach taken by some authors which has arguably made an important contribution to the literature questioning state led incorporation projects has tended to depend on public commentaries literature reviews or the opinion of some activists previous research on community engagement has tended to conclude that the formation of the pillar has led to cooptation of csos against an emerging neoliberal agenda this criticism is in large part due to the fact that membership of the cvp is by the invitation of government only it is also worth noting that the seventeen member organisations are not representative of the entire community sector in ireland rather the group of seventeen represents the main sectional interest groups the decision to take up the governments invitation to participate in social partnership by some csos has been attributed to a realisation that when it came to initiating social development other methods yielded little success our research sought to make an empirical contribution to this literature by providing a robust and ethically sound research design which captures the complexity of cso engagement in the institution of social partnership in ireland reflexivity and contextualisation of the par approach undertaken the research team funding sources and objectivity the overarching research project aims presented earlier were part of a competitive peerreviewed research proposal submitted to and funded by the irish research council for humanities and social sciences ii the proposal demonstrated the potential for the project to address gaps in extant knowledge around social policy inclusion and decisionmaking processes within social partnership in terms of methodology it was also argued in the funding proposal that much academic research had a tendency to view csos as passive subjects who had been studied and scrutinised from afar rather than as active agents capable and able to influence decisions for themselves therefore the research was not initiated by cso members of the cvp nor was it commissioned by government directly but funded as a result of a competitive blind peer review process in addition to objectivity and academic credentials the researchers also had a high degree of familiarity with the processes of communitybased decisionmaking and collective bargaining in particular the research team was aware that there is no formal funding stream for research and development in the community sector importantly upon securing the funding the research was presented to members of the cvp as an opportunity for activists and researchers to work together to capture the unique and tacit knowledge of the community sector in improving policy for their constituent groups within the social partnership process as action researchers the authors made a commitment to listen to what participants had to say to revise methods where appropriate and be inclusive and reflective throughout research participant recruitment once the research proposal gained approval from the irchss the process of participant engagement and recruitment began like many real world research projects stages and events do not always run as smoothly as often portrayed in textbook descriptions indeed in the initial stages cso members were resistant to being researched as a collective pillar furthermore an offer to present the research proposal and subsequent data collection plans to the pillar was declined the research team was instead asked to contact individual cso member organisations with individual invitations to participate reflections on this and other significant issues are elaborated next each of the 17 member organisations took part in a separate onetoone interview typically involving the senior officer or the person designated as the social partnership coordinator for the participant organisation in using this approach we drew on the work of palshaugen and others in recognising that there is no uniform approach to capturing the diversity of organisations in this strand of action research it became apparent that previously published research had angered some members of the pillar who saw research as at least troublesome and at worst destructive all participants could see the utility of the proposed research as long as the topic of the research stayed focused on the lifecycle approach no incentives to participate were offered iii as the formative evaluation progressed some participants reported that engaging in the research process was useful for reflection on their own work elaborated later trust and empathybuilding in participatory action research the actionresearch process itself was highly iterative and the research team had to continuously engage in a trustbuilding process to ensure that all 17 cso members felt comfortable participating as similarly reported by dundon and ryan engagement with politically astute activists was essential to cement researcherparticipant empathy to move beyond description and into a space where interviewees could feel free to discuss contentious issues this was especially important given that members felt previous research was less than transparent with the cvp as a collective entity in order for this research to be valid and genuinely participatory time and care had to be taken to ensure that full membership of the pillar took part in the research this was the first step in truly understanding the pillar as a collective entity it was at this point that the inbuilt reflexivity of the par method became a key strength as it allowed the team to listen to participants and seek their input in terms of refinement and design building on the findings of the separate interviews with each cso member group it became evident that the cvp was at times regarded as a construct of government by cso members it was therefore a mistake to view the cvp as a unified collective component in social partnership instead we needed to reassess the approach and recognise this was now a study of 17 csos who may or may not have a collective standpoint on social policy the individual interviews were completed by september 2009 later that year all participants were invited to attend an information meeting this meeting proved crucial in recruiting participant organisations when there were later disagreements about the content of the discussion at deliberations the trust established through this iterative process of engagement proved vital in two respects first it allowed the researchers to retain integrity by sticking closely to the research questions and objectives of the original proposal which participants were by now familiar with and generally supportive toward secondly the trustbuilding exercise allowed the formative evaluation to stay on track as social partnership stalled as the irish economic and political landscape became increasingly volatile and unstable indeed the micro politics shaping social partnership as a governmentled institution was exposed as a major cause of what some described as an elite consensus at the heart of irelands severe recession although the system of social partnership was criticised this did not mean the model failed to deliver gains for some other cso participants who remained advocates of the principles of cooperation and engagement through social partnership given that this is real world action research disagreement and diversity among such activist csos is not in itself unusual or surprising the added value for this paper is that the processes and stages of trustbuilding through a par approach of listening and involvement maintained the equilibrium of the project throughout this period ultimately the trusting environment created by the par process contributed to a deeper understanding of the cvp the participatory mode of engagement the final research design maintained key elements of the original plan to compare how different lobbies used the institution of social partnership to represent vulnerable groups the participatory process allowed the research team to adjust the design in light of changes to the significance of social partnership as a policymaking institution with the onset of the global recession from 2008 thus the participatory mode of engagement led to refinement of the research design in tandem with participants this allowed the research team to capture what they now saw as most relevant to the implementation of the lifecycle approach a deliberation was to be held for each lifecycle stage each cso member organisation was free to choose which meeting was relevant to their work so all cso members were invited to attend all deliberations at the request of the many organisations who identified their work as cutting across the lifecycle two extra deliberations for crosscutting groups were held participation between the different specific lifecycle stages varied enormously crosscutting groups attracted the greatest number of participants by contrast two deliberations involved only two cso members this was to be expected given that some life cycle stages were represented by only three organisations in the cvp some participants took part in a number of deliberations while others participated in just one all member organisations of the cvp who could not attend an individual deliberation had been interviewed or had attended an earlier group meeting in the final analysis both participants and researchers were confident that the mode of engagement added validity and reliability to the study as opportunities to influence the research design and outcome held constant for participants across multiple lifecycle deliberations table 2 summarises the final research design including the mode of engagement and its purpose to the research project and to the participant organisations provide information to participants on an individual basis and gather background information to inform the research design information meeting group meeting to which all members of cvp were invited to provide information on project feedback from interviews and demonstration of research methods brainstorming grouping and ranking in two groups of seven individual group deliberation group meeting to which all members of cvp were invited brainstorming grouping and ranking in groups from 26 final reflection meeting group meeting to which all members of cvp were invited discussion and reflection on draft report including title presentation and plans for public launch of research report data collection techniques and analytical tools a number of different research tools were utilised to record participant interaction and general findings at each of the lifecycle deliberations these methods are explained in detail here in the interests of offering as transparent an account as possible a number of techniques favoured by participants included brainstorming diagramming mapping ranking and use of matrices all or some of these methods were used at each deliberation participants were invited to engage with the research questions using inclusive and equal means each participant was provided with a set of postit notes and asked to list one idea per postit note in response to the following questions  what are the priority issues for each lifecycle group  what strategies are used to address these issues  what impact has the lifecycle framework had on participants organisational strategies used to represent their constituents  what potential has the lifecycle approach to enhance or undermine intergenerational relationships the participants responses were subsequently placed on a flipchart by the researcher who then facilitated wider discussion by all groups in attendance after discussion participants were invited to group similar ideas and rank them in order of importance in this way the relationships between ideas were mapped where disagreement existed on ideas a ranking exercise helped to work out differences the result is a dataset which includes a list of ideas group decisions around those ideas and a final diagram or matrix illustrating the collective responses of each deliberation on a particular issue figure 2 illustrates the evolution of datagathering techniques from the raw data to analytical tools used by the researchers and the participants at a deliberation meeting the first photograph shows all the issues identified as priorities according to the cso members attending the session for the older peoples stage typically through a brainstorming exercise then participants were asked to consider headings and thematic clustering of the priority issues identified in photo 2b the thematic headings have been added following agreement by participants and prioritised issues grouped by thematic cluster according to participants finally in photo 2c the importance and significance of the clustered issues were prioritised again by participants themselves each deliberation meeting found different issues strategies and ranking of issues according to participants concerned with each lifecycle stage in addition to the notes and priorities for each cso group handwritten notes were taken at each deliberation by one member of the research team these notes were subsequently reviewed and verified by a different member of the research team summary reports of the research notes were then circulated to participants who were given two weeks to make comments or offer clarifications this process occurred in early 2010 a further level of validation was then added to the analysis by forming a qualitative internal review panel the research team met to discuss the research findings and consider any subsequent changes or amendments returned from participants no substantive changes were suggested by participants following their two week review period at this point each team member separately reviewed each lifecycle deliberation report to establish on a questionbyquestion basis the most significant insights and findings for the most part researchers autonomously identified similar themes as prominent where there was full agreement that a particular point was relevant it was included in the final report where there was disagreement discussion followed until the team reached agreement or further clarification was sought if the issue was unique to a single cso member participants perspective and researchers reflections on par several participants stated that they found the sessions to be useful because it gave them the space to discuss the priority lifecycle issues without a watchful government eye so often present within the social partnership system it also afforded participants an opportunity to consider other cso members priorities which facilitated mutual learning some participants reported that the research process gave them a chance to tease out issues and they welcomed the opportunity to answer difficult questions importantly using postit notes gave participants more control over the generation of ideas and gave those who were less vocal the tools to ensure that their point of view was articulated moreover participants commented extensively that the research enabled them to reflect on achievements air differences between groups and enable mutual learning that typically did not occur in the cvp itself in short by participating in actionled research cso members were able to track their own thinking and to realise that there were common themes across other member organisations concluding that as a collective body the cvp was much more cohesive than initially imagined by participants themselves however and as might be expected among the type of activist csos involved here some participant groups were critical and these point to important limitations and lessons for par methods for example some cso members felt constrained by the research methods used in one of the group deliberations as the methods were designed to reach consensus a small number of participants commented that the while disagreements were reported the full extent of discord during the session was not always clear in the report a minor concern was that some lifecycle deliberations included a small number of participants which meant that views and involvement was limited to those with a vested interest in that particular lifecycle issue participants from one of the crosscutting deliberations felt that the research focus on the lifecycle approach limited their contribution which was not age related but concerned with broader equality and social justice paradigms or more focussed on homelessness issues for migrants or women of all ages perhaps one of the more important practical limitations and a lesson to be considered for the future is that the par method was found to be especially labour intensive for csos who have to operate with limited resources ii researchers reflections on the formative evaluation the lead author was previously employed as a policy analyst at one of the member organisations of the cvp the second author was a former trade union officer now an academic at the same university as the lead author and this added a specialism around social partnership as a bargaining institution the third author is an employed researcher at the universitys research centre who has long experience of undertaking research commissioned by community organisations iii no incentive was offered to the participants those who did take part were sent a €100 token in appreciation of their participation following publication of the final report they were not made aware of this at any stage in the research process how par played a crucial role in initiating and maintaining high levels of trust and empathy between participants and researchers we are open and transparent about both positive and negative aspects of the par journey which are used to enrich a conversation about formative evaluation an important aspect of the action research agenda the article began with a contextual background to the research project and irelands social partnership model identifying the specific role for csos within its cvp the importance of an actionresearch agenda was reviewed in particular the role of the par as a research methodology this provided a basis for the analysis which followed developing a reflective contextualisation of par in terms of engaging participant organisations building trust and empathy and considering the utility of the research techniques and analytical tools used this detailed account of the challenges and rewards of engaging in this formative evaluation can be of use to others employing this approach to understand complex collective and contentious aspects of policymaking

the inclusion of community activists in policy planning is increasingly recognised at the highest international level this article shows how the use of participatory action research par can present a deeper and more holistic picture of the experiences of civil society organisations csos in shaping nationallevel social policy by utilising actionbased research the community and voluntary pillar cvp of irelands system of social partnership is shown to be an important agent in deliberating national bargaining outcomes known as the towards 2016 national agreement the key contribution of this research is the reflective methodological considerations in terms of par design execution and participant integration in the research process as a way to enrich and develop a deeper and more informed community of practice

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introduction background as of december 2021 over 18 million covid19 cases and 29000 deaths have been reported in canada 1 to limit the spread of infection the canadian government has implemented for example social distancing protocols lockdowns school and nonessential business closures travel restrictions and social gathering size limits 2 both the virus that causes covid19 as well as restrictions associated with the pandemic have triggered various cascading stressors including concerns related to contracting or spreading the virus social isolation changes in employment andor financial stability barriers to accessing supportive services or a scarcity of these services the widespread exposure to health threats and their multidimensional impact may lead to adverse mental health outcomes research conducted across countries revealed elevated rates of anxiety and depression throughout the pandemic 34 more specifically research has shown associations of symptoms of depression and anxiety with perceived threat of covid19 infection social isolation financial and occupational insecurity and resource scarcity 5 6 7 the impact of these pandemicrelated stressors may be more detrimental to populations with increased vulnerability to mental illnesses such as military veterans epidemiological surveys consistently reveal that canadian armed forces veterans experience higher rates of mental and physical health conditions relative to the general canadian population these include posttraumatic stress disorder depression and anxiety diagnoses as well as chronic pain arthritis and high blood pressure 89 recent research has also found that the presence of prepandemic mental illnesses and medical conditions has been associated with greater risk of adverse mental health outcomes during the pandemic among the general population 41011 thus it is plausible that veterans exposed to pandemicrelated stressors may be vulnerable to adverse psychological consequences additionally the high rates of psychological and physical conditions in caf veterans result in a strong reliance on physical and mental health care services relative to the general canadian population 1213 consequently transitions and overload in health care sectors may disproportionately impose barriers to health care services and result in unmet health care needs among veterans this may contribute to mental health concerns directly or indirectly through worsening health conditions another contributing factor to veterans increased vulnerability during the pandemic involves their social networks and interpersonal relationships veterans frequently report feelings of loneliness and dysfunctions within their interpersonal relationships unprecedented governmentimposed restrictions on inperson gatherings may further negatively impact veterans recreational occupational and therapeutic activities indeed research has underscored the associations between social isolation and elevated symptoms of depression and anxiety in the general public within the family context there is evidence for existing relationship strain and disruptions between veterans and intimate partners especially among veterans with mental illnesses 1617 the accumulation of stressors experienced throughout the pandemic may exacerbate psychological symptoms and amplify relationship strain for veterans and their spouses moreover spouses of veterans are the most common source of unpaid caregiving to veterans 18 which can lead to significant caregiver burden and psychological distress 1920 reductions in health services due to covid19 paired with associated exacerbations in preexisting health conditions may result in additional responsibilities for spouses of veterans further impacting relationship strains and psychological symptoms on the opposite side of the vulnerability continuum veterans represent a unique population that has been specifically trained to demonstrate resilience in the face of adversity and extreme circumstances 21 despite the profile of vulnerabilities and risks there is reason to expect that this population may adapt well compared to the general population research conducted in samples of veterans during the covid19 pandemic has revealed nonsignificant differences between veterans and the general population in levels of psychological symptoms 2223 however these studies collected data at only a single time point during the pandemic with specific samples that may not generalize to all caf veterans additional research is warranted to evaluate the longterm psychological impact of the pandemic and associated stressors on the mental health of veterans this is especially important in light of theories that avoidance behaviors common to mental illnesses including xsl • fo renderx ptsd may be temporarily validated and reinforced 2425 these changes may lead to transient improvements in mental health that will create additional challenges when and if society returns to a prepandemic state the current study this manuscript details the protocol for a longitudinal study aiming to capture the impact of the covid19 pandemic on the wellbeing of veterans and their spouses we will assess a variety of psychological outcomes and determine how they fluctuate according to perceptions of social support loneliness family functioning changes in health care delivery and access disease status and precautions occupational and financial insecurity and demographics future publications from this study will explore the following the impact of the covid19 pandemic on psychological outcomes with consideration for possible mechanisms of action such as the mediating andor moderating roles of social support and loneliness or occupational and financial concerns on wellbeing and experiences satisfaction and psychologicalwellbeing outcomes related to health care access and telehealth services methods study design we employ a prospective longitudinal panel design using the secure webbased data collection platform research electronic data capture hosted by lawson health research institute participants completed questionnaires at baseline and provided their emails for followup surveys to be completed every 3 months for a total of 18 months the survey was conducted and will be reported according to the checklist for reporting results of internet esurveys 26 this study was approved by the institutional research ethics boards of western university health sciences on july 16 2020 and lawson health research institute on july 17 2020 participant selection and recruitment participants were recruited using a convenience snowball sampling strategy recruitment sources included a research participation recruitment platform emails distributed across professional and veteran group networks social media advertisements targeted media releases and word of mouth recruitment channels directed prospective participants to the participaid study webpage which offered further information on the study procedures and directed eligible participants to the redcap survey link eligible participants were at least 18 years of age currently residing in canada and were caf veterans or spouses of caf veterans at the time of baseline data collection eligibility was selfreported by participants via screening questions presented on the recruitment website participaid and at the outset of the baseline redcap survey veteran participants representativeness was monitored weekly throughout the recruitment period by comparing the sampling distributions against canadian national databases on gender age and province of residence 27 recruitment efforts were adjusted accordingly to target underrepresented demographic segments no monetary compensation was provided to participants data collection survey design and administration the online survey was designed in consultation with international research teams to evaluate the crosscultural effects of the covid19 pandemic on veterans and their families a drafted version of the survey was presented to the macdonald franklin operational stress injury research centre advisory council comprising caf veterans spouses of caf veterans experts in veteran and military research health care professionals providing treatment to veterans and military members and other stakeholders engaged in the veteran community the advisory council provided feedback and guidance on scale selection and relevance to issues faced by caf veterans during the pandemic to cater to participant availability participants can choose between two versions of the baseline survey a shortform version or a longform version the shortform version consists of 9 measures which contain between 171 and 240 items collectively and is presented over 9 screenspages the longform version consists of 15 measures which contain between 221 and 312 items collectively and is presented over 14 screenspages the longform survey can be completed immediately at baseline or be returned to within a 6week window after beginning the baseline measures after baseline an automated followup survey is sent every 3 months for a period of 18 months to all participants who provided an email address for contact the followup survey consists of 13 measures which contain up to 293 items collectively and is presented over 13 screenspages to reduce participant burden all survey versions use conditional display logic to hide certain questions or modules that are not relevant only eligibilityrelated questions require a response all other items can be skipped there is an option for participants to use a return code to change their responses once submitted the surveys are offered in english or french based on participants language preferences psychometrically validated french scales are used when available otherwise professional translations of the english scales with certificates of translation provided are used implied econsent is collected at each data collection event by completion of questionnaires a team of 3 researchers was responsible for testing the technical aspects of the survey researchers tested the survey by assuming the role of hypothetical participants that systematically varied in all conditions on which conditional display logic is based automated processes including emails for followup surveys were systematically tested by the same researchers for all hypothetical scenarios questionnaires demographics participants are asked to report their province of residence age gender marital status characteristics of area of residence education level ethnicity living arrangements and employment status including changes to employment during the pandemic veteran participants are asked for their rank at time of release branch of service and length of service spouses of veterans are asked whether their veteran partner has a mental health condition and if yes whether the condition occurred as a result of occupational service covid19 experiencesimpact using items adapted from the coronavirus health and impact survey 28 participants are asked about their exposure to infection with and associated consequences of covid19 for self and family members participants are also asked about frequency of social contacts and time spent outside the home perceived difficulties and stress related to physical distancing recommendations changes to the quality of close relationships concern over living situation and finances media consumption and an openended item to describe any concerns not otherwise addressed additional items created for this survey assess concerns relating to the pandemic general mental health and stress of participants and their spouses pastweek covid19related behaviors and impacts on work response options vary by question and are rated on 4point 5point or 6point likert scales with various yesno options for covid19 exposurerelated questions health care access participants are asked about whether they have had difficulties accessing health care and whether they have avoided health care with yes and no options with respective questions about the specific types and domains of care for each domain of care that was avoided or difficult to access participants are asked about their pastweek distress levels on a 5point likert scale ranging from 0 to 4 participants are asked about their usage frequency and interest in telehealth prior to the pandemic for physical and mental health care on 4point and 3point likert scales as well as their current interest in receiving telehealth services participants are also asked about telehealth experiences since the pandemic in terms of whether they have accessed it for which domain of care respective satisfaction with the telehealth services 4 mental health questionnaires and moral injury participants are asked about their symptoms of depression 33 ptsd 34 general anxiety 35 alcohol consumption 36 positive wellbeing 37 and moral injury expression using the moral injury outcome scale 38 and litz bt unpublished data an additional item was added at the end of the phq9 pcl5 and gad7 for participants reporting the presence of at least one symptom on the respective scale to assess whether their symptoms are directly related to the covid19 pandemic made worse or exacerbated by the covid19 pandemic related to traumatic events unrelated to the covid19 pandemic or not sure an item was added after the audit items to assess whether participants alcohol consumption decreased increased or stayed the same relative to before the pandemic social support and family function participants are asked about their experiences with loneliness 39 perceived social support and family functioning 42 physical health questionnaires participants are asked about their symptoms of chronic pain using the brief pain inventoryshort form 43 social desirability social desirability is measured using the marlowecrowne social desirability scale 44 this instrument assesses whether participants exhibit a tendency to respond in a socially desirable rather than truthful manner this instrument was included for psychometric analysis on measures in this study that have not yet been validated the mcsds will be used to assess the discriminant validity of measures data management participant data are maintained in accordance with western university and lawson health research institute institutional regulations pertaining to participant privacy and cybersecurity source data including electronic consent patient identifiers and all questionnaire responses are stored on redcap which is securely housed behind an organizational firewall and only accessible to approved investigators through an institutional login each participant is assigned a numerical code that is used to label and link source data when exported from redcap all data are passwordprotected and accessible only to members of the research team data quality validation is performed directly through redcap data entry forms by specifying acceptable numerical ranges when applicable and by using logic to hide questions irrelevant to subsamples details on missing data and attrition will be discussed alongside corresponding results in future publications data analytic plan descriptive and exploratory analyses quantitative descriptive statistics will be used to examine sociodemographic characteristics including age gender ethnicity income education occupation and illnessrelated variables as well as social psychological physical and health carerelated variables these will include general descriptive analyses measures of internal consistency and correlational analyses analyses will be performed on spss statistics and rstudio qualitative openended data including participant descriptions of the impact of the covid19 pandemic on their health and wellbeing comments about telehealth and descriptions of morally injurious events will be analyzed using content analysis data will be analyzed using nsr nvivo 11 software a minimum of two independent coders blinded to study hypotheses will code responses individually using both inductive and deductive approaches 4546 themes will be explored and identified and observed trends will be summarized longitudinal analyses data pertaining to psychological wellbeing and distress will be analyzed using latent growth modelling and mixed modelling methods to evaluate how psychological wellbeing and distress evolve over time longitudinal models will aim to identify predictors that influence individual trajectories of mental health and distress analyses will explore relations between mental health functioning in relation to social support and relationships covid19related variables and health care access and satisfaction modelling and mixed modelling will be conducted using rstudio results survey completion and representativeness baseline data were collected from july 31 2020 to february 1 2021 a total of 1538 eligible participants initiated the survey among those participants 1047 were caf veterans 366 were spouses of caf veterans and 125 were both caf veterans and spouses of caf veterans most participants who initiated the baseline survey chose to complete the longform survey version most participants who completed the shortform survey indicated interest in completing the additional longform questionnaires with 550 subsequently initiating those remaining questionnaires this represents a conversion rate of 374 of those prompted and an overall increase of 64 in longform survey data see figure 1 for the flow of participants from redcap survey initiation to baseline retention for followup the veteran participants of our baseline sample were compared against national survey data of caf veterans 27 using chisquare goodness of fit tests on distributions of age gender and province of residence by canadian regions atlantic provinces central canada prairie provinces west coast and northern territories 47 overall our veteran sample was largely similar to the canadian veteran population in age gender and region of residence slight deviations from the national distributions were found in each variable with absolute percentage differences ranging from less than 1 to 11 for age absolute percent differences varied from less than 1 to 10 with absolute differences greater than 5 observed in older age categories our sample had more participants in the 5059 and 6069 age groups and fewer participants in the 8089 and ≥90 age groups chisquare results revealed a significant difference in age distribution the absolute difference in proportions xsl • fo renderx of males and females between our sample and the national estimate is 110 relative to national estimates females were overrepresented in our veteran sample with a medium effect size the absolute differences in proportions for region of residence varied from less than 1 up to 7 the regional distribution of our participants differed from that of the national estimates with a medium effect size participant data retention the median survey completion time varied by 115 minutes between the shortform and longform versions of the survey the percentages of participants completing each questionnaire at baseline varied according to whether participants completed the long or short version of the survey the dropoff trend was similar between both survey lengths for the longform version completion dropped from 100 at demographics to around 90 for the covid19 factors questions with participation remaining above 80 for health care access social support and loneliness questions before dropping to approximately 80 in the moral injury questionnaire and ranging between 70 80 for the remainder of the questionnaires participants who initiated the shortform version exhibited a similar trend the rate of decline was steeper particularly from the health care access questions to the mios questionnaire with the completion rate of the full set ranging between 60 and 65 renderx based on the date of baseline survey initiation participants receive systemgenerated notifications to complete their followup surveys every 3 months for a total of 18 months the baseline retention with email addresses is being used as the reference point to evaluate participant retention and attrition during each of the followup periods as of november 2021 a total of 8311513 participants completed the 3month followup whereas 6821513 missed the response window and a total of 6671513 participants completed the 6month followup and 8461513 missed the response window data collection is ongoing into the 9month and 12month followup periods with 6831513 and 581513 participants missing the response window for each of these data collection periods respectively participants missing the response window for followup time points will still be contacted for the next followup data collection over the full 18month followup period is projected to end in midseptember 2022 discussion this paper details the protocol for a longitudinal study evaluating the impact of the covid19 pandemic on the wellbeing of canadian veterans and spouses of canadian veterans the use of convenience sampling and a flexible survey format yielded a large crossnational sample of veterans and spouses the longitudinal data gathered as part of this study will provide key insights in mapping out the longterm consequences of the covid19 pandemic and associated changes on dimensions of wellbeing among veterans and spouses our findings will contribute to the identification of vulnerabilities and protective factors that may enhance or reduce wellbeing in veterans and their spouses throughout the pandemic and during similar emergencies should they occur in the future moreover findings from this study will contribute to the optimization of health care for veterans and their families a strength of this study is the comprehensive and rigorous development of the online survey given the wideranging implications of the covid19 pandemic it is crucial to survey an exhaustive range of dimensions to understand their multifaceted and interactive impacts on wellbeing further this survey was developed with leading researchers and health care providers for veteran communities and was refined with feedback from veterans and spouses the likelihood of feasibly capturing relevant experiences is high the longitudinal design of this study is another important strength for several reasons it is essential to capture data across several time points due to the evolving nature of the pandemic dynamic changes such as fluctuating public health restrictions and regulations waves of community outbreaks and the progressive development of covid19related research and vaccines underscore the value of longitudinal data collection in addition the pandemic will likely have complex indirect influences on veterans and spouses wellbeing through mediating roles of social support social isolation andor financial insecurity finally longterm monitoring is needed to capture lagged impacts of the pandemic on psychological wellbeing which have been anticipated as society moves toward notions of a new normal 49 there are several challenges associated with this study these include maintaining a sizable response rate over the data collection period strategies were employed at the outset of data collection to achieve a large baseline sample size in anticipation of participant attrition for example both longform and shortform survey designs were incorporated in this study to encourage participation among those who may have otherwise declined due to time constraints the use of longform and shortform survey versions has been successful in other longitudinal studies 50 ongoing retention strategies include sending reminder emails and tracking rates of attrition to monitor sample sizes during followup periods as of november 2021 data collection is ongoing with participants currently completing surveys for the 9and 12month followup periods data collection will be completed in midseptember 2022 this study offers a unique opportunity to characterize the impacts of the pandemic on veterans through both their own perspectives and through the lenses of their spouses the results of this study will be used to inform policy and treatment planning to better support canadian veterans and their families in the aftermath of the pandemic and during similar future events conflicts of interest none declared abbreviations

the covid19 pandemic has resulted in significant changes to everyday life including social distancing mandates changes to health care and a heightened risk of infection previous research has shown that canadian armed forces caf veterans are at higher risk of developing mental and physical health conditions veterans and their families may face unique social challenges that can compound with pandemicrelated disruptions to negatively impact wellbeing objective this study aims to longitudinally characterize the mental health of caf veterans and spouses of caf veterans throughout the pandemic and to understand the dynamic influences of pandemicrelated stressors on psychological health over timewe employed a prospective longitudinal panel design using an online data collection platform study participation was open to all caf veterans and spouses of caf veterans residing in canada participants were asked to complete a comprehensive battery of assessments representing psychological wellbeing chronic pain health care access patterns physical environment employment social integration and adjustment to pandemicrelated lifestyle changes followup assessments were conducted every 3 months over an 18month period this study was approved by the

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background to achieve the united nations millennium development goals for health improving access to key interventions such as antiretroviral therapy immunizations and tuberculosis and malaria treatment are top priorities for most health systems 1 2 3 however in addition to financial resources for commodities 4 scaling up requires a wellfunctioning health system and adequate workforce capable of delivering interventions at a large scale 5 6 7 8 9 however the 2004 joint learning initiative report on human resources for health and others have concluded that shortage and maldistribution of health personnel with few in rural areas undermine scaling up efforts particularly in lowincome countries 10 11 12 13 in subsaharan africa it has been argued that nearly 1 million additional health workers are needed to realize mdg health outcomes 14 in kenya understaffing in rural primary care facilities is particularly acute staffing norms for dispensaries are 2 to 5 nurses but 9 have no nurse at all and 48 only one similarly health centers should have 8 to 12 nurses with the larger health centers expected to offer shortterm residential basic obstetric care but 48 have less than three 15 the most obvious solution to address the rural and general nursing workforce shortage is a major increase in recruitment as there are many qualified and unemployed nurses in kenya 1 in an attempt to address staff shortages quickly donor partners have supported recruitment of just over 3000 nurses from 2005 to date hired on shortterm contracts of 2 to 3 years duration and posted to public sector facilities in underserved rural areas with high hiv prevalence 16 however major shortages remain posts in rural areas are often considered less desirable urban settings have superior infrastructure and services 31718 while rural posts are often associated with high workloads and poorly aligned incentive systems that disadvantage rural staff once they are posted in rural areas some health workers make repeated demands to be reallocated to urban postings there are two main cadres of nurses in kenya registered nurses and enrolled community nurses rns and ecns undergo a 35 year and 25 year preservice training respectively the majority of kenyas nursing colleges now train predominantly rns while previously the majority of trainees were ecns rural posts in health centers and dispensaries are currently mainly filled by ecns while posts in hospitals are mainly filled by rns as of 2008 entrylevel rns and ecns received monthly basic salaries of kes 22 519 and kes 11 518 respectively converted at a rate of 19 ecns have the option to upgrade to rn status either through a 15 year oncampus program or a 2 year distance learning program which many are currently choosing to do given the salary differentials and the limited career progression for ecns a minority of rns have a bachelors degree but this group is not considered in this paper the debate in kenya over how to ensure adequate numbers of nurses in rural areas to provide and supervise essential community and primary care services is poorly informed by evidence this study focusing on rn trainees near graduation set out to explore the views of final year nursing students on rural and urban areas nursing posts in rural areas and strategies to recruit and retain nurses results are presented separately for those completing preservice training and those upgrading from ecn status as variation in characteristics and experience between the two groups is expected to affect their attitudes methods between september 2008 and january 2009 data were collected from 345 rn students in their final year of training at four medical training colleges using a structured selfadministered questionnaire and focus group discussions mtcs were eligible for the study if they had at least 30 preservice and 30 upgrading students scheduled to complete training in 2008 of a total of eight eligible mtcs four were purposively selected nairobi mtc is located in the capital city while muranga meru and kakamega are 87 km 238 km and 355 km from nairobi respectively representing a range of settings across four provinces all students who intended to sit their final exams in the second half of 2008 were invited to participate the saq data covered respondents backgrounds training plus sets of likert scale statements designed to assess their attitudes towards living and working in rural areas the terms rural and urban are open to varied interpretation 20 we advised students completing the saq to consider rural areas as those in remote places far from major cities and towns and with poor infrastructure and limited recreational facilities though they may also have incorporated their own individual views of these terms their interpretations were explored further in the fgds the development of the likert scale statements drew on those reported in the literature 21 adapted to improve applicability to the local context through discussions with locally qualified nursing staff and researchers statements were adapted to ensure that they covered all key issues raised by local stakeholders that all issues were relevant to the kenyan nursing profession and that the language was easily understandable in the local context students were asked to respond to each statement on a 6 point scale of 1 2 3 4 5 and 6 to reduce response bias 18 of the statements were phrased negatively and randomly distributed within question sets the saq tool was pretested with students from two mtcs not included in the study including a group discussion of the meanings of the questions and statements two fgds were carried out in each mtc one each for preservice and upgrading students 68 participants were randomly selected for each group from all those completing the saq each group included both male and female students the discussions covered trainees experiences attitudes towards rural areas rural postings and nursing in general and potential interventions to improve health worker distribution discussions lasted between 45 and 90 minutes and were digitally recorded supplemented by note taking draft topic guides were piloted with nursing students from urban and rural mtcs the voluntary nature of participation was emphasized and informed written consent was obtained from all participants no mtc tutors were present during data collection data from the saq were doubleentered and verified simple descriptive analysis was used to compare the characteristics of preservice and upgrading students and to calculate the mean response for each likert scale statement as each likert scale statement was rated on a scale from 1 to 6 we considered an upper confidence interval less than 35 as an indication of general disagreement with the statement and a lower confidence interval above 35 as an indication of general agreement principal components analysis a data reduction technique that enables one to identify from a large set of variables those that contain information common to all was performed across all statements on ruralurban perceptions to determine how the statements grouped together under the broad constructs of perception of life in a rural area and perception of working in rural areas additional pcas were then run within these two constructs the first component for each construct was retained and pca derived scores calculated for each construct these scores were used as dependant variables in separate linear regressions to assess the influence of a range of trainee characteristics on attitudes to rural life and work all analyses were conducted in stata version 101 fgd recordings and field notes were reviewed for clarity transcribed uploaded into the qualitative analysis software nvivo7 and subjected to content analysis this involved development of a coding tree or thematic framework a draft coding tree was developed from the fgd topic guide tested by two researchers separately on about 30 of all data collected and refined using themes emerging from transcripts information under each code was then compiled and tabulated to obtain a clearer picture of the issues arising from the data and to compare views across different groups of participants results results are presented on respondent characteristics their perceptions of life and posts in rural areas and their perceptions of strategies to improve rural recruitment and retention drawing from both the saq and fgd data characteristics of respondents of the 462 students invited 345 agreed to participate giving a response rate of 92 for preservice students and 63 for upgrading students the lower rate amongst the latter was attributed to difficulties in communicating the invitations long travel distances from work stations to data collection points and students work commitments respondents were divided approximately equally between preservice and upgrading students and 345 were from the most urban mtc in nairobi two thirds described themselves as having been born in a rural or relatively rural area most students were female the upgraders formed an older group with a mean age of 38 years compared with 24 years for preservice students upgraders were also more likely to be married and to have children level of education of parents was higher for preservice students than for upgraders for most students parents and family members paid for their studies with only a small proportion obtaining scholarships for their training of which the majority received government scholarships all preservice interviewees were fulltime oncampus students while all upgrading interviewees were studying on a distance learning basis reporting to the college for a few weeks to attend introduction to modules or to sit exams more upgrading trainees had chosen nursing as their first career choice compared to preservice trainees in fgds some preservice students stated that they had agreed to pursue nursing in response to parental pressure or that nursing only became an option because they failed to get accepted into their preferred training programmes such as clinical medicine and pharmacy …actually i applied for pharmacy… but they took me for nursing and i had no choice because i had already applied three times i was not going to lose the chance preservice nursing student experience of working in rural areas was very different between the two groups 687 of upgrading trainees had already held posts in rural areas in contrast to preservice students who had no rural job experience when asked in fgds which sector they would target upon graduation upgrading students did not appear to have a strong preference for any particular sector but a minority of preservice students favored private hospitals and nongovernmental organizations which are mainly located in urban areas these facilities were associated with higher salaries i would prefer after college to go maybe to private sector because there one im assured of a good salary… preservice nursing student perceptions of rural areas a preliminary pca was conducted of statements numbered 112 in additional file 2 which indicated that they could be broadly grouped into two domains the first group of variables included statements 14 which all described life in rural areas the second construct pooled together statements 511 which pertained to work in rural areas one statement did not fit within either domain life in rural areas students responses in fgds suggested they generally understood rural areas to be those which are fairly remote with poor infrastructure poor health services limited variety of available housing and hardly any recreational facilities …you know our country how it is infrastructure is bad if you take me to a remote area there is no accessibility there is no infrastructure there are no telephones and there are no roads it rains…i stay there for months without talking to my people in the urban… upgrading nursing student comparatively urban areas were perceived to be more accessible with stronger infrastructure better health services and educational institutions and a variety of recreational facilities upgrading students who were mostly married commented that they often get separated from their children when they took rural posts as their children were schooled away from them in urban areas as rural schools were considered to be of substandard quality however during fgds rural areas were more positively often associated with a lower cost of living with lower housing rents school fees and food prices reported …the nurses who are out there me i dont hear them complain they can afford they eat food from the shambas things are not as expensive… preservice nursing student like in nairobi to get a one bedroomed house you need around kes 8000 but like where i went for my district experience you could get a house for kes 1500 per month preservice nursing student when asked whether they were willing to work in any rural area in the country both groups of students expressed fear of working in communities dominated by other tribes they attributed their fear to post election violence that cut across the country in late 2007 and early 2008 mainly affecting rural areas …i was on my marks just in case something happens i run away and in fact one of the facilities that i personally initiated i never went there for a long time because of fear of the post election violence so but once you know that there is that security you feel good upgrading nursing student students cited examples of colleagues and family members who were forcefully evicted from their homes or working areas because of ethnic differences like myself if am told i go to mount elgon that place called ekopsiro i would not go for one there are two colleagues whose lives went so you could not admire going to that particular place upgrading nursing student likert scale responses contrasting life in rural and urban areas did not elicit strong views from preservice or upgrading students though respondents gave some indication that they found rural housing and lifestyles unappealing the pca conducted for this construct produced a first principal component that accounted for 503 of the total variance which was used to produce a score reporting individuals perceptions of life in rural areas we modeled the determinants of this index using multivariable regression with the following independent variables trainee type age sex marital status having children being born in a rural area and location of mtc the only significant finding was that students attending kakamega mtc had generally more positive perceptions of life in rural areas nursing posts in rural areas likert scale responses indicated that nursing students had mixed perceptions of nursing posts in rural areas on the one hand they associated them with lower incomes slow career advancement and workplace stress but on the other hand they did not feel that they would be frightened to work there that it would be difficult to bring up children or that they would be without support from colleagues and supervisors pca on the 7 variables in this domain produced a first component which accounted for 26 of the total variance from the regression being an upgrading student had a significantly negative effect on preferences for working in rural areas but being older had a positive effect during discussions upgrading students shared the view that poor communication channels in rural areas limited the flow of information on training opportunities such as workshops and seminars in addition they revealed that staff shortages denied them the opportunity to pursue their studies because a replacement was not always available …when you stay in rural community as a health worker you might end up missing some of the privileges that people in town do enjoy like maybe there are some seminars and you are not aware…like someone working here at pgh provincial general hospital you may be coming to further your studies here at mtc unlike when you are in rural area you just stagnate there there is no advancement preservice nursing student when discussing provision of allowances for nursing posts participants acknowledged the fact that rural posts attract lower housing allowances compared to those offered in urban posts upgrading students were however quick to point out that the higher allowances paid in urban posts were used to cater for higher living expenses in these areas upgrading students held the view that positions in rural dispensaries or health centers allowed for more autonomy at work reflecting the low number of staff per facility and better coordination of activities they alluded to the fact that division of work and assignment of duties is much easier with fewer staff the work is there but because in the rural we have three people we know now it is the end of the month we know we have ten reports to be written … we know it is our responsibility so we know how to do division of work upgrading nursing student however some preservice students held more negative opinions of working in rural facilities stating that unfavorable work conditions such as higher workloads poor staffing infrequent support supervision and inadequate equipment and supplies would make it difficult to perform daily duties or limit them to managing minor cases you know when you are working in the rural areas its like you are just working with the community and you dont grow you just deal with the most common ailments…of course in the rural area youll never enter in a theatre like in the urban area preservice nursing student others pointed out that some rural communities reject health workers and health care in general and prefer traditional medicine adding that such rural posts were not attractive to them the real rural area is nyadhuna the patients have a poor attitude toward the nurses and they prefer the tbas traditional birth attendants preservice nursing student i think even before they post you they should consider the community where they are taking you because if i am taken to a community where i know i will be rejected i cannot accept that one preservice nursing student faithbased organizations which contribute approximately 40 of national healthcare mainly in rural and underserved areas were thought to pay the lowest salaries this particular sentiment was shared amongst upgrading students who also felt that workloads in fbos were often too high when you go to some of the private hospitals especially the mission hospitals i tell you that place is horrible because you see somebody with an experience of ten years in the same institution and cannot even afford a salary of kes 14000 so what i mean is especially the mission hospitals some of the mission hospitals the pay is very poor and the work load is too much… upgrading nursing student despite individual preferences both groups of trainees were of the opinion that all cadres of nurses are adequately trained to work in any health facility and that they should therefore be ready to work in lower level facilities in rural areas what i think like now there should be a channel of everybody having an opportunity to pass through the rural and the hospital because we are trained for all this upgrading nursing student strategies to recruit and retain nurses in rural areas varied perceptions of strategies to recruit and retain nurses were reported in the saq students generally felt compulsory rural service for government supported students was reasonable and that for preservice students the greater responsibility in a rural area might be motivating these positive work attributes could be enhanced by better housing and prospects for career advancement being able to choose the rural area to work in was also felt to be of some value while there was strong support for greater rural financial incentives as a means to attract people to such posts with the majority of students suggesting that this should be up to 50 of basic salary preservice students were significantly more likely than inservice students to agree with the statements on the motivating impact of greater responsibility and the importance of decent housing during fgds nursing students in both groups were mostly unaware of any interventions introduced in kenya to recruit and retain health workers in rural areas some upgrading students were aware that rural hardship allowances ranging from kes 600 to kes 1300 per month are currently offered as a means to retain some cadres in remote areas though they were felt to be insufficient to influence decisions on whether to work in the more remote provinces … in government … sometimes you are in a … place … so remote and you dont get risk allowance … those who get hardship allowance get a maximum of kes 1300 and something that kes 1000 can it allow me to work in north eastern no upgrading nursing student students also felt that if advertisements for public sector nursing jobs specified job location and facility type potential applicants would be able to make more informed decisions when applying for posts students reported that such details are not provided for standard government posts but have been included in advertisements for the recent shortterm government contracts recruitment procedures for the private sector and fbos were reported to be clearer than in the public sector allowing potential applicants to know what role they are applying for and where they will be posted most of the ngos adverts are more elaborate because they have job descriptions qualifications and all that and you realize that hospitals public give you very little information about the job you intend to apply for maybe they just say a krhn nurse with a diploma and a working experience of this number of years but i find ngos and cbos more elaborate on what they want when they advertise their jobs preservice nursing student in fgds upgrading students supported the view that rural postings in health centers and dispensaries offered nurses a valuable opportunity to carry out managerial duties as incharges of the facilities … in the villages you will be performing your managerial functions you will manage yourself the drugs… upgrading nursing student it was suggested that rural recruitment could be boosted by recruiting mtc students from rural areas and perhaps training them in mtcs located in relatively remote areas many students favored the idea and one upgrader argued that rural mtcs should implement a quota system and restrict three quarters of their students to be recruited locally however others thought this strategy would be unlikely to have a major impact on rural recruitment in the face of persistent infrastructural problems moreover high illiteracy levels in some marginalized communities where very few people attain the qualifications necessary for college education were cited as a major challenge meaning that the most marginalized would be unlikely to benefit fully although likert scale responses indicated that students felt support from colleagues and supervisors was adequate in rural areas during fgds students argued that supervision was often focused on faultfinding and that more supportive regular supervision would encourage nurses to practice in rural areas since they would feel less neglected …i have been working in a rural set up where they do not come but the moment they will hear that facility has a problem they will come every month hunting you stopping your salary yeah…that is their idea they do not give you support…supportive supervision upgrading nursing student in the saq about half the upgrading and preservice students felt that a safe job with no risk of closing down or unemployment was the most important factor when looking for a job ranking this more highly than a good income so that you do not have any worries about money doing an important job that gives you a feeling of accomplishment or working with people you like this was reflected during fgds where the new shortterm contracts for specific rural posts were generally unpopular with permanent public contracts preferred by both preservice and upgrading trainees those disliking short contracts feared the lack of pension plan and longterm job security short term contracts you can get a lot of money at a go but going to get another job is difficult that money you may stay with it at home and spend it completely what will you do upgrading nursing student in addition delayed salary payments experienced by shortterm hires came out as an issue of contention …they just pay for one month then they carry forward the rest of the months you see when a person is permanently employed at the end of each month at least… they get their salary upgrading nursing student discussion inadequate human resources have been identified as a key constraint to scale up of health interventions 78 maldistribution of health workers continues to be a global challenge with high concentration of health workers in urban areas while rural areas are understaffed 22 this situation threatens equitable delivery of health services to people living in rural areas who are often less educated poorer and with a higher disease burden there has been a general neglect of health policies which focus on strengthening human resources for health reflected in poor budget allocations and limited time within the national health agenda devoted to this topic in both developed and developing countries 520 this paper provides evidence from kenya about the challenges of recruiting and retaining nurses in rural posts and the potential of a range of strategies to address this we studied responses from both preservice and upgrading students the latter were older more likely to be married to have children and to have been born in a rural area than preservice trainees more upgraders reported that nursing was their first career choice this may have reflected a survivor bias as upgraders interviewed had already worked in the profession for several years or the declining popularity of the nursing over time reflecting the reduced attractiveness of the profession or the wider range of career options available in more recent years however responses from the two groups in the saq and fgds were broadly similar the only significant differences in likert scale responses were that preservice students were more positive about the potential impact of greater responsibility and improved housing on rural recruitment multivariable analysis showed that when other factors were controlled for being an upgrading student had a significantly negative impact on perceptions of rural posts the reasons for this are unclear but could reflect their greater experience of the realities of rural posts or a preference for urban areas making it more likely that an ecn will choose to upgrade kenya is planning to phase out ecns an approach already adopted in other african countries 23 there is concern that as a result kenya will have a more qualified nursing workforce which is more marketable locally and internationally and less willing to work in rural areas however the data do not allow a direct comparison of rn and ecn preferences as all respondents were close to becoming rn graduates at the time of data collection across both groups likert scale responses indicated generally negative perceptions of nursing posts in rural areas although stated preferences were rarely strong during fgds trainees raised both positive and negative aspects of rural life on the positive side they mentioned lower costs of living and more autonomy at work on the negative side they cited poor infrastructure inadequate education facilities and opportunities higher workloads and inadequate supplies and supervision factors also highlighted in other studies 22 parents working in rural areas may also be forced to separate from their children who attend schools in urban areas an issue also highlighted in south africa 24 particular concern was expressed about working in communities dominated by other tribes reflecting kenyas recent electionrelated violence quantitative analysis showed that attitudes to living in rural areas were significantly positively affected by studying at the mtc furthest from nairobi and attitudes to working in rural areas were positively affected by being older one might expect students born in a rural area to have more positive attitudes towards living and working in such locations for example a review related to doctors found strong evidence that students with a rural origin are more likely to practice in a rural setting 20 however in this study rural birth did not have a significant impact on attitudes once other factors where controlled for however such conclusions should be considered tentative given the relatively low cronbachs alpha associated with the pca derived constructs and the limited explanatory power of the regression models students expressed mixed views on the relative merits of working in private and public sectors while preservice students perceived commercial and ngo facilities to pay the highest salaries upgraders emphasised that the fbo organisations had the lowest salaries despite their high workload the fact that the fbo segment of the private sector is located predominately in rural areas while the commercial segment is predominately in urban areas may be a further factor influencing ruralurban job choices quantitative and qualitative data indicated that students believed a number of strategies could work to improve rural recruitment and retention with particular emphasis on the introduction of substantial rural allowances many studies point to the value of financial incentives to enhance rural recruitment and retention 25 although it has been argued that multidimensional programmes are more successful than those relying on financial incentives alone 20 the implementation of such strategies requires clear definitions of rural areas to ensure equity and fairness in distribution of allowances 26 and the allocation of adequate funds to ensure sustainability 27 preservice trainees perceived that increased responsibility would motivate nurses a factor also noted in other studies 22 fgd data also indicated that trainees thought more supportive supervision would encourage nurses to practice in rural areas other studies have highlighted the important role that managers can play in job satisfaction 2328 while there is some evidence that improved infrastructure and supportive supervision improve retention 2930 it is worth noting that infrastructural problems themselves limit the amount and frequency of supervisory visits to remote areas views of compulsory rural service were positive but not strongly supportive other studies have found that the evidence that this has a positive longterm impact on ruralurban mismatch is weak 20 qualitative work revealed importantly that in a context of political instability interventions aimed at improving recruitment and retention in rural areas may fail to meet their objectives as a consequence of recent post election violence trainees expressed concern about accepting rural posts where ethnic tensions may affect their personal security highlighting that for rural recruitment strategies to be attractive to nurses their basic safety needs must be assured 24 the ability to select the location of a rural post was also highlighted as likely to encourage application during fgds and reflected in likert scale results interestingly the recently introduced short term donor funded contracts that target critical human resource gaps in underserved areas were regarded as less attractive than standard government posts due to their lack of pension plans and job security despite a stated policy that such posts be absorbed by the government at the end of the contract however applications for such posts are plentiful probably reflecting both the strong supply of nursing graduates and the lack of alternative opportunities in kenya a number of limitations should be highlighted first for logistical reasons it was not possible to select a nationally representative sample of trainees in addition data were collected within a year of the post election violence which may have modified nurses perceptions of rural postings thirdly the term rural is difficult to define 20 and its interpretation is likely to have varied across interviewees for example some may have considered district towns as urban while others may have classified them as rural however the characteristics students identified for rural areas during fgds were similar to those that we proposed during quantitative data collection other terms used in the saq may also have been open to varied interpretations such as lifestyle motivation stressful and decent housing the list of potential interventions assessed was not comprehensive others identified as potentially useful in other studies include conducting training placements in rural settings providing scholarships with an enforceable rural service agreement accelerated promotion and increased recognition by the employer or community 202227 finally the findings are based on the stated opinions of trainees and may not translate into actual career decisions it is notable that while many strategies to improve recruitment and retention have been proposed in the literature 31 few studies have investigated their effectiveness further research is therefore necessary to investigate the extent to which the intentions of qualifying nurse graduates translate into career moves and the effectiveness of interventions to influence recruitment and retention patterns over time in developed countries retrospective studies have been conducted to document the career paths of health workers 32 but similar databases are not available in kenya while results from the developed world are unlikely to be applicable to developing countries which have very different health labor markets and health workforce distribution 33 conclusions the issue of workforce shortage and maldistribution is complex and not unique to the nursing cadre or to kenya poor infrastructure limited training opportunities high workloads inadequate supplies and supervision undisclosed job locations for public sector jobs and most recently political instability all continue to be barriers to successful rural recruitment and retention interestingly we found no suggestion that those born in or with experience working in rural areas are more willing to seek rural employment while donor funded shortterm contracts have increased recruitment in recent years it is possible that their impact will be compromised by their unpopularity among nurses due to their lack of pension plans and job security the most popular proposed policy intervention among respondents was the provision of additional financial incentives for rural posting though these may be more effective if implemented as part of a multidimensional package such a package would require collaboration between economic and health policymakers to earmark funding to not only secure salaries but also improve working conditions it should also be accompanied by investment in information systems capable of monitoring its impact with rigor additional material authors contributions me and km designed the study with contributions from cg jw ml and db db sm and ml performed quantitative analysis while km and jw performed qualitative analysis of the data all authors participated in the interpretation of the results km and sm drafted the first version of the manuscript and all authors contributed to subsequent versions and revised it critically all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests published 2 july 2010

background kenya has bold plans for scaling up priority interventions nationwide but faces major human resource challenges with a lack of skilled workers especially in the most disadvantaged rural areas methods we investigated reasons for poor recruitment and retention in rural areas and potential policy interventions through quantitative and qualitative data collection with nursing trainees we interviewed 345 trainees from four purposively selected medical training colleges mtcs 166 preservice and 179 upgrading trainees with prior work experience each interviewee completed a selfadministered questionnaire including likert scale responses to statements about rural areas and interventions and focus group discussions fgds were conducted at each mtc results likert scale responses indicated mixed perceptions of both living and working in rural areas with a range of positive negative and indifferent views expressed on average across different statements the analysis showed that attitudes to working in rural areas were significantly positively affected by being older but negatively affected by being an upgrading student attitudes to living in rural areas were significantly positively affected by being a student at the mtc furthest from nairobi during fgds trainees raised both positive and negative aspects of rural life positive aspects included lower costs of living and more autonomy at work negative issues included poor infrastructure inadequate education facilities and opportunities higher workloads and inadequate supplies and supervision particular concern was expressed about working in communities dominated by other tribes reflecting kenyas recent electionrelated violence quantitative and qualitative data indicated that students believed several strategies could improve rural recruitment and retention with particular emphasis on substantial rural allowances and the ability to choose their rural location other interventions highlighted included provision of decent housing and more rapid career advancement however recently introduced short term contracts in named locations were not favoured due to their lack of pension plans and job security conclusions this study identified a range of potential interventions to increase rural recruitment and retention with those most favored by nursing students being additional rural allowances and allowing choice of rural location greater investment is needed in information systems to evaluate the impact of such policies

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introduction leading international bodies in health and social care research and governance advocate the integration of stakeholder involvement in the design and development of novel health interventions 1 2 3 stakeholder input in intervention development is important to ensure that the intervention is relevant and useful for those people or groups who have or could have an interest in it this in turn has the potential to maximize the acceptability and potential effectiveness of the intervention contemporary methods for designing products or services have moved away from using material and suppliercentered processes to more social and usercentered processes 4 consequently designoriented approaches to health care innovation are being more widely recognized 5 6 7 involving relevant stakeholders as codesigners of health interventions allows the stakeholders to help define the health care problem and identify preferred intervention solutions 8 9 10 11 12 divergent and convergent thinking may result in the generation of new intervention ideas and selection of the best idea available intervention ideas are prototyped and explored handson through sequential processes to rehearse the future 47 despite the growing use of codesign techniques in health care innovation there is no explicit replicable and accepted description of their application in the development of complex health interventions stakeholder involvement alone is not sufficient for effective intervention development a range of research methods also needs to be applied including careful consideration of existing evidence of need and for effectiveness and costeffectiveness of interventions to tackle the specific problem qualitative research provides depth of understanding to the relevant issues evidencebased medicine has been formally recognized as one of modern medicines most important milestones 13 and is applied increasingly across the fields of public health behavioral medicine and health and social care systematic and rigorous methods including systematic reviews metaanalyses and metasyntheses for identifying and evaluating the evidence base and identifying and developing theory are key elements in the process of developing complex health interventions 14 quantitative andor qualitative data are synthesized to draw conclusions about likely intervention effects and potential effect modifiers for example the active ingredients or features of interventions such as behavior change techniques associated with more positive behavior change and theory underpinning effective interventions can be identified 15 16 17 18 19 these conclusions can then be used to inform the development of novel interventions including the features that are most likely to be effective 2021 this systematic and theoretical approach to intervention development along with accuracy of reporting the intervention protocol facilitate the evaluation and replication of the intervention while this approach to evidence synthesis is desirable in practice it can be challenging because of the absence of established methods to guide the application of evidence to the specific population or clinical context in building a complex intervention 2223 qualitative research methods help inform the development of complex health interventions 2425 interviews focus groups and observational methods can explore the needs attitudes behavior and contextual factors of the specific population and health topic under investigation 26 the outcomes of such qualitative research can help intervention developers identify potential further intervention effect modifiers which may inform tailoring of the intervention thereby increasing the likelihood that the intervention will be accepted and effective in practice intervention developers are likely to use deductive and inductive research methods to generate the evidence base on which the novel intervention is based mixedmethod studies attempt to bridge the epistemological differences between quantitative and qualitative data acquisition approaches 27 such an inclusive approach to evidence synthesis integrating different forms of scientific evidence can be challenging especially when mixedmethod findings conflict 28 moreover methodological guidance on how to integrate this evidence with stakeholder needs and preferences is lacking this paper aims to fill this important methodological gap describing and appraising a systematic and sequential approach to intervention development drawing on techniques of codesign specifically we detail the stages and techniques used to integrate quantitative and qualitative evidence and expert knowledge and experience to engage stakeholders in a codesign process the process is illustrated through the development of a webbased lifestyle intervention to promote health and wellbeing of people in retirement obrien et al journal of medical internet research xsl • fo renderx methods and results overview an iterative codesign process involving sequential validation of the evidence generation of intervention ideas and prototyping testing analyzing and optimizing the intervention was followed this process is described as a series of stages in which each stage in the process resulted in output to inform the design of the intervention after each stage the research team discussed and analyzed the output and critically reflected on the process outputs from each stage were used subsequently as inputs to the next stage of development the methods and results of each stage are therefore presented sequentially figure 1 displays an overview of the methods employed and outputs derived at each stage the context and underlying rationale behind developing a webbased lifestyle intervention to promote health and wellbeing of people in retirement is presented in the following summary xsl • fo renderx summary of the intervention development context retirement from fulltime work is a life transition that has been shown to be associated with changes in key lifestyle factors some crosssectional and longitudinal studies have shown that people engage in more healthy behaviors with retirement 29 30 31 however the evidence is inconsistent and other studies have shown reduced physical activity 3233 less healthy dietary behavior 34 and a loss of perceived status and purpose 35 the population health and wellbeing benefits of physical activity a healthy diet in particular one based on a mediterranean dietary pattern and social engagement are well documented 36 37 38 despite recent evidence that todays older adults are healthier than they were 1020 years ago 39 with a globally ageing population and the accompanying increase in the prevalence of chronic ill health and morbidity 40 maintaining a healthy lifestyle into later years is vital for individual wellbeing and to lessen the burden on society as engagement with key health and social behaviors may change in retirement the retirement transition offers a unique window of opportunity to intervene to improve health and wellbeing of older adults 41 a small number of studies have delivered lifestyle interventions in the retirement transition 42 43 44 45 and systematic reviews synthesizing data from this life stage provide support for their effectiveness 46 47 48 49 a predefined priority for the research team was to develop a personalized scalable sustainable and potentially costeffective intervention webbased interventions can be tailored to the individual user and may be more compatible with modes of accessing information and support in future cohorts of older people they also have greater potential for wide scale use in the target population as such the possibility of a webbased intervention was a planned consideration of the research team figure 2 details the process by which the sequential intervention development approach was applied to develop leap a webbased lifestyle intervention in retirement the specific outputs of each stage in the development of leap are presented stage 1 compiling the evidence base stage 1 procedure evidence from systematic reviews qualitative research and other sources including the wider evidence base for behavior change and consultation with relevant experts was summarized by the research team stage 1 analysis the evidence was recorded as a list of evidence statements 50 that informed the aims and content of codesign workshop 1 stage 1 outputs the evidence statements are listed in figure 2 and descriptions of the evidence are enlarged upon in multimedia appendix 1 the systematic reviews which in part underpinned these statements have previously been published 1819 47 48 49 stage 2 codesign workshop 1 stage 2 participants a total of 42 stakeholders participated in codesign workshop 1 participants included 12 members of the research team 22 adults aged 55 years or over as potential intervention users and 8 health and social care professionals from the voluntary sector and public health organizations whose role was related to improving health and wellbeing of people in retirement the research team included health researchers from a range of disciplines involved in improving health and wellbeing in older people and with combined expertise in design behavior change public health physical activity nutrition and dietetics and social gerontology older adults from local older peoples forums were sampled purposively to represent men and women at different stages in the retirement transition and from diverse socioeconomic backgrounds stage 2 procedure the aim of stage 2 was to determine the face validity of the evidence statements and brainstorm new intervention ideas which were informed and inspired by the evidence statements in preparation discussion among the research team identified that the qualitative work provided the context in which the intervention would be built the qualitative work emphasized individual experiences through retirement retirement was commonly experienced as a process rather than a discrete event the systematic review evidence and the theoretical framework of the health action process approach provided recommendations regarding intervention content modalities and timings through these discussions the research team identified the need for codesign techniques that could combine descriptive contextrich narratives with more discrete evidence regarding health and social behaviors the workshop took place in a university space participants were divided into small groups each comprising older adults health and social care professionals one facilitator and one scribe facilitators guided the structure and timing of the workshop and scribes recorded participants comments and ideas the first technique used in the workshop was the codesign of a persona as retirement is both a process and idiosyncratic persona building 51 was a useful technique in order to orient each group to real world issues in retirement each group of workshop participants was assigned a different persona with a description that was a composite of different accounts and experiences of participants in the qualitative study and from clinical experience of the research team the personas represented male and female older adults from a range of socioeconomic positions each workshop group considered one of the behaviors examined in the systematic reviews 47 48 49 for example jeff was said to be physically inactive but had enjoyed being active when he was younger the second technique was experience mapping 52 of the retirement transition to generate intervention ideas including considering when it would be most needed accepted and potentially effective we mapped different retirement pathways identified in the qualitative study each group considered the possible key stages in the personas retirement transition such as jeff gets made redundant jeff retires and jeff gets a parttime job this technique allowed participants to discuss how the persona might feel during the retirement transition reflecting on their own experiences each group generated intervention ideas that would help tackle the specific health social or resource challenges of the persona in each scenario in particular groups were asked to consider webbased intervention ideas drawing on evidence statements regarding the importance of the local environment and community resources to facilitate behavior change groups were presented with a map of the personas local area and asked to think about whether local resources could support the intervention ideas generated wild cards representing random events that might disrupt the retirement story were introduced to mimic the unpredictable nature of real life and challenge the participants to consider whether these events would alter the retirement story the wild cards also provided opportunities to discuss how specific intervention features such as behavioral change techniques could be incorporated in the personas retirement pathway the third technique was storyboarding 53 this allowed the group to pull their different ideas together to form a new intervention to support an ideal retirement experience for their persona the intervention ideas from each group provided an outline of a potential intervention which was defined to include its name how it would be signposted or advertised features to encourage initial and longerterm engagement and the lifestyle behaviors it would help to promote stage 2 analysis shortly after the workshop the facilitators prepared detailed notes to capture group discussions and describe how the participants tackled each activity reflecting on the key insights and ideas discussed within each group analyzing the outputs of the workshop activities revealed recurring design ideas which became the principles underpinning the intervention the intervention principles were derived from validating the acceptability and importance of the evidence statements with potential users and therefore the principles reflected the context in which the intervention would be built and ideas for intervention content modality and timing these principles were further explored and developed by stakeholders at subsequent workshops to generate more tangible ideas for products and features for the intervention the method used to analyze the facilitator notes and workshop materials resembles thematic analysis 54 a technique that allows for the identification of repeated patterns of meaning as used here it captured design ideas in addition to themes stage 2 outputs the outputs of codesign workshop 1 were the potential intervention ideas from each of the six groups the potential intervention components resources for the intervention and the key design priorities were identified by the research team the most common themes and features in the intervention ideas formed the following intervention principles 1 selfreflection on financial time social health and community resources the intervention should provide practical assistance in planning or structuring activities focusing on key life events rather than age 2 personalization to individual circumstances preferences and goals providing a flexible intervention with individual feedback and tailored support from a mentor 3 social relationships linked to being physically active eating healthily in order to reduce risks of social isolation promote a sense of social support and share experiences in an engaging way stage 3 codesign workshop 2 stage 3 participants a total of 20 stakeholders participated in codesign workshop 2 6 members of the research team and 14 older adults older adults were recruited from local forums as before stage 3 procedure codesign workshop 2 aimed to obtain user feedback on the intervention principles derived from codesign workshop 1 feedback was used to assess face validity of the principles and to develop the core intervention concepts the workshop took place in a local community meeting space and lasted 4 hours including refreshment breaks participants were divided into three groups each of which was led by a workshop facilitator each group was also supported by a creative facilitator with design expertise who sketched the intervention ideas as they were being generated and facilitated the development of handdrawn prototypes of potential interventions using paper web browser templates web browser templates were used to explicitly explore the acceptability of a webbased intervention in preparation for this workshop the design expert identified further codesign techniques to facilitate the presentation and interaction with specific aspects of the intervention principles using web browser visual materials and prompts prototyping was a key technique used to communicate ideas which enabled the progression of thinking through physical making a safe space for failure leading to faster learning and encouragement and permission to explore new behaviors 55 validation of the selfreflection intervention principle was conducted using mockups of a work transition tool with interactive graphs and texts this tool which supported individuals to reflect on possible work exits or reentry as identified in the qualitative work 56 was developed in each workshop group to further explore the personalization intervention principle participants were asked to consider what questions the intervention platform should ask to learn about the personas attitudes and habits in relation to the target lifestyle behaviors the answers to these questions would shape how the intervention could be personalized to meet the personas needs circumstances and goals participants wrote the questions on cards placed them in a natural conversational order and considered options for how they could be presented the codesign technique of persona building was used to further explore and validate the social relationships intervention principle while also providing further opportunity to explore the act of planning included in the selfreflection principle groups mapped a typical week during retirement focusing on the absolute and relative time the persona engaged in lifestyle behaviors related to being physically active eating healthily and spending time with other people stage 3 analysis detailed notes capturing each groups discussion how the participants tackled each activity and key feedback on the intervention principles were produced by the facilitators using thematicbased analysis as in stage 2 facilitator notes and the handdrawn prototypes of potential interventions were analyzed to identify recurring design ideas and intervention user requirements and to define the core intervention concepts which reflected the intervention principles and the target lifestyle behaviors of physical activity healthier eating and social roles stage 3 outputs the outputs of codesign workshop 2 were core intervention concepts and the handdrawn prototypes of novel interventions which served to document how the intervention principles were validated through user feedback the work transition and mapping a retirement week tools were evaluated as enabling selfreflection providing feedback on financial time and social resources and facilitating future goal setting and planning seeing when new activities could take place was deemed to be extremely valuable providing insight into potential spare time it also served to prompt people to set boundaries and goals a core set of personalization questions were defined whose answers would allow the intervention to be tailored to individual needs and goals the result was a lowfidelity prototype of the user registration component of the intervention with each webpage handdrawn on a deck of paper templates the majority of participants welcomed a webbased intervention acknowledging the benefits of having access at home and at convenient times and the intrinsic ability of a webbased intervention to be tailored to the individual however there were concerns that some individuals may feel unsupported by technology and consequently disengage from the intervention further reinforcing the need for support from a mentor outlined in the personalization design principle potential costeffectiveness and scalability of the intervention were predefined priorities of the research team therefore providing access to someone to support use of the intervention such as a health care assistant was considered unfeasible consequently the role of a virtual mentor within the webbased intervention who could help the user explore retirement transition options and lifestyle behaviors was explored and positively appraised the research team identified common themes and features of the handdrawn prototypes that related to the target lifestyle behaviors to form the following core intervention concepts time use and work exit planning as an opportunity to assess current financial time and social resources receive feedback and encourage the planning of new activities personalized goal setting based on identified available resources selfmonitoring of behavior and regular reviewing of lifestyle goals and a webbased intervention as an acceptable mode of delivery providing that support to use is available stage 4 translating outputs into a design brief and specification stage 4 procedure the aim of this stage was for the research team to examine critically evaluate and translate the outputs from the previous stages into a detailed design brief and specification document to inform the intervention build stage 4 analysis the evidence statements design principles handdrawn prototypes and core intervention concepts were examined for recurring design ideas and intervention requirements across all outputs these ideas and requirements were evaluated critically by the research team for concurrence with the teams predefined priorities the intervention development context and their suitability to support the promotion of the target lifestyle behaviors stage 4 outputs the output was a design brief and specification document detailing the aim of the intervention and the design features it should include the design brief stated the need for an interactive website including a set of intervention tools to support people to have a healthier and more fulfilling retirement the design specification detailed the following design features that the intervention should include personalized scalable sustainable interactive digital user flow through the intervention and visually and functionally engaging the following intervention sections or modules to be included were also detailed user profile workexit and cost of living time and activity planner physical activity eating well and social relationships stage 5 intervention build stage 5 procedure the aim of this stage was to produce a functional version of the intervention prototype this involved a tendering process to identify a web development company that would support the building of a functional webbased intervention prototype the design brief and specification were included in the tender the research team worked closely with the contracted company throughout the process holding regular facetoface meetings to discuss emerging ideas for presenting the intervention content to order and structure the intervention modules and to maximize user engagement with the intervention stage 5 outputs wireframes for the intervention modules detailed module content and decision trees guiding user flow through the intervention were developed wireframes are simple images that show how a website and its webpages are structured and how the content is arranged a set of six virtual mentors connected if desired to audio files recorded by local actors to provide cultural links were also developed to guide and support users through the intervention the final output of this stage was a functioning webbased intervention prototype for testing and optimization with stakeholders stage 6 codesign workshop 3 stage 6 participants a total of 37 stakeholders participated in codesign workshop 3 8 members of the research team as facilitators and 29 older adults older adults were recruited from local forums stage 6 procedure the aim of the third and final codesign workshop was to derisk the prototype 57 through testing intervention functionality and identifying necessary modifications using a cognitive walkthrough activity 58 the final workshop took place in a university space participants were divided into small groups each of which was led by a workshop facilitator the intervention derisking techniques focused on exploiting user experience testing participants were provided with a tablet and asked to use the intervention with the aim of testing its functionality usability and aesthetics feedback queries technical and functional issues that participants expressed were recorded by the group facilitator on printed screenshots of each page of the intervention the technique of persona building was used as the vehicle for the group to navigate the intervention from the perspective of the persona stage 6 analysis the feedback and issues identified by each group were collated by the facilitators technical and functional issues were added to a list of required revisions to the intervention prototype other feedback such as comments relating to the design esthetics or content of the intervention was considered by the research team to ascertain whether the revisions were feasible and essential stage 6 outputs the output of this stage was a comprehensive list of revisions to the intervention prototype required to improve user experience and acceptability of the intervention identified revisions to the prototype included refining color contrasts and font size revising text content order and position including an intervention overview page a dashboard summarizing the parts of the intervention with which the user has already engaged and a diary summarizing the users activities scheduled for the following weeks adding progress bars for questionnaires and providing options to hear the mentors voice and viewing the time planner as a calendar or pie chart an optimized functioning intervention prototype was produced following the amendments and refinements stage 7 iterative intervention optimization stage 7 participants a group of 30 representatives of stakeholders provided feedback on the revised intervention prototype stage 7 procedure the aim of this final stage was for the revised intervention prototype to be further tested by stakeholders to identify additional ways to improve and refine the intervention this stage adopted an iterative testing user feedback and intervention refinement process whereby optimization occurred in parallel with testing to ensure that new or revised features were also tested the research team liaised closely with the web development company to ensure that optimization occurred promptly and efficiently stage 7 outputs the output was a final prototype webbased intervention ready for formal field testing in a pilot randomized controlled trial the intervention was named leap table 1 1618193856 59 60 61 62 63 64 presents a summary of leap intervention modules tools and interactive features and the evidence on which each element was based ethical approval this work was conducted as part of the livewell program ethical approval was acquired from newcastle university ethics committee informed consent was obtained from participants in the qualitative study the workshops were based on a codesign methodology where all stakeholders held shared power in the development of the new intervention no personal data were collected thus ethical consent to participate in the workshops was not obtained however informed consent was obtained for the purpose of photographically recording the activities at each workshop table 1 the leap features and modules and the objective tools and evidence on which they were based at different stages of the intervention development process evidence base leap tools objective leap section module qualitative research found that retirement transitions and available resources are idiosyncratic the user profile supports register the user and set preferences user profile the tailoring of leap to address the variable nature of retirement transitions 5659 preliminary information about the users retirement stage physical activity diet and social circumstances is captured and used to tailor the introduction of the related module codesign workshop 3 identified the need for an overview to provide a guide to the intervention modules and tools including codesign workshop 1 identified the need for a mentor to support user journey through the intervention this idea was appraised positively during codesign workshop 2 virtual mentors were developed and optimized during codesign workshop 3 optin for leap to be personalized and supported by a virtual mentor one of eight mentors could be chosen with the option of hearing their voice or reading the text systematic review of dietary interventions found that the bct followup prompts was associated with greater intervention ef optin to receive weekly email bulletin summarizfectiveness 19 selfregulation prompts for action control 60 is an effective behavior change strategy 61 ing recent usage of leap and prompt revision of goals and plans qualitative research indicated that assistance to reflect on current and future time use was important considering how time might interactive calendar or pie chart time planner reflect on current and desired future time use over the retirement transition time module be spent in retirement might help identification of personalized goals and potential barriersfacilitators to goal achievement 56 this module provides space and tools for the user to think through the possibilities and opportunities for lifestyle behaviors goals and aspirations codesign workshop 1 found that a time reflection tool would be useful codesign workshop 2 found that providing a choice of how the time planner tool is presented is desirable and that this module was valuable to set the scene for other modules where activities could be considered and scheduled experiences and the adoption and maintenance of lifestyle choices 59 this module allows the user to consider their circumstances and opportunities to engage in new activities and the effect on income and expenditure codesign workshop 1 showed that a work exit tool was appraised positively by potential users codesign workshops 2 and 3 further developed and refined this tool evidence base leap tools objective leap section module physical activity was a predefined target behavior pedometer to facilitate selfmonitoring goal setting including stepcount receive feedback schedule activities identify barriers and revisit and review step and activity goals awareness of current physical activity level opportunity and tools to engage in selfregulation of pa moving more module systematic review of physical activity suggested that the bct providing feedback was associated with greater longterm effectiveness 18 evidence for the effectiveness of other selfregulation bcts to promote pa in line with the health action process approach 16 62 63 64 codesign workshop 1 confirmed that the bcts of selfmonitoring goal setting and action planning were acceptable to stakeholders and potentially valuable for most codesign workshops 2 and 3 further developed and refined this module social connectedness was a predefined target behavior interactive social relationship mapping social role case studies and schedule activities explore potential benefits of having a meaningful occupation role or spending time with significant others being social module systematic review of social roles suggested that interventions providing explicit roles with group support were effective 48 the social roles tool provides resources to explore explicit roles participating in social relationships has been identified in the literature as key to wellbeing in later life 38 qualitative research confirmed the importance of social relationships but did not identify a clear opportunity for intervention 56 codesign workshop 2 identified a potential intervention mechanism through a relationship reflection tool supporting by structured suggestions for maintaining and building social relationships a predefined target behavior mediterranean diet quiz and feedback goal setting recipe book schedule trying a new recipe identify barriers and revisit and review goals awareness of current diet and provision of information to make diet more mediterranean in style eating well module systematic review of mediterranean dietary patterns suggested that the bcts of goal setting identifying barriers feedback and followup prompts were associated with greater effectiveness 19 codesign workshop 1 identified the need for a selfassessment tool to appraise fit between current diet and mediterranean eating pattern with personalized feedback and suggestions to improve codesign workshop 2 confirmed acceptability of the modules core functions including personal goal setting feedback and followup prompts in line with bcts identified in systematic review 19 a meal planner and recipe guide were also judged acceptable codesign workshop 3 confirmed acceptability of the barrier identification and coping planning features stakeholders suggested improvements to interface usability and clarity this feature arose in codesign workshop 3 and was developed subsequently as a way to summarize the activities a user had scheduled and link with the weekly email bulletin to encourage revisiting the intervention to update data get feedback revise goals and plans and schedule new activities evidence for the effectiveness of selfregulation behavioral change techniques to promote health behaviors in line with the health action process approach 161819 62 63 64 intelligent design remembers previously named significant others and prompts to add them to the scheduled activity schedule pa trying a new mediterranean diet recipe or social activity for the current and following week diary discussion principal findings this papers key contribution is providing a description of a systematic sequential approach to integrating scientific evidence from systematic reviews qualitative research and expert knowledge and experience with stakeholder involvement to develop an evidencebased complex health intervention we have detailed the stages employed including the codesign techniques used and the outputs produced and have demonstrated the application of the approach in the development of leap a webbased lifestyle intervention for people in the retirement transition here we provide a critical appraisal of this approach strengths and limitations the approach presented in this paper follows and complements the medical research council guidance for the development of complex health interventions 14 as advocated in this guidance our approach applied systematic and rigorous methods to identify and evaluate the evidence base and the theoretical basis for a novel intervention in addition we have described the practical stages and methods required to integrate this evidence with stakeholder input specifically we have utilized codesign methodology to facilitate stakeholder engagement and input which can be modified and refined to suit the specific intervention context and target population our approach adds to recent studies using codesign techniques for health care innovation 5 6 7 providing a concrete example of how to apply these methods in the development of a webbased lifestyle intervention in retirement our intervention development approach follows seven distinct stages each of which has the following strengths limitations and challenges stage 1 compiling the evidence base is an essential component of intervention development 14 but depending on the size and extent to which the evidence base has been interrogated previously this stage can be resource intensive which may be a barrier for projects with scarce resources in the example of developing leap there was limited existing evidence for the effectiveness of lifestyle interventions in retirement and on experiences of the retirement transition the wider evidence base for behavior change and knowledge of local resources with which the intervention could link were evidence sources that already existed yet required explicit interrogation in relation to the intervention objectives a challenge faced during stage 2 codesign workshop 1 involved the use of personas some stakeholders struggled with this concept initially but when the purpose of using a persona was further explained by researchers stakeholders engaged with the process in addition many stakeholders found that the wild cards used to assess how specific bcts could be incorporated in the personas retirement pathway were too abstract and difficult to grasp thus limiting the assessment of their potential value and acceptability in the intervention however allowing stakeholders to explore how bcts work in practice using a prototype intervention at a later stage in the intervention development process was found to be more effective the possibility of a webbased intervention was a planned consideration of the research team as the aim of the livewell program set out in the funding agreement was to develop a personalized scalable sustainable and potentially costeffective intervention however a webbased intervention was suggested as a potential mode of delivery for the intervention by several of the groups of stakeholders in this workshop a strength of using codesign techniques is that they can be used to support stakeholders to explore the evidence base for a novel intervention but they can also be used to stimulate the creation of other intervention ideas although a webbased intervention was a planned consideration of the research team we were cognizant of the potential limitations related to the socalled digital divide and subsequent health inequalities in intervention access and use 65 this issue was further explored in the formal pilot evaluation of leap the success of stage 2 codesign workshop 1 stage 3 codesign workshop 2 and stage 4 translating outputs into a design brief and specification relied critically on contributions from our design expert during stage 2 the design expert identified established codesign techniques including personabuilding and storyboarding to facilitate the development of persona narratives within the scope of the qualitative evidence and as a means to punctuate these narratives with opportunities to pursue the specific lifestyle behaviors identified in the systematic reviews they also ensured that the evidence statements written in scientific terms were translated into plain english and presented in a visually engaging way so that they were accessible and interesting for all participants during stage 3 the design expert guided the creative facilitators to sketch the intervention ideas generated and prototype potential interventions when testing prototypes the researchers observed that the level of fidelity of the prototypes was important sketched ideas were easier for participants to engage with than more detailed mockups of one part of the intervention were which was interpreted as a finished product inviting little useful feedback 66 these visual aids served both as prompts for discussion in the workshop and as illustrations of design ideas for use in stage 4 the challenge of stage 4 was to ensure that recurring design ideas contained in the prototypes were translated into specific features for tools modules or requirements of the intervention here the design expert supported the production of a design brief and specification that reflected the outputs from previous stages while also detailing the intervention content and function that should be included in the intervention build a challenge of stage 6 codesign workshop 3 was that some user feedback suggested revisions to the prototype that were deemed unfeasible or nonessential by the research team and therefore were not addressed in the revisions for example idiosyncratic feedback about the value of particular modules or features indicated that not all parts of the intervention would be useful to all users rather than trying to anticipate which parts of the intervention would be most valuable to a user on the basis of their user profile the team decided to emphasize in the intervention overview that leap is designed to allow a user to choose which modules or features to engage with in an order of their choice this would also allow an individual to revisit other parts of the intervention at a later date when perhaps their needs and priorities had changed the challenge of translating requirements from multiple perspectives and evidence sources alongside the scope and stated aims of the research program required that pragmatic compromises were made decisions were taken through discussion by the research team in addition the contracted webdevelopment company had many design decisions to make in the functional intervention build that were not directly influenced by codesign stakeholders until the prototype testing stages a strength of our approach is that it draws on the diverse skills of a multidisciplinary team with expertise in a range of research methodologies including systematic reviewing qualitative enquiry and intervention codesign and development teams also need the subject expertise required to develop the particular intervention which in our case included pa nutrition and dietetics social gerontology and information technology expertise comparison of our intervention development approach with other approaches our sequential approach fills an important methodological gap in the complex health intervention development literature providing the description and appraisal of how to integrate systematic review qualitative research and other evidence with stakeholder engagement in a codesign process other approaches have advocated the integration of user perspectives in intervention development demonstrating the importance of conducting qualitative research with a wide range of people from the target user populations at every stage of intervention development from planning to feasibility testing and implementation 2567 in addition the application of codesign techniques in health care intervention development has been demonstrated 8 9 10 11 our approach values the role of qualitative research and stakeholder input in intervention development but also details how to integrate systematic review evidence in the process which is an important component of the mrc guidance 14 moreover we provide detailed information on the stages and methods required to follow the approach to develop an intervention that is not only evidencebased but also fits the needs of intervention stakeholders thereby increasing the likelihood of the intervention being acceptable and feasible a 6step guide 68 attempts to fill the methodological gap in the literature by providing a guide of how to develop public health interventions from defining the problem and identifying the modifiable causal and contextual factors through to collecting preliminary evidence of effectiveness our approach complements this guide describing the specific methods and codesign techniques that can be employed at each step as illustrated by our example of developing leap the approach we have tested enables a clearly documented description of the intervention development process including the evidence on which each intervention featurecharacteristic was based and the potential causal mechanisms of change in terms of bcts used documenting the process in this way ensures that the intervention can be clearly described and reported facilitating future replication thus our approach supports researchers to conform to the template for intervention description and replication intervention reporting guidelines 69 and to develop an intervention logic model or theory of change which can direct an evaluation of the effectiveness of the intervention as advocated in the mrc guidance on process evaluation of complex interventions 70 implications of our approach the approach we present provides a sequential description of the methods needed to pursue evidence and theorybased complex health intervention development the codesign techniques we employed namely persona building 56 experience mapping 59 storyboarding 60 and prototyping 43 originate from product and service design adopting a social and usercentered process 4 codesign techniques have been used to involve stakeholders as codesigners in health care innovation and intervention development 5 6 7 8 9 10 11 our approach adds to this growing body of literature providing an explicit and replicable description of how to apply the techniques using the example of the development of leap a complex lifestyle intervention for people in the retirement transition as discussed the approach can be labor and time intensive in the illustrative example of developing leap a large proportion of the project timeline was attributed to delivering the outputs of stage 1 conducting highquality systematic reviews is a lengthy and resourceintensive process which in our example included additional work to identify the associations between intervention features and effectiveness this was a necessary stage in the process as current systematic review evidence of interventions for pa mediterranean dietary patterns and social roles for people in retirement did not exist where recently conducted highquality systematic reviews exist these can be used to develop the evidence statements to inform intervention codesign maximizing the time and resources available for the later stages of designing building and derisking the intervention further work we have demonstrated that a sequential approach can be applied to the development of a webbased lifestyle intervention for people in retirement further work is needed to apply this approach to other areas of health intervention development further application and refinement of this approach would help build evidence about its utility and acceptability this in turn could support the development of formal guidance on this process the final output of our approach to intervention development is a functional prototype ready for formal testing to ascertain the effectiveness of the intervention webbased interventions have significant promise to reach the rapidly expanding older adult population who are increasingly becoming routine internet users 71 and have been shown to have positive effects on lifestyle behaviors including pa in older adults 72 73 74 the feasibility and acceptability of leap has been formally tested in a pilot randomized controlled trial which will be reported elsewhere the pilot data will be used to inform the design of a definitive evaluation of the effectiveness and costeffectiveness of leap conclusions this paper fills an important methodological gap in the complex health intervention development literature by describing and appraising a systematic sequential approach to the codesign and development of an evidencebased complex health intervention using the example of the development of the leap intervention we have illustrated the application of this approach and detailed the stages and techniques followed integrating quantitative and qualitative evidence derived from systematic xsl • fo renderx reviews and qualitative research expert knowledge and experience and stakeholder involvement authors contributions jm pm mw fs and sm conceived the project and secured funding for the study no bh gt and pm developed the study design the methods were further developed and fieldwork was undertaken by no bh gt ee cc sm and pm data analyses and interpretation were conducted by all authors no wrote the first draft of the paper pm wrote revisions all authors commented on drafts and approved the final version conflicts of interest none declared multimedia appendix 1 further description of outputs of stage 1 that underpinned evidence statements pdf file 24kbmultimedia appendix 1 multimedia appendix 2 example of persona used in stage 2 meet helen jpg file 73kbmultimedia appendix 2 multimedia appendix 3 example of personal used in stage 2 meet jeff jpg file 70kbmultimedia appendix 3 multimedia appendix 4 summary of design brief and specification pdf file 47kbmultimedia appendix 4 multimedia appendix 5 screenshot of leap welcome page jpg file 63kbmultimedia appendix 5 multimedia appendix 6 screenshot of mentor selector multimedia appendix 7 screenshot of mentor overview jpg file 71kbmultimedia appendix 7 multimedia appendix 8 screenshot of my time module jpg file 67kbmultimedia appendix 8 multimedia appendix 9 screenshot of changing work module jpg file 56kbmultimedia appendix 9 multimedia appendix 10 screenshot of moving more module jpg file 62kbmultimedia appendix 10 multimedia appendix 11 screenshot of being social module jpg file 68kbmultimedia appendix 11 multimedia appendix 12 screenshot of eating well module jpg file 60kbmultimedia appendix 12 multimedia appendix 13 screenshot of diary jpg file 61kbmultimedia appendix 13 multimedia appendix 14 this is an openaccess article distributed under the terms of the creative commons attribution license which permits unrestricted use distribution and reproduction in any medium provided the original work first published in the journal of medical internet research is properly cited the complete bibliographic information a link to the original publication on as well as this copyright and license information must be included

background integrating stakeholder involvement in complex health intervention design maximizes acceptability and potential effectiveness however there is little methodological guidance about how to integrate evidence systematically from various sources in this process scientific evidence derived from different approaches can be difficult to integrate and the problem is compounded when attempting to include diverse subjective input from stakeholdersthe intent of the study was to describe and appraise a systematic sequential approach to integrate scientific evidence expert knowledge and experience and stakeholder involvement in the codesign and development of a complex health intervention the development of a webbased lifestyle intervention for people in retirement is used as an example methods evidence from three systematic reviews qualitative research findings and expert knowledge was compiled to produce evidence statements stage 1 face validity of these statements was assessed by key stakeholders in a codesign workshop resulting in a set of intervention principles stage 2 these principles were assessed for face validity in a second workshop resulting in core intervention concepts and handdrawn prototypes stage 3 the outputs from stages 13 were translated into a design brief and specification stage 4 which guided the building of a functioning prototype webbased intervention stage 5 this prototype was derisked resulting in an optimized functioning prototype stage 6 which was subject to iterative testing and optimization stage 7 prior to formal pilot evaluationthe evidence statements stage 1 highlighted the effectiveness of physical activity dietary and social role interventions in retirement the idiosyncratic nature of retirement and wellbeing the value of using specific behavior change techniques including those derived from the health action process approach and the need for signposting to local resources the intervention principles stage 2 included the need to facilitate selfreflection on available resources personalization and promotion of links between key lifestyle behaviors the core concepts and handdrawn prototypes stage 3 had embedded in them the importance of time use and work exit planning personalized goal setting and acceptance of a webbased intervention the design brief detailed the features and modules required stage 4 guiding the development of wireframes module content and functionality

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introduction the healthcare system in middleand lowincome countries continue to face considerable challenges in providing accessible affordable and quality health services to a large population the rapid penetration of internet and mobile tools offers a promising solution to address these mounting challenges despite the growing enthusiasm and evidence base recent systematic reviews suggested that the quantity and quality of ehealth programs are still limited and few pilot programs have been scaledup or translated into sustainable policies as the most populous developing country china is facing such mounting challenges as limited healthcare resources unequal access to healthcare substantial ruralurban health disparities and an aging population the massive healthcare reform since 2009 was aimed to address these challenges china also hosts the largest population of netizens as of 2016 china had 731 million internet users and 13 billion mobile phone users the chinese government is encouraging all healthcare agencies to utilize chinas robust telecommunication infrastructure to assist in national healthcare reform initiatives an increasing number of governmentsponsored internet hospitals and ehealth interventions have been established however a closer look at the data from the burgeoning ehealth initiatives revealed that most ehealth interventions were pilot projects conducted in major metropolitans and the surveys on attitudes toward ehealth programs were typically collected from medical professionals or based on small convenience samples data are missing on the readiness of ehealth adoption in the general chinese population the literature from developed countries such as the us suggested that access to mobile tools is not equivalent to using mobile tools for health purposes and despite ubiquitous access to internet a persistent digital divide persists within such a complex context of high enthusiasm of chinese government to promote internet hospitals and limited global evidence of ehealth program sustainability from middleand lowcountries understanding ehealth behaviors of the chinese population is an essential first step to formulate evidencebased ehealth policies the current study aimed to fill up this literature gap by presenting a profile of ehealth behaviors in the general chinese population with two research questions whats the methods data source the survey was conducted through the research project of china governance and public policy surveys collaborated by the texas a m university in us and southwestern university of finance and economics in china from 2016 to 2017 the cgpps employed a threestage stratified probability proportion to size random sample design with additional onsite gpsgis remote sensing sampling strategy to draw a representative sample of chinese adults aged 18 and older in mainland china a total 6682 respondents were drawn and contacted and 4043 interviews were completed yielding a final response rate of 6050 the survey was administered through random dialing computer aided telephone interviewing system all data were double entered and quality checked the study protocol was approved by the institutional review boards in tamu and swufe measures the 5 measures of ehealth behaviors were adopted from the us national cancer institutes health information national trends survey since its inception in 2003 the biennial survey of hints has been considered as the leader in measuring ehealth behaviors the measures included search health information online buy medicine online communicate with healthcare providers online connect with patients of similar health conditions online and make doctors appointment online demographic characteristics included age gender education ruralurban residence employment status income and health insurance in this study education was transformed into an ordinal variable of 5 categories no schooling or primary school middle school high school or vocational school and college or above income was measured per capita income and was logtransformed for its skewness of distribution health outcome was measured by selfreported health and the responses were dichotomized to good health and poor health data analysis we first analyzed the distribution of the five ehealth behaviors then we used chisquare and ttest to examine the relationship between each ehealth behavior and demographic variables we then used multivariate logistic regression to examine the independent relationship between ehealth behavior and key demographics we used stata 120 for data analysis svy procedures were used to account for complex sampling design in estimating standard errors and incorporate sampling weights to inferential statistics results the survey data revealed that 51 of the 4043 participants had used internet however only 333 of participants had searched health information 94 bought medicine online 82 communicated with peers of similar conditions 100 communicated with doctors and 101 made doctors appointment online table 1 presents the independent association of key demographics and each ehealth behavior specifically younger age more education higher income and urban residence were significant predictors for all ehealth behaviors the most significant predictor was ruralurban residence urban residents were about twice more likely to engage in ehealth behaviors than their rural counterparts on the other hand gender employment status health insurance and health status were not associated with any ehealth behavior discussion our findings suggested that access to internet was not equivalent to ehealth behaviors with 51 population have used internet only 33 chinese have searched health info online and 10 used online healthcare communication or management chinese ehealth behaviors were strongly predicted by socioeconomic status indicating a significant digital divide the ehealth behavior adoption rates in china were lower than those in the us but the patterns of persistent digital divide were similar except that a significant ruralurban divide exists in china this study is limited in the following aspects first like other national surveys potential volunteer and sampling biases might exist however our sampling scheme and data collection methods have been used in other credible national surveys the response rates and participants demographic characteristics were similar to other national surveys second we only measured five ehealth behaviors and might have missed other important ehealth behaviors more than 90 chinese own a cell phone how they used mobile apps or cell phones for health purposes needs further study and finally the crosssectional nature of the study design prohibits interpretation of causal relationship despite these limitations the current study reports the first national survey on ehealth behaviors in china and one of the first from middleand lowincome countries the low adoption rates of ehealth behaviors and significant digital divide suggested that the general chinese population might not yet be ready for the internet hospitals or intelligent healthcare literature from highincome countries suggested that the ubiquitous internet access has created a persistent digital divide and the ehealth movement has exacerbated health disparities a recent survey on acceptance of internet hospitals in some urban residents found that a majority of chinese were reluctant to use such a system instead their primary concerns were long waiting time and difficulties of making a doctors appointment our data of low prevalence of ehealth behaviors in the general population corroborated with such observations to conclude we share the optimistic vision of ehealth systems in china but low adoption of ehealth behaviors and the significant digital divide as evidenced in this study underscore the insufficient readiness of internet hospitals in the general public hefty investment on internet hospitals which may benefit only the young healthy educated and wealthy urban residents and further aggregate health disparities we call for more resources for healthcare infrastructure building in the underserved communities and reduction of the digital health divide ethics statement the study protocol including the national survey protocol was approved by the institutional review boards in the texas a m university in us and the southwestern university of finance and economics in china 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

background the widely accessible internet has boosted an enthusiasm for ehealth in china but we know little about ehealth behaviors in the general population objective to assess the prevalence of ehealth behaviors in general chinese population and identify the predictors of digital divide methods a nationally representative survey was administered in 20162017 with a sample size of 4043 five ehealth behaviors were assessed search health information communicate with healthcare providers connect with patients of similar health conditions buy medicine and make doctors appointment online multivariate logistic regression was employed to assess the independent relationship between ehealth behaviors and key demographic variables results about 33 of participants have ever searched health information online and the prevalence of other ehealth behaviors was less than 10 the adoption of ehealth behaviors was significantly associated with younger age more education higher income and urban residence by contrast gender employment status health insurance and health status were not associated with ehealth behaviorthe adoption of ehealth behaviors in the general chinese population was low and a significant digital divide exists we caution against the speedy development of internet hospitals and call for more resources allocated to bridge digital health divide

19812_0

introduction and motivation the social force model 1 2 3 4 is one of the most prominent examples of a model of pedestrian dynamics it is formulated in a way that a most of its parameters do not have an immediate interpretation in the sense that they cannot be measured directly b often one single parameter has an impact on many aspects of walking behavior and c a certain aspect of walking behavior results from the values of more than one parameter in this regard the sfm is very different from a number of carfollowing models like the wiedemann model 5 where nearly each parameter has an immediate interpretation and has only a local effect local in the sense that within the model it affects only a certain observable properties of driving behavior ie of the results this structure of the sfm makes calibration challenging since when the meaning of a parameter is abstract instead of immediate for someone confronted with the model for the first time it is often unclear which are the most relevant parameters to adjust and even in which direction a certain modification of the value of a certain parameter changes the simulation results among models of pedestrian dynamics the sfm is not unique in having parameters with a rather abstract meaning the cellular automata floor field models for example share that property to a similar degree 6 7 8 compared to actionpoint carfollowing models the sfm also has an advantage it can be analyzed transformed and simplified in a rigid mathematical way allowing a deeper understanding of the a priori abstract parameters which leads to the aim of this paper to give practitioners an indication of how to proceed in the calibration process for this by analytical transformations the parameters of the sfm are related to real properties that have a clear and immediate meaning number of pedestrians stand still density and capacity flow the latter two are highly relevant since they frame the fundamental diagram and thus are important properties in a calibration process at the same time these are basic properties such that a model which reproduces these well does not necessarily work well in more complex situations like bidirectional flow situations with emergent lane formation thus the work done in this contribution is necessary for calibration but not complete however with regard to the numerous variants of the sfm 3 9 10 11 12 13 14 15 16 and to general forcebased models 1718 the basic character of the proposed method is beneficial since it means that it applies to most of these variants the outline is as follows in the next section we will derive the results step by step and also document the model simplifications that lead to the results a reader not interested in the derivation may skip the section and continue in the summary of results and discussion section after which follows a section with examples derivation of results our starting point is the circular specification of the sfm it is the simplest version since interpedestrian forces depend only on distance between pedestrians since in all states of the system that we use in our reasoning relative velocities between pedestrians are zero the arguments also hold for the elliptical specification ii which in addition to distance also considers relative velocity as determining property for the forces elliptical specification i on the contrary which takes into account distance and the velocity of the pedestrian who exerts the force is fundamentally different 3 the circular specification of the sfm neglecting forces from walls is defined as ¨ x i v 0i ˙ x i τ i ãi j w x j ˙ x i λ i e x j x i r i r j b i êij with w x j ˙ x i λ i λ i 1 cos x j ˙ x i 2 where v 0i is the desired speed of pedestrian i ãi 0 b i 0 0 ≤ λ i ≤ 1 and τ i 0 are parameters of the model r i denotes the body radius of a pedestrian êij has the direction from pedestrian j on pedestrian i x i is the position of a pedestrian and dots mark time derivatives the sum runs over all potentially infinitely many pedestrians in a simulation scenario function w is there to suppress forces acting from behind within it θ ij is the angle between pedestrian is velocity vector and the line connecting pedestrians i and j abstract parameters in the sense of the introduction are particularly a i b i and λ i and to a lesser degree τ i the desired speed v 0i on the contrary in this contribution and in accordance with most publications on the sfm is viewed as a parameter that has an immediate interpretation and can be measured directly by measuring the free unobstructed walking speed although it is an unproven hypothesis that for pedestrians there is a situation independent desired speed that matches the free walking speed therefore in the framework of this contribution we assume that there is no freedom in choosing the value of v 0i and count it to the empirical properties although at the same time it is a model parameter from here on we assume that parameters ã b λ τ r and v 0 have identical value for all pedestrians so we omit the indices this allows to combine ã and r into a new parameter a ãe 2r b it is essential to keep this parameter transformation in mind since some implementations of the sfm require ã and some a as input parameter put differently if there is no 2r in the exponent and if distance between pedestrians refers to surface to surface one needs to calculate with parameter ã while if it is center to center parameter a is required in this contribution distance always means center to center we use the formulation with a for theoretical investigation but for all simulations as mean ã ie the 2r are added in the simulation since it is obvious which properties are time dependent we also omit the then equation can be written for the onedimensional case ẍi v 0 ẋi τ a j we d ij b 4 d ij x j x i w λ if x j x i 0 w 1 if x j x i 0 with the additional assumption that for all pedestrians and times v 0 ẋ 0 this can be done without limiting generality since we are not interested in phenomenons far from equilibrium but only investigate a stationary state of the system considering only nearest neighbor interactions and neglecting all other forces the sum in equation is reduced ẍi v 0 ẋi τ a e d ii1 b λe d ii1 b 8 for all pedestrians who have a leading and a following pedestrians for the first and the last pedestrians in the line one of the two terms in brackets is missing assume now the first pedestrian in line is waiting in front of a red traffic signal let us define its position being x 0 0 for a finite system and if λ 0 the distances between pedestrians grow towards the end of the queue since the last pedestrian is not experiencing a pushing force from behind therefore exerting a smaller force to his leader who therefore is further away from his leader than others further down in the queue the effect is most pronounced toward the end of the queue while distances vary only slightly toward the front particularly if λ has a value close to zero much smaller than 1 we assume now that there is a long queue of z pedestrians and we are interested in the distance l from the first to the n th pedestrian where n z when all pedestrians are standing still and for each pedestrians there is zero net force ie the left hand side of equation is zero because n z for pedestrians in concern we only make a small mistake assuming as if the queue was infinitely long that all distances between pedestrians are identical setting d d ii1 d ii1 0 v 0 ẋi τ ae d b 9 where the left side is zero since we are at equilibrium this can be solved easily for d and as stated we are interested in the smallest possible distance d min ie when speed is zero d min b ln α aτ v 0 with parameter combination α defined for convenience since this parameter combination will occur often in the remainder the inverse of d min is the maximum density ρ max which we identify with the stand still density ie the upper end point in the fundamental diagram for this and for above mentioned l results trivially ρ max 1 b ln l b ln equation connects the two properties l and n which have an immediatenonabstract meaning with the parameter b and parameter combination α of the sfm and give a first indication which parameter modification has which impact on simulation results the second step is to imagine that the traffic light which before stopped pedestrians turns green and that the queue of pedestrians discharges at first pedestrians which cross x 0 ie the stop line of the signal are still accelerating yet after some time the fourth or fifth or tenth pedestrian has already accelerated to the speed which is possible at that density the further discharge occurs with capacity flow j c at capacity density ρ c also for this situation we assume that distances between pedestrians are constant we resolve equation for ẋi and use it for v in the fundamental equation j ρv ρv 0 1 αe 1 bρ 15 at capacity the first derivative of j by ρ vanishes δj δρ v 0 1 α 1 1 bρ e 1 bρ 0 for ρ ρ c next we multiply and at the same time divide the last term by e 0 v 0 1 αe 1 1 bρ c e which prepares the equation to be resolved for ρ c ρ c 1 b 1 w 1 αe where w is the lambert w function 19 20 21 22 23 which is defined as inverse of xe x ie x we w to be precise in this work w always references the lower real valued branch of the lambert w function which is denoted as w 1 when there is a need to distinguish different branches the lower branch of w is defined for all 1e ≤ x 0 this is the case for the argument 1eα since equation requires α 1 all of its values are w 1 which is what is also required in equation using this in equation we get as capacity flow j c v 0 b 1 w 1 αe 1 αe 1w v 0 b 1 w 1 αe 1 w 1 αe w 1 αe e w v 0 b 1 w 1 αe 1 1 αe w 1 αe v 0 b 1 w 1 αe 1 1 w 1 αe v 0 b 1 w 1 αe where for the second transformation we use the defining equation of the lambert w function to put it in terms of directly observable properties the time t for n consecutive pedestrians to cross the stop line with this results trivially in t j c b v 0 w 1 αe equations and or their repackings in terms of l and t can be combined to get an equation without parameter b or without parameter α for this we first define a combination of observable properties q j c v 0 ρ max l v 0 t then q can be written depending only on α but not b q ln w 1 αe 28 or on b but not α 1 qρ max t v 0 n 1 b w e the right hand side of equation has a lower limit of 0 and an upper limit of 1 since w can be approximated 24 by w ≈ ln ln for x → 0 and since lim α→∞ ln ln 1 αe ln ln 1 αe 1 the lower limit of 0 does not have any relevant implication yet the upper limit of 1 implies that under the assumptions and simplifications made in this contribution the sfm can only reproduce pedestrian system dynamics where q 1 32 it appears that this is not a relevant limitation since in 25 roughly the values v 0 ≈ 125 ms j c ≈ 08 s 1 and ρ max ≈ 20 m 1 were found such that q ≈ 032 equations and can be solved for α resp b both transformations include steps which are not obviously goal directed therefore we will do this step by step beginning with equation q ln w 1 αe w 1 αe ln q 1 αe ln q e ln q 1 e ln q e ln q ln q 1 e q 1 q lne q1 q ln q 1 e e q1 q ln q 1 q ln e q1 e e q1 q ln e q1 q ln q 1 e e q1 q ln e q1 e e q1 q ln q 1 e q 1 e e q1 q ln w q 1 e q 1 e α q1 q w q 1 e α w 1 q e e 1 q q 1q now for equation it can be written as 1 qbρ max w e 1 qbρ max e 1 qbρmax e 1 b e 1 bρmax 1 qbρmax qρ max e 1 b 1 ρ max 1 qρ max e 1 bρmax 1 qbρmax qρ max e 1 ρ max 1 qρ max 1 ρ max 1 qρ max 1 b w qρ max e 1 ρ max 1 qρ max b 1 q qρ max w 1q e to finish this section we summarize the model simplifications which we had to assume to gain the results 1 homogeneous population all pedestrians have identical parameters microsimulations allow by construction to take account for a heterogeneous population by assigning each unit individual parameters to allow analytical investigation we had to refrain from that obviously the values in our analysis would be the average or median value of any distribution to test the theory simulations can be run with identical parameters for all pedestrians 2 onedimensional movement reducing the dimensionality from two to one spatial dimension introduces a fixed order between pedestrians which is required for the next simplification step of considering only nearest neighbors 3 only nearest neighbor interaction the sfm originally assumed that each pedestrian in a simulation exerts a force on any other the reduction to nearest neighbor interactions made the analytical investigation much easier but obviously this step implies that results cannot be exact it may be interesting in this regard that it was found that the approach to consider all other pedestrians as having an impact on a certain pedestrian does not lead to the most realistic speeddensity relation but that cutting forces at a certain number or at least suppressing them with more remote neighborhood degree is beneficial 2627 thus the approximation of nearest neighbor interaction can also be interpreted as a model improvement in computer implementations of simulation models usually the number of forces on a particular pedestrian is limited anyway to achieve reasonable computation times which is another reason why this assumption is not only a simplification but matches the pragmatic ways in which the sfm is actually applied 4 stationary state it was assumed that movement is in a stationary state ie macroscopic properties are stable over time this is required by the aim of the work to relate simple macroscopic properties to model parameters without the system being stationary there are no simple properties this assumption implies that one cannot expect results to describe situations exactly which include for example an acceleration phase 5 equal spacing between pedestrians instead of increasing distances toward rear end of queue this is an assumption to which one can get arbitrarily close in a simulation by enlarging the size of the system 6 by assuming that the queue is a long queue we implicitly assumed that the time delay from the first pedestrians in line having to accelerate from zero speed can be neglected thus our results cannot be transferred to queues consisting only a small number pedestrians summary of results and discussion for n pedestrians who stand still at the front end of a much longer singlefile queue in front of a signal or service desk we find in the sfm with only nearest neighbor interaction for the length l from the first to the n th pedestrian and the time t it takes for discharge between the first and the n th pedestrian crossing a given cross section l b ln t b v 0 w 1 αe with parameter combination α α aτ v 0 where it ought not be forgotten that parameter a is defined differently in different existing literature compare equation in terms of maximum density ρ max and capacity flow j c equations and can be rewritten ρ max 1 b ln 53 j c v 0 b 1 w defining a combination of observable parameters q j c v 0 ρ max l v 0 t it is possible to rewrite equations and getting rid of either α or b 1 q ρ max bw e q ln w 1 αe these can be resolved for α and b giving α w 1 q e e 1 q q 1q b 1 w 1q e 1 ρ max 1 q q note that for q it does not make a difference if j c refers to the total flow and ρ max to the line density or if j c refers to the specific flow and ρ max to the two dimensional density since equation requires only an additional factor 1widthwidth to get from the former to the latter thus in a certain sense parameter q is independent of the dimension the first hope would now be that one could measure v 0 ρ max and j c in reality from that compute a q and with all these use equations and to compute parameters α and b then simulating with α and b the same values as measured would result for ρ max and j c in the simulation however with all the approximations we have done chances for success are doubtful we want to benefit from the results obtained from considering a 1d system also for 2d situations and we do not seriously want to consider only the two nearest neighbors in a 2d simulation but have at least 4 6 or 8 pedestrians emitting a force on a certain pedestrian doing so would definitely change the results presented above for 1d as well as 2d situations since the net value of the sum of forces will generally be larger thus we cannot directly apply these equations however we can hope that the tendencies which they give are preserved even if we change fundamental properties of the system in other words in a calibration process the results derived above might allow an educated guess and tell in which direction parameters need to be changed so that the results change in a certain direction assume you already have done a simulation and you have obtained a certain ρ max and a certain j c you find that compared to your empirical data both ρ max as well as j c are too large then looking at equations and things are easy increasing the value of b will lower the value of both result attributes and the same is true for parameter α larger α will lead to smaller ρ max and smaller j c as is shown in appendix a1 the case when ρ max as well as j c both should result with larger values is just as trivial lower the value of b or α or both however how should parameters be changed if it is required to increase the value of ρ max but reduce j c should the value of α be raised and the one of b be lowered or the other way round the answer is for the math see appendix a2 that to achieve a higher value for ρ max and a lower value for j c the value of α needs to be reduced and the value of b raised summarized this suggests the following procedure for calibration of the sfm 1 measure or define reasonable values for desired speed v 0 capacity flow j c and maximum density ρ max there is no universally correct value for l and t younger people may have different values than older ones in emergency egress situations one may assume to find smaller values for l as well as t than if people are queuing and going to carry out some rather unpleasant duty make sure that 0 q 1 in equation 2 with the help of equation compute a value for parameter b the lambert w function is implemented in numerical computing and computer algebra software like matlab 28 mathematica 29 or maple 30 one can also find plugins for excel for download on the web the easiest way to compute a few values is by using the computational knowledge engine alpha 31 in any case make sure that the value from the lower real valued branch is computed 3 with the help of equation compute a value for parameter combination α make sure that α 1 4 choose values for parameters λ τ and a such that equation holds consider what is written above and in equation about a and ã reasonable boundaries are 0 ≤ λ 04 and 005 ≤ τ ≈ 20 s also consider that 4v 0 τ b ≤ 1 should hold or that at least the left side is only slightly larger than 1 since otherwise a pedestrian may visibly oscillate forth and back when approaching another 32 5 do simulations evaluate in the simulation ρ max and j c and repeat • if both ρ max and j c need to be larger reduce the value of b andor α • if both ρ max and j c need to be smaller increase the value of b andor α • if ρ max needs to be smaller and j c larger reduce the value of b and increase the value of α • if ρ max needs to be larger and j c smaller increase the value of b and reduce the value of α • simulate again and evaluate ρ max and j c 6 set the values of all other parameters in case you are working with a variant or an extension of the sfm for this it is typically required to include more complex scenarios in the calibration procedure for example the width of the distribution of desired speeds as well as the parameter that sets the impact strength of the relative velocity in elliptical specification ii 3 both are most relevant in bior multidirectional flow situations so include scenarios with bidirectional and crossing flows remember that you are free to change the values of τ λ and a without spoiling the calibration as long as the value of α in equation is conserved verification and example in this section we first check if the math presented above can be correct by trying it with a concrete example and simulating with the same model simplifications that were assumed in a second step we release some of the simplifications most importantly applying the calibration procedure in a 2d setting we configure a simulation of pedestrian dynamics 33 as close as possible to the model simplifications and simulate a de facto one dimensional situation where 1000 pedestrians first walk toward a red traffic signal stop there and start moving when it turns green later we measure the linear density of pedestrians as they wait in front of the red signal and the discharge flow after the signal turns green we pretend we know nothing about the parameters of the sfm and use the empirical results of 25 which give q 032 and from that with equations and α 27532 and b 04937 m the first check is on the freedom to set the parameters τ a and λ that make up α the results as displayed in table 1 show that in fact the flow is constant that the maximum density varies only slightly for identical values of α such that the simulation in this aspect confirms the theory presented above looking at the particular values for flow and maximum density we see that the flow matches exactly expectations by that increasing confidence in aboves results further but that the maximum density is slightly smaller than expected this can be due to two causes first it can be a consequence of a violation of the oscillation condition 4v 0 τ ≤ b see 32 ie pedestrians are not yet at rest at the time of measurement but for some of the parameter sets clearly for others barely visible still move forth and back at the time of measurement by that requiring more space among others this is one of the reasons to not utilize the circular specification of the sfm alone but to combine it with for example elliptic specification ii which by construction suppresses oscillations second our simulation system is not exactly onedimensional but it is a 2d simulation system artificially confined to something like a 1d system this may have certain effects which would be out of scope to be discussed here in total we see the results to be in accordance with the theoretical considerations presented above table 1 parameter choices and simulation results in a 1d setting the pedestrians all had the same length of 0456 m and the desired speed was sharply 125 ms and in all cases b 04937 m the second test is in a 2d situation 8000 pedestrians walk down a 4 m wide strip we aim at reproducing weidmanns properties of pedestrian dynamics 1 and ρ max 54 m 2 implying q 0172 and with equation α 144 compared to other literature data this capacity flow is small and maximum density moderate we assign pedestrians a radius of 0213 m ± 10 implying that 54 such pedestrians cover an area of 077 m 2 this is near the maximum size which allows to reach the mentioned maximum density without overlapping this raises the expectation that it might be difficult to reproduce the desired maximum density of 54 m 2 with any set of parameters τ s a sociso ms 2 λ ρ max m 1 j c s going from 1d to 2d first bears the difficulty how to transfer equation since maximum density in 2d has a dimension of m 2 while b needs the dimension m we assumed what we believe to be the simplest assumption that the maximum density needs to be divided by a lane width w l and the explicit ρ max in equation needs to be replaced by ρ max w l as initial guess we assume a lane width of w l 05 m this leads to b 102 m going from 1d to 2d it is furthermore anything but sure that the properties and relations derived above still hold we want to test a if as in 1d also in 2d capacity flow and maximum density only depend on α but not on how a τ λ and v 0 contribute to the value of α b if equations and have a meaning in 2d and c if the calibration procedure as defined above can in fact be carried out in a 2d setting another question in a 2d environment is how many pedestrians should be taken into account as nearest neighbors for the sfm obviously two would be too few assuming a near to hexagonal walking formation 1 we choose six as number of influencing pedestrians the results as given in table 2 support two conclusions first in 2d as in 1d ρ max and j c depend only on α and not on its factors it was not clear at all that this fact would survive the expansion from one to two dimensions therefore this result is explicitly pleasant second both ρ max as well as j c result much smaller than expected from the 1d theory obviously concerning this aspect the transgression from 1d to 2d brings a major change and with it a challenge for future work the simplest way to bring the simulation results closer to the expected values is to assume larger values for w l w l 10 m leads to ρ max 410 m 2 and j c 156 1 such that one of the result parameters is smaller than desired and the other one larger this implies that the best parameters a and b may neither be both smaller nor both larger than the ones applied at this point furthermore we apply the process and change parameters a and b following results of previous simulations as described above keeping the values of τ and λ constant table 3 gives an overview of those simulations where the resulting capacity flow is close to the desired value it can easily be seen that indeed the value of parameter a needs to be reduced and the value of parameter b increased to get closer to the desired result however even for b → ∞ the desired maximum density cannot be achieved for the given flow capacity it may appear disappointing at first that the model parameters cannot be set such that the desired values of result parameters are met however at second thought this can also be interpreted as a positive property of the model since the pedestrians in the simulation had a size which implied a maximum density near the desired result for ρ max one may simply require from a model that it cannot be tweaked by parameter modifications to produce any result one could think of finally we checked once more that this depends only on α and not the parameters it is made of and varied the values of λ and τ as in table 2 adjusting a sociso such that α 02566 is preserved again j c and ρ max remained nearly unchanged summary and outlook in this contribution we were able to derive two formulas that assign values to a parameter and a parameter combination for a simplified version of the sfm using as input only observable properties based on this we proposed a calibration procedure that can be applied requiring to know neither the derivation of the results as given in this work nor details of the sfm we demonstrated the calibration procedure with a concrete example as a result of the insight into fundamentals of the social force model presented in this paper this calibration procedure is an informed procedure that exploits the model structure for calibration as opposed to optimization schemes which work irrespective of this nevertheless it may well be that a particular general optimization scheme can be combined with the particular information of the facing work to enhance the performance of an optimization process future work may concern mainly the transgression from one to two dimensions as well as the further calibration process the approach presented in this work leaves freedom to choose some of the parameters for extended variants of the sfm with additional parameters there is even more such freedom to calibrate the values of these parameters empirical data from further walking situations is required acknowledgments for the preparation of this contribution we used david pritchards transportation research board template for latex 35 a2 to lower the value of ρ max and raise the value of j c to answer the question how α and b need to be changed to achieve a smaller ρ max and a larger j c we imagine that we already have the right value for ρ max and want to raise the value of j c without changing ρ max so we have old parameters α and b and new parameters α and b since ρ max should remain constant it is required that 1 b ln 1 b ln α α b b note that if b b then α α and vice versa this allows to eliminate α in the new j c j c v 0 b 1 w 1 eα b b f j c j c 1 1 w 1 eα w 1 eα 1 1 where 1 b b parameter quantifies the difference between old and new b if 0 then b b otherwise b ≥ b the handson method to see that f 1 if 0 and f 1 if 0 is to plot f for various α and thereby see that it appears to strictly monotonically decrease with growing and for all α a more mathematical approach is to compute the linear taylor approximation of f for small values of where the value inside the top level brackets is always positive for all α 1 otherwise there would be some a 1 for which holds thus we could show that j c j c if b b coming back to the original idea of an unmodified ρ max where if b b it needs to be α α choose some b with b b b and it will obviously be ρ max ρ max df d 1 1 2 w 1 eα w 1 j c j c which shows that to have a chance to raise the value of ρ max and lower it for j c one needs to raise the value of b and lower it for α a appendix a 1 the function 1 w the easiest way to gain some insight into the properties of a function is to plot it see figure 1 there the visual impression already suggests strongly that the first derivative by α is always negative this can be proven easily with x from 1 to 6 see for example 23 we get since all three top level brackets enclose negative values for all α 1 the derivative is negative for all α 1

the social force model of pedestrian dynamics is formulated in a way that a most of its parameters do not have an immediate interpretation b often one single parameter has an impact on many aspects of walking behavior and c a certain aspect of walking behavior results from the values of more than one parameter this makes calibration difficult the aim of this paper is to give practitioners an indication of how to proceed in the calibration process for this by analytical transformations the parameters of the social force model are related to real properties that have a clear and immediate meaning and which are also highly relevant result properties of a simulation extent and clearance time of a queue respectively maximum density and capacity flow the theory for this is presented as well as a side effect it can give a deeper understanding of the model for everyone interested in theoretical aspects

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introduction t he prevalence of excess body weight is high and rising in many countries and is a major public health concern 1 obesity is associated with an increased risk of several chronic diseases 2 and socioeconomic differences in obesity prevalence may be one mechanism through which inequalities in health and mortality arise 3 in countries with low levels of economic development overweight and obesity are more common among affluent adults and children 4 in economically developed countries overweight and obesity are more common among poorer women and children 3 4 5 although this pattern is less consistent among men 34 and inequalities in obesity prevalence in some countries may be narrowing 6 many countries from eastern europe and the former soviet union have transition economies experiencing different stages of social and economic development studies examining inequalities in overweightobesity prevalence in these countries reveal mixed findings children with less educated parents are generally more likely to be overweight or obese 78 however a recent study in 35 countries found that among adolescents those from more affluent backgrounds in croatia estonia and latvia were more likely to be overweightobese 8 among adults lower socioeconomic position has been associated with a greater prevalence of obesity particularly among women 910 most of these studies involved either children or adults and few simultaneously examined the socioeconomic patterning of obesity in both children and their parents 7 few studies have examined inequalities in central adiposity which is more detrimental to health than peripheral fat tissue even in childhood 11 the republic of belarus has a transition economy and is a middleincome former soviet socialist republic with lowincome inequality 12 belarus has features in common with many highincome countries high adult literacy and low infant mortality rates but it also has high rates of adult mortality principally from cardiovascular disease which is related to obesity 1213 we are unaware of any previous published studies from belarus reporting on the socioeconomic patterning of obesity or related health outcomes we examined socioeconomic inequalities in general and central adiposity by occupational and educational status among children and their parents in belarus in addition we examined the effect of selected demographic anthropometric health behaviour and familyrelated variables on these associations methods the study cohort comprises children and their parents who were recruited into the promotion of breastfeeding intervention trial 14 and attended a followup interview and examination when the children were aged 65 years this observational cohort is nested within a multicentre clusterrandomized controlled trial located in belarus in which the experimental intervention was promotion of breastfeeding and modelled on the babyfriendly hospital initiative 15 briefly 31 maternity hospitals and their affiliated polyclinic were randomly assigned to receive the breastfeeding promotion or to continue with prevailing practices between june 1996 and december 1997 17 046 motherinfant pairs were recruited during their postpartum hospital stay inclusion criteria specified that infants were fullterm healthy singleton births weighing at least 2500 g with an apgar score 5 at 5 min and mothers were healthy and intended to breastfeed these children were followedup at polyclinic visits at 1 2 3 6 9 and 12 months since all mothers initially breastfed the experimental intervention was designed to increase the duration and exclusivity of breastfeeding the randomization procedure resulted in two groups with a similar distribution of potential confounding factors when the children were aged 65 years they were invited to a followup interview and examination between december 2002 and april 2005 13 889 children were examined at 31 polyclinics by one of 38 trained study paediatricians 16 monitoring visits were conducted during recruitment and followup to ensure compliance with study protocols at age 65 years the following anthropometric measures were taken in duplicate and the mean reading used in all analyses 16 standing height weight waist circumference and subscapular and triceps skinfold thickness seventeen of the 13 889 children had missing data for at least one of these measures at the same visit the examining paediatrician recorded parental height and weight obtained from an interview with the accompanying parent legal guardian for most of the children the mother reported height and weight for both herself and the childs father in a minority the fatherguardian reported for both parents in total 1379 of the fathers and 161 of the mothers did not have data for height and weight a remeasurement audit was used to assess the reproducibility of the childrens measurements at followup 16 briefly 190 randomly selected children were reexamined by one of the minskbased study paediatricians 53326 months after the initial examination the auditors were blinded to the initial measurements taken by the polyclinic paediatricians the testretest correlation was high for height body mass index and waist circumference but was modest for subscapular and triceps skinfold thickness reflecting the greater known difficulty of measuring skinfolds the mother reported parents occupations and education levels when the child was enrolled into the study during the postpartum hospital stay in belarus at the time of the trial mothers jobs were guaranteed during 3 years of obligatory maternity leave 17 and therefore we asked the mothers to report their usual occupation eight categories of occupation based on national classifications were supplied to us by the belarusian investigators occupation was classified as manual workerfarmer and service worker those who reported they were pupils students housewives unemployed or whose occupation was unknown were coded as missing because the relationship of these categories to usual socioeconomic position was unclear the highest household occupation was calculated as the higher of the occupation categories for the mother or the father a nonmanual worker was regarded as a higher occupational status than a manual worker highest household occupation was missing for 65 of households the average monthly wage in the agricultural sector in belarus was 398 000 belarusian rubles and in the housing and communal services 580 000br 18 educational status was recoded from seven to three categories initial incomplete or common secondary advanced secondary or partial university and completed university the category unknown was coded as missing no mother and 468 fathers had missing data for educational attainment the location of the polyclinic was categorized as either east or west of minsk and as urban or rural urbanrural location was based on the size of the villagetown that the hospital and affiliated polyclinic served the mother reported the following baseline variables parents age number of older siblings marital status and maternal smoking during pregnancy the fathers age was not obtained for 494 children smoking during pregnancy was recoded to yesno from the number of cigarettes smoked per day the childs birthweight was abstracted from the medical record during the first 12 months breastfeeding history from the mother was regularly recorded a binary variable was obtained for those exclusively breastfed at 3 months with exclusivity defined by world health organization criteria 19 covariates recorded at followup were parental smoking alcohol intake and number of siblings smoking for both parents was derived as above and was missing for 120 mothers and 1292 fathers parental alcohol intake was derived by combining average frequency of alcohol consumption and amount of alcohol consumed at these times one unit of alcohol is equivalent to 25 ml of vodkaspirit 20 data regarding alcohol intake were missing for 2 of mothers and 10 of fathers the number of younger siblings since the birth of the study child was also recorded and was missing for 112 children the institutional ethical review board of the montreal childrens hospital approved the study and participating mothers gave signed consent in russian bmi was calculated as weight in kilograms divided by height in meters squared childhood thinness overweight and obesity were defined by models which give ageand sexspecific thresholds with trajectories which are equivalent at the age of 18 to a bmi of 17 21 25 to 30 22 and 30 22 these three bmi cutoffs were also used among parents the cutoff for thinness was chosen as recommended by cole et al 21 percentage body fat was derived using the equations of slaughter et al 23 from subscapular and triceps skinfold measurements the childs exact age calculated from date of birth and date of followup examination was used in all analyses the crude association between the socioeconomic indicators and continuous outcomes was estimated using linear regression logistic regression was used for the analysis of bmi and waist circumference and percentage body fat as approximately 10 of children socioeconomic position and adiposity in belarus were classified as overweightobese 22 the 90th percentile cutoff was chosen to capture the same proportion of children with high waist circumferences and percentage body fat multivariable regression was used to adjust for covariates for children the crude model was adjusted for age at followup gender of child and study trial arm we then additionally adjusted for environmental factors and finally we additionally adjusted for factors measured around birth and age 65 years in model 3 factors measured at 65 years were considered markers for potential mediators of associations between family socioeconomic position and obesity ie parental bmi smoking and alcohol intake and additional siblings since birth were considered to reflect the environment within which the child grew up and which could influence obesity risk for waist circumference and percentage body fat the basic model and the multiply adjusted model were computed for the parents the basic model adjusted for age and study trial arm was additionally adjusted for environmental factors own factors and partners factors robust standard errors were used to compute confidence intervals and pvalues after accounting for possible nonindependence of measurements by hospitalpolyclinic site the study trial arm was included as a dummy variable in all regression models although the intervention was not associated with any of the measures of childhood adiposity at age 65 years 16 differences in association by sex were investigated using the likelihood ratio test for interaction based on the maximally adjusted models all analyses were conducted using stata version 100 results of 17 046 infants enrolled at baseline 13 889 had measurements at age 65 years supplementary tables s1 and s2 detail the characteristics of the girls and boys and their parents measured at baseline and followup overall 44 of children came from manual households at age 65 years 10 of girls and 9 of boys were overweightobese girls had higher percentage body fat than boys overall 37 of mothers and 53 of fathers were overweightobese there was little difference in the social characteristics among those living in the east versus the west of belarus eg of mothers that completed university education 48 lived in the east when compared with 52 in the west overall 180 girls 135 boys 81 mothers and 7 fathers were classified as thin and have been excluded from the main analyses as have those with incomplete data on any covariates used in the maximally adjusted models therefore 10 870 children 11 211 mothers and 11 132 fathers were included in the analyses the association of each socioeconomic indicator with bmi waist circumference and skinfolds assessed as continuous variables did not differ significantly between girls and boys thus all remaining analyses are presented for girls and boys combined child bmi was positively correlated with mothers bmi and fathers bmi children from nonmanual households or whose parents had higher educational attainment had higher average bmis waist circumferences and subscapular and triceps skinfold thicknesses table 1 shows the associations of parental education and household occupation with the odds of child overweightobesity at age 65 years in the basic model children with university educated or nonmanual occupation parents had a 38 to 62 increased odds of overweight obesity these associations were attenuated with adjustment children with university educated or nonmanual occupation parents had a 2749 increased odds of being overweightobese in the maximally adjusted model table 2 shows the association of the socioeconomic indicators with 90th percentile of waist circumference and percentage body fat in children each indicator of socioeconomic position was positively associated with measures of adiposity in the basic model a similar positive association was seen in the basic model between socioeconomic position indicators and percentage body fat in the multiply adjusted model this association remained strong for mothers education associations were similar for subscapular and triceps skinfolds when analysed separately the main covariable that diminished the association between socioeconomic indicators and childhood adiposity outcomes was fathers bmi children from nonmanual households were 39 more likely to be overweightobese than those from manual households in the basic model this reduced to 31 on further adjustment for fathers bmi in contrast the covariable that most strengthened the association between socioeconomic indicators and childhood adiposity was mothers bmi in the basic model as above children from nonmanual households changed from 39 more likely to be overweightobese to 43 more likely to be overweightobese on adjustment for mothers bmi on stratifying fathers bmi into two groups there was little evidence of a difference in the association of socioeconomic indicators with childhood adiposity between the two strata in the maximally adjusted model children from nonmanual households were 31 more likely to be overweightobese if the father was more than or equal to median of fathers weight and 20 more likely to be overweightobese if the father was less than median weight the adjusted odds ratios for each socioeconomic indicator and overweightobesity amongst mothers and fathers are shown in tables 3 and 4 mothers from more educated or nonmanual households were 2244 less likely to be overweightobese in the basic model in contrast fathers from more educated or nonmanual households were 1526 more likely to be overweightobese these associations were attenuated with adjustment for covariates fathers with partners who completed university were 16 more likely to be overweightobese the main covariate that diminished the association between socioeconomic indicators and mothers overweightobesity status was the number of children before the birth of the study child for fathers the main covariate was their smoking status of those mothers that attained the lowest level of education 12 had two or more children whereas of those mothers with the highest category of education only 5 had two or more children before the birth of the study child the association between socioeconomic indicators and overweightobesity differed between mothers and fathers discussion belarusian fathers and children from manual occupation or less educated households were less likely to be overweightobese however mothers from manual occupation or less educated households were more likely to be overweightobese among children waist circumference and percentage body fat measurements were also higher among those from nonmanual or more educated families in general these associations were robust to adjustment for a wide range of potential confounding covariates or potential mediators of these associations the covariate which resulted in the greatest attenuation of the association between socioeconomic position and childhood adiposity was fathers bmi in contrast adjustment for maternal bmi resulted in a strengthening of the associations these changes in the coefficient upon adjustment for parental bmi are as would be expected given the positive association between educational attainment and fathers bmi but inverse association between educational attainment and mothers bmi and the fact that both parents bmi are positively associated with offspring bmi the main covariate that diminished the association between socioeconomic position and mothers overweightobesity status was parity less educated mothers are likely to have more children than more educated mothers suggesting that the association between socioeconomic position and mothers adiposity may in part be mediated by the effects of parity 24 limitations of the study include the fact that the parents heights and weights were not measured most were reported by the mother and thus may be prone to measurement error if the error is random across socioeconomic groups then the expectation would be for this to bias the effect estimates towards the null though we acknowledge that bias could be in either direction previous studies indicate that bmi tends to be underestimated when selfreported but with no clear socioeconomic distribution 2526 bmi is likely to be less accurate if reported by a partner thus we may have underestimated overweightobesity prevalence among fathers in particular nevertheless we still found strong associations of socioeconomic position and overweight obesity in this group bmi tends to overestimate adiposity in taller children and underestimate it in shorter children 27 nonetheless bmi is a wellrecognized proxy for general adiposity in children 5 the equations of slaughter et al may overestimate body fat in children and compare poorly with other methods of body fat estimation 28 nevertheless our findings were similar when we analysed subscapular and triceps skinfolds separately parents who were in school housewives or unemployed were excluded from our analysis but this is unlikely to explain the associations we observed in addition no measures were available of some important factors on the causal pathway between socioeconomic position and overweightobesity such as physical activity and diet which could help to explain the findings however other markers for childhood environment were available such as parental smoking alcohol intake and the number of siblings and these were included in the analysis we found that absolute levels of overweightobesity are relatively low among children in belarus when compared with the usa 29 in comparison to other studies the association between socioeconomic position and adiposity among children in belarus is similar to that among preschool children from developing countries 30 and adolescents in some transition economies 8 where adiposity is more prevalent among children with more educatedaffluent parents our results are in contrast to those from western developed countries 5 and some other transition socioeconomic position and adiposity in belarus economies 7830 which report a higher prevalence of overweightobesity among children from poorer backgrounds amongst adults in belarus the overall prevalence of overweightobesity among women and men was lower than that reported in the usa 31 our findings among women are consistent with recent findings in developing countries 32 and developed countries 333 and other transition economies 31034 whilst our results among men are similar to those found in some developing countries 432 and some 34 transition economies comparisons between countries suggest that the relative wealth and economic development of a country may be important factors in the socioeconomic patterning of obesity in adults and children and this may be particularly important in transition economies where major economic changes are taking place 832 it has been found that the burden of obesity shifts from the more affluent socioeconomic groups to the poorer groups as a countrys wealth increases 32 this shift occurs at an earlier stage of economic development among women than it does for men 32 our findings in belarus seem to support this view data from the world bank database indicate that gross domestic product of belarus has risen rapidly since 2002 in 2000 419 of the population was below the poverty line and in 2002 this had decreased to 185 these indicators point to a recent rise in gdp and drop in poverty rates in belarus suggesting a rising standard of living generally in other transition economies ownership of cars tvs and computers fast food consumption alcohol and smoking have increased in the past decade 35 all of which are factors associated with obesity our data suggest that susceptibility to these obesogenic factors may be socially patterned in belarus the prevalence of obesity is rising in many parts of the world a trend usually attributed to reduced physical activity and the spread of the western diet in the last few decades 36 growing evidence suggests that overweight and obesity are socially patterned 834 and so may contribute to trends in health inequalities in different populations 37 there are few data regarding health inequalities in belarus however in other former soviet countries less educated adults have worse selfreported health 38 morbidity 38 and mortality 39 when compared with more educated adults in our familybased study we identified inequalities in the social patterning of overweightobesity the highest prevalence of overweightobesity in children and their fathers was in nonmanualmore educated households however in mothers the highest prevalence was in manualless educated households this information could be used to update public health knowledge on inequalities in overweight and obesity prevalence in belarus and inform the development of potential intervention strategies further investigation is required to explore the mechanisms involved in the observed socioeconomic pattering of childhood and adulthood obesity in belarus supplementary data supplementary data are available at eurpub online funding the canadian institutes of health research to mk key points studies examining inequalities in overweightobesity prevalence among children and adults in eastern european and former soviet countries reveal mixed findings these associations have not previously been examined in belarus within families and using other measures of adiposity we found that in belarus children and their fathers from nonmanual households were more likely to be overweightobese and their mothers less likely to be overweightobese than those from manual households children from nonmanual households were also more likely to have larger waist circumferences and higher percentage body fat than those from manual households the association between socioeconomic position and adiposity may vary in different populations this may have important public health implications

background socioeconomic differences in the prevalence of overweightobesity may be one factor through which health inequalities arise and may vary by the population studied methods analysing a cohort of 13 889 children born in belarus between june 1996 and december 1997 the authors investigated associations of parental educational attainment and highest household occupation with i measured body mass index bmi waist circumference and skinfold thicknesses at age 65 years and ii the parents reported bmi results overall 10 of children 37 of mothers and 53 of fathers were either overweight or obese children from nonmanual households were 27 95 confidence interval ci 10 47 more likely to be overweightobese based on bmi than those from manual households they also had larger waist circumferences and higher percentage body fat calculated from subscapular and triceps skinfolds similar associations for being overweightobese were seen for fathers odds ratio or 110 95 ci 102 118 but mothers from nonmanual households were less likely to be overweightobese or 084 95 ci 079 0 90 associations of childhood and parental overweight obesity with higher educational status of either parent were similar to those observed for nonmanual households conclusion we observed socioeconomic differentials in overweightobesity prevalence among children and their parents in belarus more affluent children and their fathers were more likely to be overweightobese but the reverse was found for mothers

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introduction sustainable development requires the sustainable and integrated management of land and water stateofthe art approaches for achieving such a management are sustainable land management and integrated water resources management which address both land and water albeit with a different focus these concepts promote efficient use and combined management of land water and other natural resources as a precondition for optimal socioeconomic development while reducing negative anthropogenic impacts on the environment for instance loss of biodiversity soil degradation water pollution and water depletion that would undermine a sustainable development both approaches also promote knowledge sharing and generation among multidisciplinary scientists and stakeholders close collaboration among scientists from multiple disciplines is required to produce an interdisciplinary understanding of complex socioecological systems additionally stakeholders from outside academia need to be involved to integrate their knowledge and to account for their diverse perspectives and interests in the variety of issues including income generation food security gender relations health and environmental protection stakeholders are defined as those who are either involved in the decisionmaking process affected by the decisions made or not involved in the decisionmaking process but important for a successful implementation of decisions made we regard stakeholder and practitioner as synonyms and use these terms interchangeably in this paper where not mentioned specifically stakeholder is considered to be an institutional stakeholder which is represented by a key person bringing multidisciplinary scientists and multisectoral stakeholders together to address sustainability problems requires a transdisciplinary research approach transdisciplinary research is a research mode that can be regarded as having progressed from disciplinary through multidisciplinary to interdisciplinary research with additional collaboration of multiple stakeholders from outside of academia tdr focuses on joint knowledge production and integration as well as mutual learning among scientists and stakeholders the types of knowledge to be integrated are system knowledge target knowledge and transformation knowledge by integrating stakeholder knowledge with scientific knowledge solutions that are developed based on system understanding while explicitly taking into account stakeholder values can likely be implemented transdisciplinary approaches have been applied in various fields that deal with built and natural environments these include land and water management urban studies regional planning and development sustainable agricultural development and conservation planning application of tdr approaches has been increasing worldwide and is likely to increase further among the 104 transdisciplinary case studies reviewed by brandt et al the majority were conducted in europe and north america by researchers located in the respective regions others were carried out in africa and asia mainly by european researchers according to lang et al and brandt et al the diverse experiences gained from tdr case studies across different countries including a wide range of constraints and obstacles encountered should be shared with the wider scientific community particularly with those outside of the tdr community this helps researchers and practitioners to understand better how tdr can be conducted in respective fields of application under specific sociocultural contexts in this paper we synthesize experiences gained over a period of 4 years from four tdr projects in china vietnam and the philippines in these projects we focus on knowledge integration among multidisciplinary scientists within the respective projects with knowledge of multidisciplinary scientists and multisectoral stakeholders from the respective project areas as well as organizational issues of the tdr projects using the guiding questions developed by lang et al we evaluate whether tdr was really performed in these projects based on this evaluation we then make recommendations on how tdr can be done better our ultimate goal is to share unique experiences and lessons learned with researchers who are interested in conducting tdr in foreign countries particularly in asia as well as with asian researchers who are keen to collaborate with foreign researchers to bring tdr projects to fruition evaluation of project outcomes and analysis of the link between the tdr process or project features and the project outcomes including social learning is beyond the scope of this paper our regional projects deal with land and water management under land use and climate change and put a focus on the analysis and management of ecosystems and their services in the next section we describe the four projects we then present the guiding questions used for evaluating the projects subsequently the evaluation results are discussed including the challenges encountered over the course of the projects and ways to adapt tdr the conclusions include recommendations for conducting tdr in asian countries like china vietnam and the philippines description of transdisciplinary research projects the regional distribution of the four tdr projects in china vietnam and the philippines is shown in fig 2 the projects are among 12 regional projects funded by the german federal ministry of education and research under the research program sustainable land management module a all projects started in 2010 or 2011 and are funded for a total of 5 years other regional projects are located in russia africa and the baltic region the funding measure aims at generating scientific knowledge for an improved understanding of sustainable land and water management and at providing relevant strategies for action in the study areas including suitable technologies and integrated solutions all of the 12 regional projects are supported by the bridgeproject glues that facilitates synthesis data sharing and knowledge exchange among the projects the goals foci targeted outputs and the scales of the four regional projects are listed in table 1 each project differs in the comprehensiveness of the problem fields addressed regional project 1 sumario sustainable management of river oases along the tarim river is a germanchinese collaboration project funded since march 2011 the tarim river basin is located in the southern part of xinjiang uyghur autonomous region northwest china it is the largest inland basin in china with approximately one million km 2 and is inhabited by about eight million people due to the arid climate water resources for the basin stem almost exclusively from high mountain glaciers and snow melt that is transported to water users by a small number of rivers water allocation and the impact of water use in different regions by different users on the environment are the major issues of concern in the region the tarim basin water resources commission seeks an improved land and water management particularly with regard to water allocation and use the commission is a basinlevel water management body that comprises governmental organizations from different sectors and administrative levels regional project 2 surumer sustainable rubber cultivation in the mekong region is a germanchinese collaboration project funded since december 2011 and outside of the project area hohenheimde the project is implemented in xishuangbanna in the southern part of the chinese yunnan province which was once covered by tropical rainforests the area was converted to largescale rubber plantations and has become the second largest rubber growing region in china rubber production provides a high income potential to local farmers however switching from traditional subsistenceoriented farming to intensive rubber cultivation has degraded the natural forest ecosystem and its services with a loss of plant and animal biodiversity as well as clean water an integrative land use concept is required to foster socioeconomic development while protecting the environment regional project 3 legato land use intensity and ecological engineeringassessment tools for risks and opportunities in irrigated ricebased production systems funded since march 2011 covers seven study areas in the philippines and in vietnam and seeks practical options for sustainable rice cultivation in both mountainous regions and lowlands the mountain regions of the philippines and vietnam are inhabited by ethnic minorities with strong roots in animist belief systems they show more similarities between them in some respects than with the rest of their respective countries filipino farmers own their land and trade with it which is more important for small and medium size farmers who produce for local markets vietnamese farmers have a land use right while the ground remains state property the structure and intensity of land use vary widely among areas and between countries subsistence agriculture prevails in the mountainous areas in the philippines farmers use traditional rice varieties without chemical inputs while in vietnam high yielding varieties using chemical input are widespread low income of farmers and loss of traditional knowledge of rice cultivation including terrace management are main concerns regionally tourism provides additional income but both benefit sharing and integration into the rice cycle of activities are prone to problems in both countries lowlands agricultural sustainability problems involve medium to high levels of external inputs insufficient agricultural extension as compared to chemical companies influence rising costs low farm worker income and significant levels of water pollution the impact of insecticide use to control planthoppers is a major issue knowledge on timely insecticide spraying is required to avoid killing useful biocontrol agents regional project 4 lucci the project landuse and climate change interactions in the vu giathu bon river basin vietnam has been completed by the time of this evaluation the project started in july 2010 after it had been designed together with the local partners since early 2009 one of the major issues in the vu giathu bon basin is upstream hydropower development that modifies downstream hydrological conditions leading to decreasing water availability for irrigation during the dry season and salt water intrusion into rice irrigation channels in the coastal areas taking into account national and regional land and water use planning strategies recent development trends regional climate projections hydropower development as well as potential greenhouse gas emissions from agricultural and other land uses the project aims at providing a scientific basis to develop optimized land use and water resources management strategies for central vietnam on the one hand greenhouse gas emissions from different land uses and land covers are quantified on the other hand possible climate change impacts on existing land uses are analyzed and suitable adaptation strategies are developed methods to systematically evaluate the four tdr projects in china vietnam and the philippines we used the guiding questions developed by lang et al we is referred to as the authors of this paper who are directly involved in designing implementing and evaluating the respective tdr projects we reflected on issues related to the three main phases of a tdr including organization of a tdr project and knowledge integration by answering the guiding questions feedbacks gathered from other researchers within and outside of the respective consortiums as well as stakeholders in the respective countries were taken into account in this evaluation all information was compiled analyzed descriptively and organized according to the tdr phases encompassing the guiding questions only those projects funded by bmbf under the research program sustainable land management module a and located in asian region were selected for evaluation these projects address complex sustainable land and water management problems which require collaborative efforts between researchers and stakeholders to develop knowledgebased solutions the tdr phases that encompass the guiding questions are a building a collaborative research team collaborative problem framing and design of methodological framework b cocreation of solutionoriented and transferable knowledge through collaborative research and c integrating and applying the cocreated knowledge phase a can be considered as a preparation phase phase b as research phase and phase c as application phase according to lang et al the set of guiding questions can be used to conduct different types of evaluation namely exante evaluation formative evaluation or expost evaluation in this paper we focus on formative evaluation of phase a and b evaluation results results of the evaluation of the four tdr projects are presented following the sequence of guiding questions listed in table 2 evaluation of phase c is not included because all projects except lucci are ongoing phase a preparation a 1 build a collaborative research team the four regional projects were initiated by german researchers and research partners from the respective countries in asia in legato project researchers from other european countries are also involved the research teams of the respective projects which are composed of 14 to 22 research institutions are dominated by natural scientists all projects were in fact initiated by natural scientists who asked social scientists to join to fulfil the requirements of the funding call for tdr each of the research team includes researchers with different degrees of experience in the field of investigation while phd students and postdoctoral researchers have less academic experience than principal investigators some of the doctoral students and postdoctoral researchers have a better understanding about the sociocultural differences and the ways of communication in the respective countries this knowledge is essential for a successful research in a foreign country in each project staff changes occurred during the project period as some researchers left the projects due to various reasons most staff members were financed for less than the project duration of 5 years in particular the doctoral students that were typically financed for only 3 years in the case of surumer the german principle researcher team at the beginning of the project was already different from the one that applied for the project although researchers could be replaced by new ones the progress of the project was certainly affected as time was needed to get familiarize with the project building a collaborative research team that comprised all relevant stakeholders during the preparation phase could not be realized in all regional projects instead the stakeholders were involved at different stages of the research processes to different degrees stakeholders include representatives from different organizations and sectors such as governmental nongovernmental and private sectors as well as individual local people the legato team could already integrate stakeholders during a funded 6month project preparation period because the project coordinator has longterm experience in the project areas and relevant background knowledge about the problem at hand during this period relevant experts and stakeholders from local and provincial levels were consulted to shape the final application for project funding in the lucci project an interdisciplinary research team consisting of german and vietnamese researchers was defined and the stakeholders were also involved during the preparation of project proposal although the project did not get additionally funding for the preparation period the stakeholders provided information on local problems and formulated research questions together with the research team by so doing the project objectives could be defined considering the stakeholder needs and research demand in the project area during the preparation stage the local partners of the surumer project were involved in the discussion about the concept of the overall project immediately after the project had been kicked off throughout the project period the intensity of interactions between stakeholders and subproject teams varied in sumario the key stakeholders from the river basin organization and the provincial water resources bureau became involved only after the project start too in all projects some of the relevant stakeholders might not have been engaged in the transdisciplinary processes to the degree desirable because they were involved at a later stage the early involvement of relevant stakeholders is important for creating the ownership of the respective projects by stakeholders from the beginning of the project as well as for ensuring successful implementation of research results during the results application phase however getting the right stakeholders to involve at the right time in the tdr process of each regional project was generally challenging due to several reasons due to strong political constraints in the xinjiang uyghur autonomous region that suffers from ethnic tensions and violent conflicts it was not possible to involve nongovernmental or private organizations in sumario most governmental stakeholders were reluctant to be involved officially because according to them the project was not officially endorsed by the chinese central government in both chinese projects sumario and surumer one of the chinese research partners selected the representatives of stakeholders that were invited to participate in the stakeholder dialogue from an informal network of people personally known to them in both cases these research partners were highranking and influential in surumer governmental stakeholders tended to send higher ranking representatives because the local partner was represented by its director involvement of stakeholders from county and prefecture levels was easier than of those from the provincial level in the case of legato and lucci a certain level of association with governmental stakeholders at the local provincial and national levels and farmers was necessary in vietnam farmers could not be selected freely by the researchers the selection must be agreed first by the administration officials according to the officials local administrative structures and hierarchies must be considered when identifying stakeholders while the freedom of choice of stakeholders was constrained by the local political framework due to these restrictions relevant stakeholders have been excluded which may lead to insufficient consideration of diverse interests during the process of addressing conflicting objectives that arise from resource use some stakeholder representatives might have had interest in participation in the respective transdisciplinary processes but did not have the capacity to do so in a meaningful way for instance stakeholder representatives from the government sector usually have limited time to participate in a workshop and even less so to continuously participate in a series of workshops in sumario the government staff could only allocate about three to 4 hours of their time for each workshop when receiving last minute tasks from the government they had to cancel their participation in general research activities in tdr are given lower priority particularly when the project is not endorsed by the government in lucci there was a lack of financial means for stakeholders to become involved actively in vietnam as well as in china stakeholder and farmer participation requires financial compensation additional budget would have been needed but getting extra funding for this purpose was not possible the legato team did not face this problem because the budget needed was already included in the financial plan a 2 create joint understanding and define the sustainability problem to be addressed the research team of each regional project reached a common understanding of the sustainability problem to be addressed and developed a joint problem definition together with the stakeholders involved in the processes at different stages in legato and lucci the sustainability problem was discussed and identified jointly with stakeholders already during the preparation phase the core team of surumer used the outcomes of a previous germanchinese collaboration project living landscape china as a basis for discussion with stakeholders to achieve a common understanding after the project start in sumario a problem perception shared by researchers and stakeholders was achieved at the second stakeholder workshop a 3 collaboratively define the boundaryresearch object research objectives as well as specific research questions and success criteria german and nongerman researchers of all four regional projects were involved in writing proposals according to the requirements set by the call of the funding agency bmbf they defined the overall boundaryresearch object research objectives and research questions collaboratively the crosscutting question was how ecosystem services can be sustained and used to support livelihoods by means of improved land and water management under climate land use and societal change only in legato and lucci stakeholders directly influenced the definition of research object and objectives as only in case of these projects they were consulted by the research teams during project preparation however chinese scientists involved in defining research object and objectives in sumario and surumer often are in close contact to governmental stakeholders and may have reflected stakeholder perceptions common success criteria were neither defined nor agreed on by the research teams and stakeholders of the respective projects they were believed to be either too vague to be meaningful orif more specificcould hardly fit to the diverse types of research done within individual subprojects a 4 design a methodological framework for collaborative knowledge production and integration table 4 shows diverse approaches and methods for stakeholder involvement and collaborative knowledge production and integration in the respective regional projects the approaches and methods were designed and selected by the team responsible for the execution of the tdr process in each project during proposal writing stage they were chosen based on the objectives of the respective projects as well as the preferences and expertise of the researchers the approaches for stakeholder involvement were stakeholder dialogues and stakeholder discourses knowledge integration was supported by inter alia integrated modelling and assessment methods and scenario development in legato stateoftheart participatory methods like integrative iterative discourses and citizen science were also applied for knowledge integration all the approaches and methods were designed and selected in light of their ability to facilitate collaborative knowledge production and integration their suitability and adequacy in the actual situations was tested while applying them in the tdr process phase b research b 1 assign and support appropriate roles for practitioners and researchers the roles of german and nongerman researchers in the respective regional projects were defined according to the tasks they were involved in disciplinary researchers in each subproject were responsible for carrying out field experiments interviews or modelling in the respective fields of study german researchers responsible for enabling tdr identified and engaged stakeholders in the research processes together with their respective project partners from the project areas additionally they integrated research results gained from different subprojects disciplines with knowledge of diverse stakeholders from inside and outside academia in sumario the main stakeholder dialogue on overall land and water management along the tarim was complemented by a second stakeholder dialogue on the subtheme dust and heat stress mitigation by urban and periurban vegetation in addition many of the disciplinary scientists organized workshops about their specific research in which both chinese researchers and stakeholder representatives took part the overall coordination monitoring of project milestones project reporting and strategic decision making in each project were facilitated by a german project coordinator who is a researcher as well while a researcher assumed multiple roles the roles of the coordinators and researchers responsible for tdr overlapped sometimes for example with regard to leading the production of scientific outputs within the respective projects to improve the overall project integration and coordination surumer built a project monitoring and strategy team which proved to be quite effective the steering group consisted of five members including representatives of different important subgroups the members were the project leader the coordinator one representative of natural sciences one of social sciences and one of modelling in all projects stakeholders from inside and outside academia who were involved as interview partners participants in workshops discussion groups or citizen science were cocreators of knowledge as well as informants who provided important knowledge and insights on the relevant issues in the study regions in legato project for example terrace rice farmers agricultural advisors administrators and tourism operators identified practical options for maintaining rice cultivation in the uplands and taking best advantage of the terraces to improve farmers livelihoods combining sustainable agriculture and ecotourism b 2 apply and adjust integrative research methods and transdisciplinary settings for knowledge generation and integration transdisciplinary settings and methods designed in phase a4 were applied and adjusted according to the sociocultural contexts in the study areas to achieve optimal knowledge generation and integration in sumario the actor modelling method which was planned to be used for integrating the problem perceptions of institutional stakeholders from outside academia in the form of a perception graph was modified by first eliciting the problem perceptions of chinese scientists as described in a1 the research team of the sumario project had limited access to stakeholders while governmental stakeholders were reluctant to be interviewed officially at workshops a combination of methods was applied to facilitate communication as well as to elicit knowledge of stakeholders and scientists for instance the world cafe ´format was used at the first workshop for questionnaires are a useful means because some participants did not express their views openly in plenary or even small group discussion sessions likely due to hierarchy issues at workshops participants who ranked lower in the administrative hierarchy usually showed respect to those higher in ranking gaining direct input from stakeholders particularly those from the governmental organizations was almost impossible in sumario stakeholders preferred to provide feedback on input given by researchers for instance with regard to the development of two qualitative scenarios and possible management measures while this type of stakeholder intervention maybe considered rather passive it was found to be both effective and efficient in light of the limited time available for generating robust results at the workshops nevertheless a continuous knowledge development and integration with stakeholders was impossible in sumario as there was a very large fluctuation of participants from workshop to workshop the other projects did not face this problem in surumer the methodology of interaction was shaped by the surumer project team after internal and external evaluation towards participatory problem analysis and scenario development according to stakeholders they preferred to discuss preliminary research results and possible management options for sustainable rubber cultivation in a concrete way instead of problems and scenarios they perceived to be too abstract to be of interest based on stakeholder feedbacks the surumer team had strengthened the discussion about concrete results and options for sustainable rubber cultivation the approaches and methods applied in lucci and legato projects for knowledge generation and integration did not require major adaptation in the lucci project workshops working meetings of small research groups visits to the relevant institutions as well as interviews and questionnaires were applied as transdisciplinary settings for knowledge integration all project activities including data collection as well as scenario and strategies development were carried out jointly by the vietnamese and german researchers in strong collaboration with the local stakeholders from public and private sector identified land use planning and water management strategies were implemented in the final phase of the project as compared to other projects legato focused stronger on integrating knowledge of local farmers particularly regarding farming practices other projects focused more on integrating system target and transformation knowledge of institutional stakeholders in legato the joint preparation phase was followed by intensive communication stakeholder discourses and as a result of this knowledge coproduction a refocusing and extending of the initially formulated research questions adapting them to local details and updating them as the local situation evolved subsequently after a phase of disciplinarybased information gathering and analysis the results were combined to provide a comprehensive picture of the situations and the challenges and the options for problem solving were identified the analysis was evaluated by scientific reviewers and the options identified in a feedbackloop by local and regional stakeholders the final results are coproduced knowledge and will be made available to all stakeholders in bilateral discussions or focus group meetings they will finally be disseminated to the public at large via tv programs and a tv comedy show as a tested means of communicating ecological engineering to farmers in legato scenario development was based on climate change and land use projections derived from expert knowledge farmers and decision makers were asked regarding their expectations but the answers given by the former were vague and by the latter either summaries of the respective 5year plan or a bit like election campaign promises to facilitate scientific communication with stakeholders a river basin information centre was established in the project region in danangin during the last phase of the lucci project at the centre stakeholders could access to project results in the form of graphics posters reports and brochures all these materials were written in both vietnamese and english language rbic offers a crosssectoral neutral space to discuss fair water allocation and land management strategies and helps to improve the communication among the water and land use related stakeholders in the river basin additionally the team of the lucci project also communicated the project results and data using a river basin information system interdisciplinary communication among researchers the basis for any tdr was gradually intensified as the projects progressed a basic approach to promote communication between the researchers in the respective projects was organizing regular project meetings or annual conferences for all researchers this was usually preceded or followed by activities of field research where different teams could coordinate their different approaches regular interactions greatly contributed to shape a common understanding of objectives terminologies and methods beyond disciplinary boundaries cutting across phase a and b d 1 facilitate continuous formative evaluation each regional project took different measures to monitor and evaluate the respective tdr throughout the project period so far two assessments were conducted in sumario to evaluate interdisciplinary collaboration among german researchers questionnaires and a swot analysis such internal assessments provided inter alia a better understanding about the practice of interdisciplinary collaboration and how it could be improved in surumer measures for monitoring and evaluation which was led by the monitoring and strategy team were developed the measures included a joint problem analysis in the plenary and reflection of the objectives by all researchers after the first year project meetings twice a year with subprojects reports to exchange information on activities and share preliminary results between subprojects discussions on integration issues and publication of quarterly newsletters in which processes were reported and which were synthesized into annual reports in lucci the project progress and research results were presented and discussed each year in a consortium workshop which brought together all researchers and relevant stakeholders in addition to regular small project workshops organized by subproject research teams all regional projects were subject to a milestone evaluation by scientific reviewers commissioned by bmbf 15 years after the initiation of the project and a midterm evaluation about 3 years after project initiation the evaluations were critical and helped to improve tdr however as the review team consisted of reviewers of all projects the level of knowledge regarding each project was very unevenly distributed resulting in questions of varying relevance and quality the value of advice of the reviewers depends strongly on the reviewers familiarity with the local situations d 2 mitigate conflict constellations in all projects conflict management was not a central issue and institutional processes foreseen for dealing with conflicts were not activated so far however measures were taken to support and enhance mutual understanding among researchers as well as between researchers and stakeholders these measures focus on communication information exchange and trust building for example sumario phd meetings were organized annually at different universities to provide a platform for interactions among doctoral students and postdoctoral researchers in surumer discourses were established to improve the internal communication regarding the importance of stakeholder communication in legato a workshop was held to familiarize natural scientists with social science methods thus improving interdisciplinary understanding to save experimental equipment from sabotage natural scientists of the legato project recognized the necessity of building trustful social relations with local famers at experimental sites therefore farmers were informed and involved in setting up the experiments d 3 enhance capabilities for and interest in participation over the course of the project researchers responsible for tdr made considerable efforts to enhance the capacities and interests of disciplinary researchers and stakeholders in participating in tdr stakeholder workshops in all projects were conducted in a way that allowed maximum participation and interactive discussions local languages were used during interviews workshops and roundtablefocus group discussions to enable interview partners and participants to articulate their perspectives and to engage in meaningful deliberations on the field farmers were involved in the legato project to set up the experiments citizen science which was implemented in the legato project was a way for enhancing the capabilities of farmers to participate within the respective projects regular exchanges among researchers were facilitated and joint focal points were set for example the development of scenarios and integrated models as boundary objects additionally joint publications were used as an incentive for enhancing interdisciplinary collaboration among researchers for instance in sumario and legato projects enhancing and sustaining the interest of stakeholders in participation were more challenging in sumario the decision support system has been used as an instrument to sustain the interest of the key stakeholders from the water sector in participation to enhance the interests of stakeholders surumer project team shifted the focus of stakeholder discussion to very practical farming issues providing research outputs is therefore a way to enhance the interest of stakeholders who according to the surumer project did not want always to give information only lessons learned along the time span of the four evaluated projects a number of outcomes have demonstrated the benefits of joint projects that integrate the expertise of different disciplinary backgrounds with stakeholder knowledge particularly system understanding of researchers and stakeholders about the variety of issues could be improved and transformation pathways were discussed by the time of this formative evaluation system and goal knowledge have been integrated while the integration of transformation knowledge is ongoing experience during these years has shown that doing tdr is challenging due to the topdown governance and hierarchical institutional structures the involvement of stakeholders from different sectors and levels is particularly difficult the general guideline of stakeholder involvement and management provided by the bridgeproject glues was useful but it needed to be adapted to the specific conditions in the project areas researchers in charge of stakeholder involvement and management benefitted from the twoday workshop on stakeholder dialogues that was organized annually by the glues team the workshops provided a platform for exchange and mutual learning among the 12 regional projects funded by bmbf in all projects there is a clear concept about tdr regarding stakeholder involvement and how stakeholder knowledge could be integrated with scientific knowledge however as tdr is still in its infancy many researchers are not familiar yet with this research mode this resulted in a lack of understanding and integration among disciplinary researchers in the first phase of the research projects after internal workshops and some pressures exerted by external reviewers the tdr approach with some adjustments could be implemented with better understanding and stronger support from researchers within the project the involvement of the stakeholders is important to create project ownership and to motivate agents to effectively take up project outcomes in all projects however it was unclear who the right discussion partners were and who had the power to take decisions in the study areas at the beginning of the project although key organizations were known stakeholder analyses were conducted as a result of the recommendation of the external reviewers to help identify relevant and important stakeholders by asking the question who is in and why to establish contacts with the right stakeholders and get them involved in transdisciplinary processes it is certainly useful to have a project leader who has long term experience in the project area or better a project partner who is influential and has broad networks with stakeholders in asia informal networks or friendships are often emphasized trust building between stakeholders and researchers is essential in tdr trust enables stakeholders and researchers to engage in cooperative behaviour to address shared problems including data sharing in all projects there was initially a feeling of distrust or at least suspicious unfamiliarity between stakeholders and researchers especially if the researchers were newcomers during the first visit of the legato team at the study sites researchers could not access information about important cultural issues related to inheritance rules gender and the role of traditional knowledge due to the lack of trust in sumario governmental stakeholders were generally reluctant to provide data and information to foreign researchers for example for hydrological modelling while this may partially be due to lack of trust staff of governmental organizations and scientists stated that access to certain data was not possible due to legal restrictions in some cases data could be purchased but it could be very expensive as experienced by the lucci project in vietnam and by the legato project in the philippines in another cases of the legato project in vietnam data access could be facilitated through cooperation this indicates that emphasizing mutual benefits can be a way to overcome data access problems furthermore trusts can be built via informal networks in all regional projects it was clear that good communication among researchers and particularly with stakeholders is important in tdr for knowledge integration however communication between foreign researchers and stakeholders in the four projects was hampered not only by language barriers but also by the culturally different ways of communication the sumario team experienced that open discussions about certain issues such as water quality and agricultural land expansion were avoided as they were deemed to be sensitive and could be related to state secrets this was frustrating for foreign researchers used to open discussions in a participatory setting where discussion is encouraged participants especially those from lower hierarchical structure were also frequently reserved and did not want to express their opinions in the presence of their superiors this might be a result of negative experiences in the past therefore while some information given by stakeholders was inconsistent or contradictory it remained unclear whether this was due to divergent knowledge or the reluctance of stakeholders to reveal available information in legato it was common that farmers discussed lively among themselves before a joint answer to a question was given language barriers are related to insufficient command of english as the international lingua franca or of the national language also in cases where ethnic minorities do not speak it communication via translation was usually necessary in all projects including the translation of key terms such as ecosystem services and transdisciplinary research the problem is that translating information from one language to another by translators can cause a loss in information especially when it is done orally this may be caused by translators not being familiar with the research fields but also occurs if the translator choose to not translate correctly what she regards as not appropriate to be translated for political cultural or for politeness reasons in situations experienced by the legato team some information was not revealed not due to a lack of trust of stakeholders in the foreign researchers but distrust in the external translators therefore it is necessary to select translators who are appropriate for the specific project areas as mentioned before strong support from all disciplinary researchers within the project consortium is essential for the achievement of the project goals however in all projects researchers had different levels of interest in the overall tdr project most of the researchers in the project team wanted to focus on disciplinary research results while only a few of them were open for interdisciplinary integration for example some doctoral students wanted to focus strongly on their own research projects because they needed to complete their theses within the planned timeframes delays in their projects due to difficulties in the project areas caused frustrations which led to lower motivation and interest to commit to the overall transdisciplinary project tdr suffers from the tension between obtaining academic merits and the delivery of policyrelevant outputs this tension may become increasingly apparent as a tdr project evolves measures can be taken to sustain the interest of researchers in tdr as demonstrated by different projects described here including joint publications workshops for interdisciplinary knowledge integration by eg scenario development or integrated modelling and workshops for doctoral students involved in the tdr project these measures have to be taken for promoting the willingness of researchers to adjust and integrate their disciplinary approaches conclusions four tdr projects in the field of sustainable land and water management have been conducted in china vietnam and the philippines to improve the design of tdr projects in particular in those countries we evaluated the four projects with respect to transdisciplinary knowledge integration and organization of tdr projects using the guiding questions developed by lang et al the results of the formative evaluation show that tdr did occur in all four projects but achieved different levels of stakeholder involvement as well as different degrees of integration of stakeholder knowledge these variances can be explained by differences in the political conditions and as well as by the scale and comprehensiveness of the problem fields addressed in the individual projects the difficulty of getting stakeholder involved to the degree desired in tdr projects is not exclusive for asian countries similar problems were also encountered in other regions such as africa and the usa as well as other case studies that deal with complex sustainability problems however there are specific conditions in asia based on the experiences gained so far we provide the following recommendations for the design and implementation of future tdr in asia especially in china vietnam and the philippines some recommendations may also be applicable in other contexts • the strong formal and topdown hierarchies in china and southeast asian countries are a barrier to getting stakeholders involved in transdisciplinary processes under such conditions people from as top as possible should be contacted while those who are important informal multipliers at the lower hierarchical level also need to be sought for both are only possible through the established networks of the local project partners or the long term experience of the project leader to sustain the relationships with the stakeholders direct contact with local actors through extended periods or recurrent visits is also highly advisable • stakeholder involvement in asian countries is likely to require some financial compensation for the stakeholder representatives therefore funding agencies need to provide some budget for financing stakeholder involvement beyond travel costs within tdr projects specific measures are needed throughout the project duration to promote interdisciplinary collaboration beyond general project meetings these measures include workshops for interdisciplinary knowledge integration and joint publications but also regular communication of organizational issues • tdr processes aim at scientific results that are useful for solving realworld problems as well at social learning therefore researchers need to explicitly elicit stakeholder perspectives and to listen carefully to what stakeholders express they need to ensure that stakeholder perspectives are fully considered when identifying strategies at the same time they should make stakeholders aware that colearning with researchers is also an important outcome of a tdr process it is important to emphasize that tdr is a recursive process it requires intensive communication among researchers and stakeholders as well as continual adaptation and specific knowhow sufficient financial resources over a long period of time should therefore be provided for tdr projects as well as for building capacity of researchers interested and involved in tdr in addition funding for a preparation phase is required to enable a joint problem identification and the definition of detailed research questions with stakeholders before the detailed proposal for the tdr project is written then the positive impacts of tdr on sustainable development and science can be further strengthened and sustained over a longer time period the described tdr processes led to the identification of some jointly developed management options in legato project the establishment of flower strips in rice production landscapes as a means of biological pest control and the use of mass media campaigns for promoting sustainable rice production in vietnam was agreed on in surumer the need for training workshops on responsible pesticide usage was identified as a means for capacity building for local farmers to facilitate scientific communication with stakeholders the lucci project established a river basin information centre in the project region in the sumario project severe political constraints prevented the joint identification of specific management options while social learning has been observed in an anecdotal way during all tdr processes conclusive evaluations of social learning have not been performed we suggest that when planning tdr projects an approach for identifying in what way project outcomes are related to the specific design of the tdr process should be developed the methodological framework of wiek et al for example further develops the lang et al approach towards the evaluation of tangible and intangible outcomes by facilitating the evaluation of usable products increase of knowledge and decision capacity enhancement of networks and transformational changes

transdisciplinary research tdr aims at identifying implementable solutions to difficult sustainability problems and at fostering social learning it requires a wellmanaged collaboration among multidisciplinary scientists and multisectoral stakeholders performing tdr is challenging particularly for foreign researchers working in countries with different institutional and sociocultural conditions there is a need to synthesize and share experience among researchers as well as practitioners regarding how tdr can be conducted under specific contexts in this paper we aim to evaluate and synthesize our unique experience in conducting tdr projects in asia we applied guiding principles of tdr to conduct a formative evaluation of four consortium projects on sustainable land and water management in china the philippines and vietnam in all projects local political conditions restricted the set of stakeholders that could be involved in the research processes the set of involved stakeholders was also affected by the fact that stakeholders in most cases only participate if they belong to the personal network of the project leaders language barriers hampered effective communication between foreign researchers and stakeholders in all projects and thus knowledge integration the tdr approach and its specific methods were adapted to respond to the specific cultural social and political conditions in the research areas also with the aim to promote trust and interest of the stakeholders throughout the project additionally various measures were implemented to promote collaboration among disciplinary scientists based on lessons learned we provide specific recommendations for the design and implementation of tdr projects in particular in asia

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introduction the perinatal period including pregnancy and the first year after childbirth is increasingly seen as a time when women are at a heightened risk of experiencing psychological distress the greatest focus in the research literature has been on perinatal depression the findings from systematic reviews indicate that around one in six women experience depression during pregnancy 1 and around one in five do so in the first three months after giving birth 2 perinatal depression has been associated with a range of serious outcomes for women and their infants 34 the high prevalence of distress at this time can seem paradoxical because across many cultures having a baby is expected to be a fulfilling event in a womans life becoming a mother is commonly seen as an achievement which confers on women a recognised status and identity in society at least for those in normative family and social setups however research mostly among mothers in the global north has shown that for some having a baby not only represents a gain but can also result in a complex sense of loss of ones former life 5 6 7 8 9 unrealistic normative expectations of motherhood and strong culturally informed views about how women should feel and behave as good mothers have also been found to contribute to distress 57 womens relationships and social networks undergo changes in the perinatal period and women can become lonely and isolated social isolation is seen as resulting when people have or perceive themselves to have limited social contact 10 loneliness is subjective related to an unpleasant feeling of having inadequate social relationships in early work weiss 11 argued that loneliness consists of the following two key aspects emotional loneliness and social loneliness loneliness and social isolation are generally considered to be multifaceted overlapping constructs that are also related to other concepts like social support a small qualitative study of firsttime mothers in the uk found that they had all felt lonely in the transition to motherhood 12 while the mothers in this study were fairly homogenous they linked their loneliness to making unfavourable selfcomparisons with perceived mothering norms reduced social contact and a lack of empathy from their partners and other mothers other studies have focused on more marginalised groups highlighting experiences of isolation among teenage lone and immigrant mothers 13 14 15 feelings of loneliness and isolation have also been reported by mothers outside of the global north 16 there is growing evidence that isolation and loneliness are major risk factors for depression including in the perinatal period 1718 such findings suggest a potential benefit from developing perinatal interventions that seek to strengthen womens support networks to help reduce their distress 19 in the general population social isolation and loneliness are increasingly seen as priority areas when supporting people with mental health difficulties 17 and pregnancy and the period after childbirth when women come into increased contact with healthcare professionals may be an opportune time to intervene to prevent or alleviate depression however little is known about whether and in what ways women themselves consider social isolation or loneliness to be connected to perinatal distress qualitative studies with women experiencing postnatal depression have depicted them as enveloped in unbearable loneliness 20 detached and removed from those around them 6 and in the case of migrant mothers experiencing isolation lack of social support and a deep sense of loneliness sometimes in contrast to what they perceive as a more connected motherhood within their own cultures 21 the intersectionality theory emphasises how factors like gender interact with other social categories such as class and race to influence the exclusion and marginalisation of groups or individuals in society 22 and this too seems important to consider in the perinatal context where isolation loneliness and distress may not be experienced equally by all women 23 however to our knowledge there has been no published research directly exploring the ways in which loneliness and isolation feature in womens narratives of perinatal depression or how this may vary for different women our study therefore sets out to explore this based on qualitative interviews with women from diverse backgrounds who had been treated for perinatal depression we did not attempt to fit womens stories into a particular model of loneliness or isolation but instead sought to identify the ways in which womens narratives demonstrated that loneliness and isolation played a role in their distress our aim was to contribute to understanding perinatal distress using an intersectional lens to consider how this may differ for women in different social groups and helping inform the development of appropriate support to meet mothers needs materials and methods this study was part of a wider research programme called stakeholders views and experiences of perinatal mental health care in which qualitative semistructured interviews were conducted with 52 women aiming to explore experiences of perinatal mental health services in england 24 25 26 ethics approval was granted by the national health service data collection women were recruited from nhs services eligible women were initially approached by a mental health clinician involved in their support clinicians passed contact details of women who were interested in the study to the lead researcher who then approached them directly potential participants were informed that participation was entirely voluntary and not connected to support in anyway written informed consent was obtained semistructured interview schedules were developed for the wider study by the first author in consultation with the wider study team these were amended following review by a lived experience advisory group convened for the wider study consisting of people with experience of perinatal mental health difficulties and revised again following five pilot interviews as the wider study focused on experiences of services interviews included questions about womens experiences of support for their perinatal mental health however women were also asked for their accounts of the distress they had experienced during and after pregnancy example questions included the following can you start by telling me a bit about your pregnancy how were things after the birth women were not directly asked in interviews about loneliness or isolation but rather our analysis focused on exploring how these featured spontaneously in their accounts of depression women were also asked for basic sociodemographic and diagnostic information interviews lasting around one hour on average were conducted between june 2015 and march 2017 in womens homes except where women preferred alternative settings the first author carried out 11 of the 14 interviews two interviews were conducted by a member of the wider studys leag and one by a masters student the use of a semistructured interview schedule helped ensure consistency across interviewers to further aid trustworthiness each interviewer also wrote up and shared reflexive notes after each interview and debriefed with the first author all interviews were audiorecorded transcribed and anonymised data analysis we drew on social constructionist theory 27 taking the position that womens subjective experiences of motherhood are created through social discourse however we also acknowledge that these are experienced as real and that structural and material inequalities are important to womens experiences too 28 interviews were analysed using the principles of thematic analysis allowing for similarities and differences to be identified across participants 29 the study was informed by experiential knowledge throughout 30 data analysis was jointly led by the last author who is a survivor researcher with experience of using perinatal mental health services and the first author who is a mother and clinical psychologist with experience of working in perinatal mental health services to enhance rigour these two authors ran a series of data analysis workshops with three women with relevant lived experience from the wider studys leag and with qualitative experts our final analytic account consisted of inductive datadriven analysis of the qualitative interviews interpreted with wider experiential input from the leag the participation of people with lived experience in the data analysis helped us consider womens narratives from differing standpoints and disrupt traditional boundaries between researcher and participant 31 braun and clarkes 29 six steps of thematic analysis were followed as follows the first author read all transcripts in addition kj nm and as read three transcripts each while the three leag members read a summary of every transcript that included direct quotations observationsreflections on the data were discussed in workshops 1a 1b and 2a the first author reread the transcripts and systematically arranged segments of text into codes codes were assembled into themes to create a provisional coding frame provisional themes were discussed and the coding frame was updated a comprehensive thematic framework was finalised collaboratively with the leag members and qualitative experts and the implications of the findings were discussed findings were then written up guided discussion of the final thematic account and its interpretation study implications workshop 3b qualitative experts as above for 3a as above results table 2 shows the characteristics of the 14 women included in this study just over half were white british and half were married or living with a partner five were firsttime mothers five had some degree of childrens social services involvement and four had received acute mental health support during the perinatal period all of the names are pseudonyms we present our analysis in the following two overarching themes dislocated self and dislocated relationships each of these include the following separate subthemes what have i become stigma shame and the isolating narrative of the goodbad mother difficulties in family relationships and bonds nobody to care for me and going it alone these themes are not entirely discrete but instead sometimes overlap informing and reinforcing one another dislocated self what have i become the narratives of several women in our study connected their feelings of depression to experiencing a dislocated sense of self after having a baby and in some cases during pregnancy too while the womens distress arguably extended beyond loneliness or isolation feelings of dislocated identity clearly included a strong sense of loneliness and desolation as the mothers described themselves becoming confined to their homes with their babies isolated from the wider world and disconnected from their past lives and social networks a dislocated self was particularly evident in the narratives of firsttime mothers who had stopped working or taken maternity leave to have a baby lisa a highly educated married white british mother who described herself as an olderish firsttime mum said she had a good network of friends locally who also had babies and loads of support from my parents and my husband however she nevertheless described having lots of lonely moments after giving birth explaining i felt isolated even if i havent actually been isolated she began to feel low and associated this with the sudden change in her life after giving birth describing herself as terrified of having a day with no plans she struggled to feel connected integrated and capable at home with her baby no longer having a routine or role in which she felt competent if youve been if you have been working youll be going to work every day you had a role youve been there youve been amongst these people youve been doing that thing and suddenly youre by yourself with this baby you dont know what to do with your baby really all day you just think oh what do i actually do and it yes does it is quite a lonely thing actually while some women like lisa had planned pregnancies others had become pregnant unexpectedly or had felt pressured into it and this could make the change to their identity particularly difficult lyla a highly educated arab british woman living with her husband described how having children had never been something ive particularly wanted or yearned for i just kind of did it because it was like you know when you come from an arab or asian background you just get harassed for years when are you having kids when are you having kids lyla had to stop working to look after her baby and found it became harder to go out socially she began to long for her previous life struggling to establish a new sense of self i just kept thinking about all the things that i couldnt do anymore and wishing for the life i once hadand also its about like identity its like sometimes even when she is in bed its like i dont know what to do its like apart from eat or watch tv its like im trying to think of things that what did i used to do for enjoyment you know and im trying to remember what did i used to do a dislocated sense of self was not only experienced by married highly educated mothers the narrative of lottie a young single white british mother living in local authority housing also gave a powerful sense of isolation and loneliness in the context of a loss of her prior life lottie described how she was so happy before i got pregnant however then lotties partner left her on finding out she was pregnant and lottie had to give up her job to look after her baby you lose the man that you were with youve become pregnant so you end up doing it all on your own and you havent got anyone with you and you havent got a job anymore so you end up losing your whole life in one big blow lottie explained that before i was so confident and outgoing and it was like hey wheres the party and now its just you just feel lost in a way lottie felt her body shape had changed too making her feel like an obese monster while lottie said her partner stopped contact and decided to move on to a new relationship she was left struggling to look after their baby alone lottie felt that parenthood had little impact on her partners life or social status whereas for her the impact was profound the combination of being a young single mother with no job and an appearance she no longer liked signified for lottie a new social status which left her feeling ashamed and directionless the intersect of motherhood with age relationship status and work prospects left her feeling she had shifted into a disadvantaged social position while lottie did not explicitly use the words lonely or isolated in her account she described struggling to go out withdrawing from others and feeling increasingly disconnected it was conspicuous that the language used by mothers like lisa who had lots of lonely moments but also had extensive resources to draw on including a friendship and family network she found supportive emotionally and practically gave the impression of loneliness as transient by contrast for mothers like lottie who had experienced a relationship breakdown and increased material deprivation in motherhood their accounts suggested they perceived their isolation and loneliness as more permanent and engulfing in this way disparities in womens social and material circumstances intersected with motherhood to affect their experiences 312 stigma shame and the isolating narrative of the goodbad mother it was clear from womens narratives that many experienced a sense of failure or inadequacy that could prevent them from connecting to others the mothers described feeling under pressurefrom themselves partners family members other mothers and wider societal narrativesto take on the role of a primary caregiver and to be as lottie put it a perfect mum they then experienced feelings of hopelessness when they saw themselves as falling short of this ideal or when their expectations of motherhood clashed with the reality among participating women this included for example not feeling love towards their babies having outbursts of aggression or anger not being able to breastfeed feeling unable to maintain a home or their personal appearance whilst caring for a new baby or a general a feeling of being unable to cope the mothers beliefs that they were inadequate or different could lead to them avoiding others including other mothers this could compound their social loneliness 11 or difficulty integrating into social networks lottie for instance explained how youll find that its hard to try and see people that are in the same position when you get offered the chance to see other mums quite a lot of them are generally look at my baby im so happy my baby antoine sleeps through the night hes perfect lotties comments seemed also to suggest a class divide where she felt isolated by the dominant middle class narratives of women in her local groups above all lottie said she was constantly worried that theyre going to judge you however as lottie also found it hard to maintain her previous friendship group once she was no longer working she was left isolated suddenly youve got no one youre on your own you hardly see anyone and you become a bit of a hermit when the mothers did manage to make meaningful connections with others who they perceived were struggling in similar ways however it could be very reassuring lauren for example a single black caribbean british mother took great comfort from meeting other mothers in a similar position to her on a mother and baby unit just knowing that there were other mums it was just like the biggest comfort ever i just felt like oh my gosh im not the only one because i had friends at the time and they were so in love with their babies and so kind of like you know their baby was their world and then im feeling the complete opposite and it just made me feel so bad like i was really crazy and then just coming to the mbu and seeing that you know there are other mums thats just like me among our participants the mothers who were single young deprived or from ethnic minority backgrounds seemed to experience a particularly acute fear of being judged to be bad mothers yet the narratives of mothers in other circumstances suggested that they too experienced shame connected to anxieties that they were inadequate mothers there was a sense of loneliness in the mothers beliefs that they were alone in their feelings and ought not admit to them preventing honest authentic interactions with others for example susie a married white british mother felt really disappointed after finding out she was expecting twin boys and then was ashamed of that feeling she described how she tried to hide how she felt through fear she would be seen as a bad mother similarly another married white british mother laura explained how she was ashamed for feeling depressed and not being able to cope although she knew intellectually that it doesnt mean im a bad mum she could not fully accept this and as a result felt unable to share how she was feeling explaining very few people know that i you know have depression this was the case for mira too a mixedrace muslim mother who kept her struggles private you know because not everyone understands or is willing to hear the accounts of some women in particular two women june and anaya who both identified as black african and muslim suggested that the wider stigma around mental health difficulties in their culture could also increase isolation june and anaya each said that in their cultures having depression was seen as your fault whatever youve done a mistake these two mothers appeared already very socially isolated across the following multiple interlocking axes they were each seeking asylum in england neither was living with a partner both were away from their wider family networks each lived in insecure housing and they had little access to resources to provide for their children the stigma they described within their communities exacerbated the inequalities they experienced and led them to retreat further from those with whom they might otherwise have sought connection you know depression what im going through in africa the difference is like you are not okay that person is not okay thats why i move away a little bit from people also you know its ashamed i dont want them to know about my situation dislocated relationships difficulties in family relationships and bonds the womens need for nurturing personal relationships was clearly evident across all their accounts with their experiences of depression isolation and loneliness strongly rooted in their interpersonal contexts it was conspicuous how often depression was linked to relationship turmoil particularly between women and their partners the two were often closely interwoven in the mothers accounts as illustrated by nicole a mother from a black caribbean british background who had separated from her husband and who described how they was constantly arguing when we was together so it was hard to differentiate between our kind of bad relationship and the depression the womens relationships with their partners and sometimes wider family members too went through a period of transition with the arrival of a new baby which could provoke difficulties some women described an increased sense of disconnect or lack of understanding from their partners one mother described threats of violence from her partner in several cases couple relationships had ended in the perinatal period nicole felt her husband had struggled to understand her increased vulnerability during and after pregnancy and could not accept the change in their relationship he just couldnt get his head around it he didnt understand whats the problem you know you were such a strong person it wasnt like he wasnt a nice person or like he wasnt a good person he just didnt get his head around somebody who is strong who is able to do everything that everybody depended on being the other way around me dependent on him fiona a white british mother similarly felt her husband doesnt really understand mental health in other cases women felt their partners struggled with having to share attention once they had children for example susie explained how her husband had quite a strong reaction to suddenly being number four in the pecking order from having gone from number one and the centre of my universe the relationship difficulties and breakdowns left the women feeling less able to draw on their partners for support or empathy increasing their emotional loneliness in weisss 11 definition through feeling a lack of close attachment this could be compounded when women experienced conflict in their wider family networks too emma a single white british mother whose children had been taken into foster care described her own mother as her main source of support but also said her mother had been abusive and neglectful to her during and after pregnancy meaning she could not feel confident in her availability several women also described difficulties bonding with their babies for example feeling nothing numb terrified of them or like their baby wasnt a part of me for some mothers a babys need to be close to them could feel uncomfortable even threatening yet a lack of closeness also resulted in high levels of distress as emma explained my baby used to have to sleep on my chest and because i didnt want him near me it was really hard having him on my chest so he used to just lay there and scream in pain and i used to just sit in another part of the room and just cry the emptiness guilt and shame that the mothers experienced in these cases also contributed to the feelings of disconnect particularly given the context of the goodbad mother narrative at the same time the womens connections with their babies could also make them feel less alone some spoke about their love for their babies keeping them going sometimes closeness with a baby filled an emptiness depicted in womens accounts almost as a substitute for a couple relationship in emmas case for example she described how when she eventually tried cosleeping with her baby for the first time i wasnt in my bed alone you know nobody to care for me the difficulties in family relationships coupled with trouble connecting to other mothers in part because of the divisive impact of the goodbad mother narrative contributed to many mothers feeling they lacked adequate support from those around them the women felt they were expected to take primary responsibility for meeting their babys needs yetas nicoles account highlightedoften felt more dependent on others and a need to feel mothered themselves as lisa put it i just wanted to be looked after lisa described herself as so exhausted that she was like a little husk the mothers feelings of exhaustion and overwhelm could make it difficult for them to find the energy to interact with others or socialise across the interviews it was very common for mothers to connect their feelings of depression to the relentlessness of motherhood anaya noted how in africa where she was from mothers usually had considerable support from their wider family networks in contrast to her experience in england if its back home now you know your parents you give them your children sometimes two days three days they would be with your parents you have a little rest but here theres nobody nicole similarly spoke about feeling that you dont have anybody half the participants were not living with a partner and in each case the mother had taken on the main caregiving responsibility often with little or no support from anyone else however in some cases women with partners or with larger family or social networks could also feel alone and unsupported this was the case for lyla for example who felt distressed that her husband did not help her care for their baby thats essentially part of the problem kind of feeling like im on my own basically i might as well i could just be a single mum and i wouldnt notice the accounts of mothers who felt they had little help caring for their babies and nobody to care for them contrasted sharply with those mothers who described having supportive networks which they could draw on to lessen their distress and feelings of being alone for example victoria a white british mother felt a little bit like i broke after she was left alone with her new baby while her husband went away for work she described going a little bit stir crazy from just lots and lots of baby contact and not a lot of adult contact however her feelings of distress and isolation were alleviated once her social support increased my husband managed to be sent home a bit early and also i was kind of lucky in that a few friends were on annual leave and things and they came and helped out with my baby just so that i could get a bit more sleep similarly laurawho found it hard be open with her friends about her mental health but otherwise related her depression to physical health complications rather than loneliness or isolationsaid that when she struggled her husband would take over and hell let me sort of stay in bed a bit longer although the women could feel mindnumbingly bored and isolated stuck at home all dayas carlie an older white british mother put itmany also longed for rest respite or alone time some women wanted to be by themselves they wanted peace or an escape others wanted alone time with their babies or their immediate family in order to bond however what was desired in each case was a nourishing type of aloneness or isolation in a safe calm environment away from the noise stresses and overwhelming responsibilities of their lives lauren for example described how it was her stay on an mbu that finally enabled her to bond with her baby because she felt cared for herself in a safe place that was kind of like family in this context aloneness or isolation was not a negative but could feel restorative and healing as lauren explained just shutting the world out and just it being me and her was the main thing i could just concentrate only on her oh baby yes it being me and her and getting to know each other just having that time for each other was the main thing i think women who had little support from their family or social networks sometimes relied more on professional support to help them feel cared for emma for example who did not have reliable family support had asked her clinician to be her babys godmother empathic supportive relationships with healthcare professionals who were often described as resembling friends or family members were seen as an important source of connection however these relationships needed to be enduring and empowering otherwise mothers could feel a sense of abandonment and loss once the support ended for example although lauren really valued the mbu support she received she described becoming distressed again soon after she was discharged and ultimately having to be readmitted similarly nicole said she formed a very strong bond with her midwife who she saw as in between a mum and a sister however she then felt abandoned when her midwife stopped coming going it alone finally several womens narratives depicted them as battling on singlehandedly despite the challenges they faced lottie for example described feeling as though she was in a battle because youre constantly fighting to stay on top youre constantly fighting to try and be happy an impression of the mothers going it alone seemed to depict them as isolated but also resilient it could be seen in the narratives of the women who felt unsupported by their partners or wider networks but was particularly evident among those mothers who saw themselves as parenting outside of the norms for example because they were young or single emma described her belief that she was seen as a bad mother in part because she did not match societal norms of what a good mother should be youre a young mum you have two children close in age that gives it all away while emma accepted that she had struggled to care for her children she felt she had been unfairly expected as a woman to take naturally to motherhood they think we just love it all the motherly instinct but she explained im a single mum you know and its not just going to happen by myself but i was left to do it all by myself however while emma clearly felt isolated and unsupported her account also conveyed a sense of strength and resistance she described herself as proud for struggling on by herself seeking to prove that despite everything she could succeed although she did not have custody of her children she felt that by persevering she had managed to bond with them particularly her oldest son she described how we pulled through me and my son together hes still in my care well he was at the time you know still alive and kicking and i should be proud of myself for that the intersection of motherhood with being young and single in emmas account seemed to be connected to feeling marginalised but also to being strong and distinctive almost as if she sought to harness her feeling of going it alone to carve out a unique valued identity and resist the discourses that seemed to be against her while custody loss was intensely painful she attempted to turn her sense of dislocated self and aloneness into a positive force helping her also to find some sense of togetherness with her son similarly lotties account of aloneness although clearly a source of overwhelming distress seemed also to define her as distinctive and resilient no matter how tired you are you crack on with it and no matter how much there is to do you crack on with it you can either do it miserable and sad and be depressed about it or you can put some music on like ive been doing and just crack on with it do a little dance discussion in this qualitative analysis we explored how loneliness and isolation play a role in the accounts of women diagnosed with perinatal depression we centralised experiential knowledge in our study carrying out firstperson interviews with women and then analysing their accounts collaboratively with a group of people with relevant lived experience this ensured that wider experiential knowledge shaped our understanding of the womens data and that multiple standpoints experiential and theoretical informed our interpretation of the findings this process was grounded in the notion that the interpretation of data varies depending on the standpoint of the analyst 32 for instance in their study of service users experiences of psychiatric detention gillard et al 33 found that the analysis and interpretation of mainstream researchers tended to focus on processes and procedures whilst service user researcher accounts focused more on emotions and experiences in addition our analysis highlights how occupying multiple disadvantaged statuses affected the mothers sense of loneliness and isolation indicating that the impact of intersecting identities was qualitatively different from the impact of any single identity on loneliness and isolation the mothers identity was intertwined with categories of gender raceethnicity relationship status and class which they continuously negotiated in everyday social contexts summary of findings based on the interviews with 14 women treated for perinatal depression we found that mothers often connected their feelings of depression during and after pregnancy to a sense of being dislocated from their previous lives identities and relationships some explicitly used the words loneliness and isolation to describe their experiences while others talked about feeling lost alone or having nobody although the experiences varied the accounts of all the women informed or related to at least one theme the women described changes to their identity associated with a loss of employment independence routine sleep and body shape as well as changes to their social lives relationships and friendships a sense of dislocation arguably extended beyond loneliness and isolation but the women clearly described themselves as isolated from wider social networks confined to their homes by the mothering role and struggling to connect to others or integrate into social networks for fear they would be seen as falling short of the ideal good mother while struggles with identity relationships and mothering norms have also been described by perinatal women not diagnosed with depression 12 our participants clearly connected their sense of dislocated self and relationships to their feelings of depression in intricate ways the womens relationships especially with their partners underwent transition in the perinatal period sometimes resulting in conflict breakdown and even abuse many women felt that they were left to care for their babies alone seen automatically as the primary caregiver with little support or respite and a lack of close empathic attachment by contrast the mothers with supportive networks and partners with whom they shared parental responsibilities tended to describe loneliness in more transient terms yet an important finding was that women could also feel lonely and isolated despite having people around them if they didnt feel supported and understood in the way they needed although a new baby could make women feel less alone others felt more alone in the absence of supportive adult company and some struggled to bond with their infants nevertheless isolation was not only viewed negatively in some contexts for example if a woman felt she was in a safe supportive wider environment having time to herself or time alone with her baby could be restorative and nurturing some women also harnessed their aloneness to define themselves as strong resilient and distinctive setting the findings in context our study reinforces previous findings that having a baby can result in a complex sense of loss for women 5 6 7 8 9 feminist scholars in particular have connected postnatal depression to losses and inequalities in womens lives following childbirth such as an increasingly unequal division of household work a gendered employment market loss of occupational status and identity increased confinement to the home and a high burden of care in which women are also held responsible for their infants developmental outcomes eg 3435 in our study loss was clearly apparent in the womens accounts particularly among firsttime mothers who had given up their jobs or taken time away from work to have a baby more than forty years on our themes of dislocated self and dislocated relationships resonate with oakleys 36 seminal sociological study of childbirth in which she argued that a change in self particularly the loss of paid work roles and of previous more equal or joint relationships with partners can be akin to a form of bereavement which can lead to significant mental distress the themes of dislocated self and dislocated relationships also have resemblances with mauthners 7 relational approach to postnatal depression in which she argues that depression results when mothers feel unable to experience communicate and validate their needs and feelings within supportive relationships and an accepting wider social and cultural context she sees relational issues and womens sense of agency within these relational settings as key to understanding postnatal depression mauthner 7 also views depression as linked to a disconnect between the expectations of motherhoodhow mothers think they should be in order to be good mothersand the reality in which women often feel inadequate and unsupported however as in our study mauthner notes that isolation is also twoway with women who feel depressed actively withdrawing from relationships and networks and silencing the self 37 through fear of being a burden or being judged as bad mothers this selfreinforcing relationship between mothering norms isolation and depression is also noted by knudsonmartin and silverstein 38 in a qualitative data synthesis of postnatal depression they found across studies from a range of different countries that social constructions of the good mother made it difficult for women to express negative emotions and to have these validated by others provoking feelings of incompetence that precipitated isolation from others in our analysis the binary narrative of the goodbad mother featured strongly across the womens accounts it organised how women thought about interpreted and performed their mothering roles this master discourse 39 was to some extent reinforced by the women themselves who used it to define themselves as worthy or unworthy of moral respect yet it was experienced as monolithic and coercing creating rigid expectations around womens feelings behaviours and supposedly innate mothering abilities and provoking a sense of lonely distress and disconnect from others when women felt unable to meet these expectations as found by knudsonmartin and silverstein 38 expressing negative feelings was seen as incongruent with social constructions of motherhood this acted to silence and isolate women who at times became overwhelmed with feelings of incompetence making authentic connection with others difficult some women did however make meaningful connections with other mothers who they felt were in similar situations to themselves such as in the case of one mother who connected with others on a psychiatric mother and baby unit when this happened it was experienced as comforting and motivating similarly mauthner 40 found in her research that forming honest friendships with other mothers was key to reducing womens feelings of depression enabling them to challenge and resist cultural norms of motherhood through shared experiences mauthner 40 suggests that peer relationships may be even more important than couple relationships at this time however in our research difficulties in couple relationships were often presented by women as central to their distress we found that women could also open up to and gain important support from relationships with professionals as in previous research when womens own families did not provide adequate support they appeared more likely to view other people as family 41 however as professional relationships were often not enduring their temporality could ultimately increase womens feelings of loneliness or abandonment particularly among those who relied more on these relationships because they were already isolated or marginalised this reinforces previous research that has shown how people accessing mental health support may experience a painful sense of loss and insecurity if a therapeutic relationship ends 42 a strength of our study is that the heterogeneity of our participants allowed us to draw on the intersectionality theory to consider how womens positions within different social categories could influence their feelings of depression isolation and loneliness the intersectionality theory is principally concerned with how peoples locations across multiple interdependent social categories can affect experiences and result in privilege or marginalisation 43 in our study although there are themes that were common to all participants our findings show how ethnicity relationship status age and the material and subjective components of class and deprivation could intersect with motherhood to affect womens experiences motherhood could be a location for increased disadvantage or privilege depending on different elements of intersectional identity leaving some women more vulnerable than others to sustained loneliness isolation and marginalisation in particular while fears of being judged to be a bad mother were apparent across most of the womens accounts our findings point to a perception among women that certain characteristics are more likely to be associated with deviant deficient motherhood increasing the feelings of rejection and isolation for example one woman who was parenting alone believed that being young with two children close in age led others to reject her as an inadequate mother another woman described how she lost her partner and job and gained weight during pregnancy shifting her from an identity with which she had felt happy into a new disadvantaged social status as a young single unemployed mother the intersect of age relationship status and work prospects with motherhood left her feeling an overwhelming sense of failure constraint and aloneness other women found themselves situated in disadvantaged social positions as mothers because of factors such as their status as asylum seekers which left them cutoff from wider family networks and struggling to access housing or other resources they felt they needed to provide for their children the stigma around mental health particularly within minority ethnic groups could further exacerbate womens marginalisation in this way our work also has similarities with abrams and currans 23 study of identity among lowincome mothers experiencing postnatal depression in which they found that postpartum depression and poverty could converge to create a troubled identity of maternal failure nonetheless abrams and curran also found that women sought to resist this identity by portraying themselves as loving selfsacrificing and engaged mothers in our analysis we also noted how mothers who felt they were parenting outside of the accepted norms in some ways appeared to embrace aloneness and marginalisation harnessing it to define themselves as strong resilient and distinctive this could potentially be viewed as an example of narrative repair 44 where those who feel they are prevented from occupying valued social roles because their identities categorise them as inferior seek to resist or repair this by reidentifying themselves as competent members of the community while our study offers insights into womens experiences it also had limitations as outlined the women were not explicitly asked about loneliness and isolation in interviews but rather we explored how these concepts featured spontaneously in their accounts either because mothers directly mentioned them or where they were implicit in their narratives further insights could be gained by asking women directly about loneliness and isolation in the context of perinatal depression while the 14 women we interviewed came from diverse social and cultural backgrounds they all lived in the south of england many in london and some ethnicities were not represented future research would benefit from interviewing women from a wider range of geographical areas including rural areas as well as interviewing women from more ethnicities and those who do not speak english finally future research should seek to explore with women what support they believe might help to reduce their feelings of loneliness or isolation or strengthen their social networks conclusions and implications our analysis suggests that loneliness and isolation are related to perinatal depression in complex intricate and often mutually reinforcing ways our findings have important implications while it is important to be aware that in rare cases mothers can pose a serious threat to their children our analysis supports the work of those who argue that if we wish to improve the experience of motherhood for women we must seek to broaden the societal frameworks within which mothers are expected to operate and challenge the artificial binary goodbad mother divide 37 our research also suggests there is a need to advocate for broader social change to lessen pressures on women and their families reduce deprivation among mothers and seek to improve gender equality the womens accounts in our study point to the often social nature of perinatal depression an implication of this is the importance of developing support for women which is not only focussed on the individual but also addresses interpersonal relationships social networks and wider social structures while healthcare professionals like midwives increasingly ask women about feelings of depression during and after pregnancy it may prove helpful also to ask about womens families and wider social networks and to explore whether women may benefit from support to strengthen these our findings support the idea that finding ways to facilitate connections between mothers in the perinatal period for example through peer support may be valuable 4546 however this must be done in a way that is sensitive to ethnicity class age and relationship status and recognises that mothers may be fearful of connecting with others a focus on developing and evaluating interventions focused on couple relationships and wider social networks is likely to have value the interventions should help parents to identify and expand their ideals of parenthood including emphasising how cultural norms can affect parents feelings of competence finally while our findings suggest that womens relationships with professionals can also lessen their feelings of isolation and help them feel supported and validated there is a need to ensure services offer women support in a way that is sustainable and that recognises the human nature of therapeutic interactions data availability statement the datasets generated andor analysed during the current study are not publicly available due to them containing information that could compromise research participant privacyconsent but are available from the corresponding author on reasonable request informed consent statement informed consent was obtained from all subjects involved in the study written informed consent has been obtained from the patient to publish this paper conflicts of interest blt lmh kj nm sn ays and as declare no conflict of interest funds for the project from uk research and innovation were awarded via the loneliness and social isolation in mental health research network of which sj was lead but she was not involved in the decision to fund this project or in the administration of the award the funders had no role in the design of the study in the collection analyses or interpretation of data in the writing of the manuscript or in the decision to publish the results

in this study we explore the role that isolation and loneliness play in the narratives of women diagnosed with perinatal depression isolation and loneliness are increasingly seen as risk factors for depression including in the perinatal period but little is known about whether and in what ways women themselves associate isolation or loneliness with perinatal distress based on the thematic analysis of semistructured interviews with fourteen mothers in england we found that women often connected feelings of depression during and after pregnancy to feeling dislocated from their previous identities and relationships women felt lost confined to their homes and often unsupported by their partners and families however fears of being judged to be inadequate mothers made it difficult for women to make authentic connections with others or to express negative feelings increasing isolation and depression we drew on the intersectionality theory to illustrate how the intersect between motherhood and other aspects of womens identities being young single deprived andor from an ethnic minority could leave some women particularly isolated and marginalised our conclusions emphasise the need to challenge social constructions of the goodbad mother advocate for social change to lessen pressures on mothers and develop support that addresses womens interpersonal contexts and social networks

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introduction a person is said to be paranoid if they have a persistent belief that a person or group is attempting to deliberately harm them in some way although typically seen as a symptom of psychosis in which case the paranoia may be said to constitute a delusion substantial psychometric evidence now shows that clinical paranoia exists on a continuum with subclinical paranoid thoughts that are common in the general population subclinical paranoia is also associated with common psychiatric disorders such as depression and anxiety and may be a bridge symptom linking these common disorders to adverse circumstances such as harsh urban environments thus understanding the determinants of paranoia in the community particularly in vulnerable populations could make a substantial contribution to the development of policies and interventions that improve population mental health research suggests that paranoid delusions are often grounded in real external events indeed people who suffer from negative life experiences are overrepresented among patients with psychosis and several studies have found associations between traumatic life events in childhood and adulthood and psychotic symptoms given that paranoia is characterized by a severe distrust of others it could be hypothesised that peoples experiences within their immediate environment will influence the extent to which they will be affected indeed paranoia is more sensitive to adverse socioeconomic and family circumstances when compared with other symptoms of psychosis such as hallucinations and manic states in this study we examine the relationship between paranoia and the social environment among people from black african and black caribbean backgrounds who are at extreme risk of psychosis compared to other ethnic groups drawing on theory and research from social and clinical psychology outlined below we hypothesize that when a person belongs to a social group that is positive and supportive paranoid beliefs should be reduced conversely when a group to which someone belongs is hostile or unsupportive paranoid beliefs will be elevated terminology there has been inconsistency in the use of terminology in the research literature referring to people of african descent inline with recommendations from bhopal we use the terms african and africancaribbean to indicate more recent geographical heritage and black or black britons when referring to all people of african descent the terms briton and british are commonly used to refer to nationals of the united kingdom of great britain and northern ireland our approach is theoretically driven and we therefore make hypotheses regarding the entire population of african and africancaribbean people but nonetheless examine potential ethnic group differences in the preliminary analyses indeed while african and africancaribbean people have different sociocultural histories the identity and social challenges faced by black people in the united kingdom are likely to be similar and the effects of identity on paranoia and related psychological processes are theorised to be comparable across ethnic minority groups social identity and paranoia in ethnic minority groups consistent with the proposition that social group belonging is related to paranoia the social cure model of mental health posits that people who belong to and identify with positive and meaningful groups experience better mental health outcomes research on the social cure suggests that social identities protect people from several mental health symptoms including paranoia there is also evidence that social group membership might be associated with the prevalence of paranoia in the community specifically it has been shown that ethnic minority groups experience psychosis and paranoia in particular at substantially higher rates than majority group members according to data from the longitudinal aetiology and ethnicity in schizophrenia and other psychoses study which compared firstepisode psychosis patients to a sample of community controls people from africancaribbean backgrounds living in great britain are at particular risk within this subgroup the aesop study found that psychosis incidence rates were 67 times higher among africancaribbeans 45 times higher among black africans compared with white britons while this effect extends to other minority groupsfor example people from asian backgrounds have an incidence rate 15 times higher than white britonspeople from african backgrounds are particularly vulnerable there is strong evidence that these ethnic differences are not biological in nature thus a better understanding of the social processes influencing paranoia in ethnic minority populations may inform social interventions that reduce the health burden of psychotic disorders a theoretical model proposed by mcintyre et al detailed the psychological processes by which social identity might influence paranoid beliefs and the conditions under which these effects materialise mcintyre and colleagues proposed that people from ethnic minority groups who develop positive and meaningful identification with the majority culture should be at a lower risk of developing paranoid beliefs but group processes such as norms prejudice and social contact may moderate this relationship further the authors proposed that the relationship between social identity and paranoia should be mediated by selfesteem and locus of control this is because social identities are a source of selfesteem and low selfesteem is an important predictor of paranoia indeed it has been found that selfesteem mediates the relationship between social identity and paranoia in general population and student samples however the potential mediating role of selfesteem in identitymental health relationships has not been tested in ethnic minority populations similarly possessing an external locus of control has been implicated in paranoid ideation in several studies social identity conversely has been posited and shown to promote feelings of personal control and has therefore been hypothesized to also mediate the relationship between social identity and paranoia in ethnic minority groups faris and dunham first noted that immigrants who live in areas with mostly majority group members are at a higher risk of developing psychotic symptoms compared to people who live near people from their own ethnic group thenceforth several studies have replicated this ethnic density effect in different countries and ethnic groups the role of ethnic density was first demonstrated among africancaribbean people living in london by boydell et al and later in a dutch study that found only immigrants living in areas with few people of their own ethnicity experienced higher rates of psychosis one plausible explanation for the ethnic density effect is that negative contact with people from the majority ethnic group increases risk of psychotic symptoms a proposition supported by the finding that experiences of racism and psychosis among minority group members are elevated in low ethnic density areas the role of social contact according to social identity theory people gain meaning and a sense of self from the groups to which they belong as such social groups provide psychological fortification against low wellbeing mental health symptoms but only when those groups are supportive and positive intergroup contact theory suggests that contact between groups can reduce prejudiced attitudes towards outgroup members however it has also been shown that positive contact reduces prejudice while at the same time negative contact increases it thus in the same way positive and negative contact has divergent effects on peoples attitudes positive and negative contact with ingroup members may have divergent effects on peoples mental health little empirical work has examined contact in the domain of mental health mendozadenton and pagegould found that crossgroup friendships between black and white university students improved wellbeing among black students who were particularly sensitive to racebased rejection conversely everyday racism such as being insulted or discriminated against while applying for a job was found to be related to higher levels of psychological distress among immigrants living in finland moreover the effects of these everyday experiences were stronger predictors of distress than hate crimes which suggests that seemingly less severe threats to belonging may have substantive detrimental effects on mental health in the domain of paranoid beliefs research has found that perceived religious discrimination is associated with subclinical paranoia among muslimamericans and that perceived ethnic discrimination is associated with persecutory paranoid beliefs among minority populations living in the united kingdom consistent with social identity theory and research on contact and discrimination we propose that among black britons the relationship between social identification and paranoia will be influenced by their social experiences that is when black britons have unsupportive or hostile contact with white british people identifying as british should increase paranoid thoughts because group membership is no longer a source of meaning and selfworth rather it is a source of oppression and distress however when black britons have supportive and inclusive contact with white british people identifying more strongly as british is expected to protect against paranoid thoughts because the group is a source of personal control and selfworth the present study we aim to test the relationship between british identification and paranoid beliefs in a sample of black participants living in the united kingdom it has been found that ethnic minorities experience elevated rates of paranoia and recently proposed that social identity and social contact processes may explain these effects however no empirical studies have tested this idea here we test our predictions using a crosssectional design because it avoids difficulties associated with creating naturalistic positive and negative social interactions in a laboratory setting moreover as we are conducting the first test of these hypotheses crosssectional data can inform the utility of more resourceintensive longitudinal and qualitative work we predict that stronger identification will be related to lower paranoia however we expect that this will only be the case when ingroup members are supportive and inclusive when ingroups are unsupportive and hostile stronger ingroup identification should predict higher levels of paranoia finally consistent with previous empirical work and theorising we predict that the relationships between british identification and paranoia will be mediated by selfesteem and locus of control method ethical considerations all respondents were given detailed information regarding the sensitive nature of the study to ensure they were aware of potential risks they were also provided with details of organisations they could contact if they became distressed on the information page and debrief page participants were reminded of their right to withdraw at any time and did not have to provide any reason for withdrawal all participants received financial reimbursement in return for their participation the research was approved by the faculty ethics committee of the lead authors secondary institution measures ethnicity participants selected their ethnicity in a screening question with 16 different options only participants who responded as being black african black caribbean black african mixedrace or black caribbean mixedrace were able to continue to the full survey identification with great britain identification with great britain was measured using the four item measure of social identification which has been validated against longer measures of social identification and correlates with related constructs such as selfinvestment participants indicated on a sevenpoint scale the extent to which they identified with great britain and british people the four items were i am glad to be british i feel committed to great britain i am glad to be british and being british is an important part of how i see myself response options ranged from 1 disagree completely to 7 agree completely the scale showed excellent internal consistency α91 positive and negative contact positive and negative contact with white people were each measured using a single item positive contact was measured with the item on average how frequently do you have positive contact with white people negative contact was measured with the item on average how frequently do you have negative contact with white people participants responded to both items on 7point scales 1 never to 7 extremely frequently selfesteem participants completed the singleitem selfesteem scale which has been shown to be reliable and possesses good criterion and convergent validity participants indicated on a sevenpoint scale how true or untrue the statement i have high selfesteem was for them 1 not very true of me 7 very true of me locus of control participants completed the brief 9item version of the levenson locus of control scale the scale has three dimensions internality powerful others and chance with each subscale consisting of three items for this study the powerful others subscale was used because previous research had shown it to be the subscale most strongly linked to paranoia and because it is the most conceptually relevant to paranoid thoughts the items were my life is chiefly controlled by powerful others people like myself have very little chance of protecting our personal interests when they conflict with those of strong pressure groups results preliminary analyses independentgroups ttests were performed to test for differences on the key variables between participants identifying as african and participants identifying as caribbean no corrections for multiple comparisons were performed to provide a liberal test of potential group differences with alpha set at 05 no significant differences were found between black african and black caribbean participants on any variable thus the sample was considered as a whole means standard deviations and zeroorder correlations are reported in table 1 paranoia was significantly associated with an external loc lower levels of british identification higher levels of negative contact lower levels of positive contact and lower selfesteem an external loc was significantly associated with higher levels of negative contact and lower selfesteem higher british identification was significantly associated with higher levels of positive contact and higher selfesteem finally positive contact was significantly associated with higher selfesteem and lower negative contact main analysis we conducted a parallel moderated mediation analysis to test whether the indirect effect of british identification on paranoia through selfesteem and locus of control was moderated by positive and negative contact with white britons we used model 9 of the process extension in spss v24 to run the analysis this model allows the assessment of conditional indirect effects at different levels of two moderators also entered simultaneously indirect effects were calculated via bootstrapping with 1000 resamples and are reported at low and high levels of the moderators the two moderators were positive contact and negative contact the two mediators were locus of control and selfesteem inline with previous research on the determinants of paranoia and research testing the relationship between identity and paranoia age and sex were included in the model as covariates excluding age and sex did not affect the direction or significance of the reported effects coefficients for the regression models are reported in table 2 indirect effects are reported in tables 3 and4 as shown in table 3 there were no significant indirect effects of british identity on paranoia via selfesteem for any combination of positive and negative contact there was however a significant negative effect of british identity on paranoia via locus of control at high levels of positive contact and low levels of negative contact there was also a significant positive indirect effect of british identity on paranoia at high levels of negative contact and low levels of positive contact discussion in the present study we tested the prediction that among people of african and africancaribbean heritage identification with great britain would be associated with paranoia but that the nature of this effect would depend on their social experiences with white british people we also examined whether the relationship between social identification and paranoia was mediated by two previously theorised psychological mechanisms selfesteem and locus of control the correlational analysis revealed an overall medium association between negative contact and higher paranoia and a significant but small relationship between positive contact and lower paranoia consistent with predictions loc mediated the relationship between british identification and higher paranoia when there was low positive contact and high negative contact with white british people loc also mediated the relationship between british identification and lower paranoia when participants experienced high levels of positive contact and low levels of negative contact with the majority white british population thus the relationship between social identification and paranoia completely reversed depending on whether participants had mostly positive or mostly negative contact with white british people contrary to predictions selfesteem did not mediate the relationship between british identification and paranoia overall our results suggest that for black britons the relationship between british identity and paranoid beliefs is partly explained by feeling that their life is controlledor not controlledby others who are more powerful and dependent on the valence of contact with the majority population our findings support previous theorising that suggests experiences with the majority group are important in the development of paranoid symptoms in minority populations and that this effect may be explained by changes in locus of control mcintyre and colleagues propose that immigrants who live our findings further support the idea that people from ethnic minority groups who live in majority areas may be at a higher risk of developing psychotic symptoms because they are more likely to experience negative contact with the majority group indeed it has been found that psychotic disorder diagnoses and delusional ideation vary with perceived discrimination this explanation is also consistent with the finding that experiences of racism and psychosis are higher in low ethnic density areas while the present study did not specifically examine the experiences of immigrants refugees or asylum seekers the results have implications for acculturation research our results suggest that the effects of discrimination on symptoms of psychosis may be most potent when people have incorporated their new culture into their identity the findings are therefore consistent with berry and kim s model of acculturation which suggests being marginalised from the host culture is the most stressful form of acculturation when compared to integration assimilation and separation indeed our finding that selfesteem mediates the relationship between identity and paranoia is consistent with berry and kims proposal that marginalisation is harmful to adjustment while integration is beneficial however our work suggests that a more nuanced acculturation model may be required that acknowledges marginalisation in the form of negative contact or discrimination may occur in the context of integration or assimilation of cultural identity thus the four categories may represent overlapping constructs that change as peoples identities mesh with their social experiences the findings also provide a potential explanation for mixed findings in the acculturation and mental health literature which have suggested integration is associated with increases and decreases in the severity mental health symptoms our findings suggest that this inconsistency may in part be due to the complex interplay between cultural identification and peoples social experiences specifically cultural integration is likely to be beneficial to mental health only when it is combined with positive social experiences with people from the host culture our results elucidate the psychological mechanisms by which social identification might influence paranoid ideation in minority groups low levels of selfesteem have been found to play a crucial role in the manifestation of paranoid symptoms however selfesteem did not mediate the identityparanoia relationship in our sample which is inconsistent with previous empirical research in majority white samples nevertheless high selfesteem was associated with stronger british identification and lower paranoia in the bivariate analyses which is consistent with previous work on paranoia and low selfesteem the absence of a mediating role for selfesteem could be explained by the inclusion of loc in the model in the context of the ingroup rejection literature it is unsurprising that loc was a more important mediator than selfesteem indeed group acceptance has been shown to be particularly important in childrens development of internal loci of control and racebased rejection has been found to be associated with the higher scores on the powerful others loc subscale among black american women it is also critical to note that people living in the uk from ethnic minority backgrounds are more likely to be detained under the mental health act and that this compulsory psychiatric admission may contribute to reduced feelings of personal control among people experiencing mental health symptoms because loc has not been tested as a mediator of the relationship between social identity and paranoia in general population samples it is unclear whether its explanatory role is specific to minority groups or africancaribbean populations conducting studies that examine selfesteem and loc as parallel mediators in other populations is therefore an important next step for future research our work extends the intergroup contact literature by demonstrating that the effects of contact on society can be both damaging and protective in the domain of mental health of note we found that the effect of primarily negative contact on the pathway from social identity to paranoia was of the same magnitude as primarily positive contact this partially conflicts with barlow et al who found that negative contact was a stronger predictor of more prejudiced attitudes than positive contact was of less prejudiced attitudes however this asymmetry was only evident when examining the impact of contact on the identityparanoia relationship overall the relationship between negative contact and paranoia was nearly four times stronger than the relationship between positive contact and paranoia suggesting that negative social interactions are a source of severe psychological distress the effects of contact on society are farreaching impacting on prejudice intergroup anxiety and empathy the present findings extend this literature by implicating contact in both the formation and reduction of paranoid beliefs in minority populations a limitation of our research is that the contact items although being the standard questions used in the contact literature did not explicitly refer to white british people thus it possible that some participants recalled contact with white nonbritish people however it should be noted that whiteness is associated with national identities in western nations and that similar wording has been used in studies of contact with white australian white american and white british people the study was also crosssectional and is therefore limited in the extent that it can explain causality however the causal pathways proposed here are supported by evidencebased theoretical arguments and are acknowledged to be to some extent bidirectional moreover it should be noted that people from ethnic minority groups protect their identities by derogating the majority group which may manifest as increased negative contact with the majority group future work using experimental paradigms that manipulate social identity salience or longitudinal research assessing the role of identity change in paranoia symptom development would provide a more robust test of causal pathways finally while our study focused on people currently living in great britain we did not specifically target refugees or asylum seekers who may be at most risk of paranoia associated with disidentification and negative social contact we encourage researchers to recruit people from these populations in future studies our findings strengthen calls for the implementation of more social prescribing programs to reduce mental health problems and subsequently ease pressure on mental health services connecting people with positive and meaningful social groups should according to our findings reduce the risk of people from africancaribbean backgrounds and potentially other minority groups developing paranoid beliefs and psychosis given that paranoia lies on a continuum with healthy functioning increasing positive cultural identification through supportive social groups before symptoms become severe represents a viable prevention strategy for mental health policymakers this suggestion dovetails with mental health service recommendations detailed in a review by the sainsburys centre for mental health which suggests that creating a welcoming atmosphere within mental health services and encouraging communityintegrated services will improve mental health among people from african and caribbean backgrounds concurrent efforts to reduce discrimination and negative social interactions are also critical if psychosis rates are to be reduced among people from africancaribbean backgrounds indeed it is plausible that current social prescribing interventions sometimes inadvertently increase negative contact for people from minority cultures qualitative research that aims to identify the factors that facilitate positive contact and reduce negative contact may help guide future social interventions it is also important to examine the role of ethnic identities in the development of paranoid ideation it is likely that experiences of negative contact have contrasting effects on ethnic identities compared with host culture identities and also subsequent mental health for example according to the rejectionidentification model racebased rejection can both enhance and decay wellbeing through different psychological pathways depending on the extent to which the rejection enhances ethnic identification future studies assessing whether experiencing negative contact has beneficial of harmful effects on both ethnic identity and paranoia would be of interest to researchers in this area when assessing ethnic identity in future work researcher should consider that african and caribbean identities are likely to be dissimilar due to their unique cultural and social histories the present research represents the first test of the relationship between social identity and paranoia in an ethnic minority population we found that british identification is a doubleedged sword for people from africancaribbean backgrounds relating to lower paranoia when they had largely positive social contact with white british people and higher paranoia when contact was mostly negative for both of these effects possessing an external locus of control was the key explanatory psychological mechanism specifically peoples british identity predicted the extent to which they felt their lives were controlled by other more powerful people which in turn predicted their level of paranoia the findings increase our understanding of the potential causes of elevated psychosis rates among ethnic minority groups and the role of contact in the development of mental health symptoms they also add nuance to social identity and acculturation models of mental health showing that strong social identities can be harmful under certain conditions practical initiatives that encourage positive and meaningful contact between people from ethnic minority and majority groups therefore have the potential to reduce psychosis symptom risk among vulnerable populations table 1 descriptive statistics and bivariate correlations figures and tables

objectives people from ethnic minority groups experience higher rates of paranoid delusions compared with people from ethnic majority groups identifying with social groups has been shown to protect against mental health symptoms however no studies have investigated the relationship between social identification and paranoia in ethnic minority populations here we investigated the association between british identification and paranoia in a sample of people from african and africancaribbean backgrounds living in the united kingdom we also assessed the role of potential mediating selfesteem and locus of control and moderating contact with white british people factors design crosssectional quantitative survey designwe recruited 335 people from african and africancaribbean backgrounds who completed online selfreport measures of identification with great britain selfesteem locus of control positive and negative contact with white british people and paranoiaa parallel moderated mediation model indicated that british identification was associated with lower paranoia when participants experienced primarily positive contact with white british people british identification was associated with higher paranoia when participants had primarily negative contact with white british people both effects were mediated by changes in locus of control but selfesteem was not implicated in either pathway conclusions identification with the majority culture is associated both positively and negatively with paranoid beliefs depending on the types of social interactions people experience the findings have implications for preventative social prescribing initiatives and for understanding the causes of the high rates of psychosis in ethnic minority populationspeople from african and africancaribbean backgrounds experience high rates of paranoia which may stem from social causes such as lack of belonging and negative social experiences among people from african backgrounds living in the uk british identification is associated with lower paranoia when peoples social experiences with white british people are positive and higher paranoia when their social experiences with white british people are negative it is recommended that social interventions designed to reduce paranoia in vulnerable groups foster positive social contact and community belonging which should enhance feelings of personal control understanding the complex interplay between social identity and social contact in the development of paranoia may help therapists and researchers better understand the phenomenology and riskfactors of paranoid symptomology the relationship between ingroup identity and paranoid ideation among people from african and africancaribbean backgrounds

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there is a significant association between lipid biomarkers for cvd risk and the frequency and intensity of selfreported and perceived physical activity these data support thenotion that socioeconomic status mediates the relationship between lipid biomarkers and physical activity low physical activity in lower socioeconomic groups may be contributing to widening health inequalities promotion of more active transportation may help to encourage physical activity of the required intensity and frequency to improve cardiovascular health background the leading cause of global mortality is cardiovascular disease there is a wellestablished link between cvd risk and physical activity 1 2 3 the underlying biological mechanisms explaining the link between cvd and physical activity are not fully understood one previous study 4 investigated the relationship between biomarkers physical activity and cvd risk and found that traditional lipids explained approximately 19 of cvd risk reduction for those who engaged in more than 200 kcalweek of physical activity there is currently no evidence if this physiological pathway holds for different types of physical activity current physical activity recommendation from the centre for disease control 5 suggests that adults participate in at least 2 days of muscle strengthening activities and 150 min of moderate intensity aerobic activity or 75 min of vigorous intensive physical activity each week if these types of activities have different relationships with lipids associated with increased cvd risk this may impact on how individuals should engage with physical activity additionally there is no evidence if factors such as socioeconomic status and perceived difficulty in accessing sports facilities attenuate this relationship this may be a mechanism explaining inequalities in cvd risk the aims of this study are to determine if there is an association between two biomarkers for cvd risk cholesterol ratio and triglyceride levels and four different measures of physical activity moderate mild selfreported activity rating and walking 30 min or more a week and if this association is mediated by socioeconomic status and difficulty accessing sports facilities using a nationally representative sample of 4823 individuals methods source data we use crosssectional data from the second round of data collection of the understanding society survey 6 understanding society is a longitudinal household panel survey of approximately 40000 household in the uk which began in 2009 7 individual participants are interviewed annually on diverse topics such as health work education income family and social life further information on the study design and sampling methodology are discussed elsewhere 8 in the second round of data collection a representative subset of the main sample participated in a nurseled health assessment 9 a total of 13107 respondents had data on at least one biomarker for this study we further limited the sample to respondents that had valid measures for triglycerides hdl cholesterol and total cholesterol biomarkers the final restriction placed on our sample was that participants needed to have valid measures on socioeconomic status physical activity and demographic characteristics reducing our sample to n 4823 comparing cvd biomarkers between the two groups of the sample population and those who were excluded from the analysis because of missing ses variables generated similar results the only exemptions were the education variables and access to a car for both variables the difference in the number of individuals between groups was less than 5 as the nurse assessment sample use for the analysis was chosen to be nationally representative this suggests that our results should be fairly a representative of the target population as there is less than a 5 difference between those who reported the ses variables and those that were missing for whatever reason ethical approval was not required for the secondary analysis of this anonymised data source respondents provided written consent for their blood to be taken and to be stored for future scientific and genetic analyses 10 outcomes and key variables biomarkers for cvd risk that were included as key outcome variables were cholesterol ratio 11 and triglyceride levels 12 different cholesterol levels were measured from blood serum using enzymatic methods with a roche module p analyser calibrated to cdc guidelines 10 triglycerides were measured from serum blood using an enzymatic method on a roche p module analyser 10 individual total cholesterol and hdl cholesterol level were used to calculate the cholesterol ratio which was classified as a binary variable equal to 0 if the ratio of hdl to total cholesterol was less than or equal to 38 mmoll and equal to 1 if the cholesterol ratio was greater than or equal to 39 mmoll 13 triglycerides were classified as a binary variable where the base category was between 03 and 19 mmoll and was equal to 1 if triglycerides were between 2 and 319 mmoll 14 three different measures of physical activity were used in the main analysis moderate intensity physical activity was defined based upon a positive response to engaging in 29 sports activities that would classify as moderate activity 7 a binary variable was created that equaled zero if the respondent engaged in moderate activity less than three times a week and was equal to 1 if the respondent engaged in moderate activity three or more times a week the second measure was a selfassessed sports activity rating where individuals rated on a scale of 1 to 10 how active they were through leisurebased sport this was classified as a binary variable for high activity which was equal to 0 if respondent scored themselves a 4 or less and was equal to 1 if respondents reported a score of between 5 and 10 the final physical activity variable captured individual walking activity a binary variable was created that was equal to 0 if respondents walked for 30 min for four times during the last 4 weeks and was equal to 1 if respondents walked more than 30 min for at least four times in the last 4 weeks 15 as a validity check on our findings we used a measure of mild physical activity that should not be significantly associated with reducing cvd risk mild intensity physical activity was based upon individuals reporting that they engaged in a sporting activity that would require mild exertion this was classified as a binary variable that was equal to 0 if respondents engaged in mild activity less than three times a week and was equal to 1 if respondent participated in mild activity three or more times a week we controlled for a number of other factors that may confound the relationship between the biomarkers for cvd risk and physical activity participation the biomarkers used in this analysis especially triglycerides 10 may have been affected by medications and consumption of food or drink we therefore controlled for the individual currently taking lipid reducing medication and if they had eaten 30 min before blood was taken demographic factors such as age age squared marital status presence of children under the age of 12 in the household and region 16 were included in the analysis to determine if the relationship between biomarkers and physical activity were mediated by socioeconomic status and difficulty accessing sports facilities in some model specifications socioeconomic status was measured by binary variables for having access to a car or van owning ones house or having a mortgage on it if the individual was employed highest level of educational attainment achieved and log of equivalised household income 17 in addition in some model specifications we included a binary variable for if the respondent reports difficulty in accessing sports facilities 14 statistical analysis descriptive analysis was undertaken to gain a better understanding of the prevalence of unhealthy cholesterol ratio and triglyceride levels and to identify physical activity levels and patterning of the confounding variables in the study population these findings were used to inform the multivariate analysis we also performed a number of different multicollinearity tests between the physical activity variables and separately for the socioeconomic status variables for the physical activity variables the correlation within different intensities of physical activity was less than 040 suggesting that there was no evidence for correlations between the different physical activity measures therefore separate consideration in different models was considered appropriate to describe the behaviours and associations with cvd risk among the sample population we also tested for multicollinearity between the different socioeconomic status variables correlations between all seven ses variables were very small less than 01 the correlation between income and being educated to a degree level was 023 and there was a slightly higher correlation between the different educational levels of just above 040 which is to be expected as one level of educational attainment is usually correlated with lower levels of educational attainment the basic statistical analysis involved multivariate logistic regression models in which the two biomarkers for cvd are a function of one of the four physical activity variables as well as cofounding variables including demographic characteristics currently taking lipid lower medication if the respondent has eaten a half hour before blood is taken to determine if socioeconomic status attenuates the relationship between physical activity and the biomarkers variables related to socioeconomic status were added to the basic model finally a variable controlling for difficulty in accessing sports facilities was added to the logistic regression significant differences were found between physical activity and gender for all types of physical activity except walking significant differences by gender were found in the outcome variables of cholesterol level and triglyceride levels all analysis was therefore stratified by gender survey respondents with missing responses to any of the outcome or explanatory variables required for the analysis were excluded the analysis was undertaken in stata v13 18 results table 1 showed the descriptive analysis of the raw data approximately 25 of men and 21 of women engaged in at least 30 min of moderate physical activity three times a week approximately 42 of men and 33 of women reported being highly active in sports activity fiftyseven percent of men and 59 of women walked at least 30 min a week and 14 of men and 18 of women engaged in mild activity for 30 min or more three times a week approximately 45 of men and 25 of women had an unhealthy cholesterol ratio and 41 of men and 24 of women had unhealthy triglyceride levels the mean age of the sample was 51 years old the majority of survey respondents had a university education access to a car was married and owned their own home approximately 5 of men and 8 of women reported difficulty in accessing sports facilities table 2 showed the results of genderstratified logistic regressions to investigate the relationship between the two biomarkers for cvd risk and moderate physical activity accounting for socioeconomic status in all models except for the female triglyceride models adjusted for socioeconomic status and difficulty accessing sports facilities there is a negative and significant association between moderate physical activity and having an unhealthy cholesterol ratio and triglyceride levels the size of the association is similar for men and women this provided some evidence that socioeconomic status attenuates this relationship for cholesterol ratio for men and triglyceride level for women for both men and women age was associated with an increased likelihood of having an unhealthy cholesterol ratio and triglyceride levels for both genders taking lipid lowering medication was associated with an increased likelihood of having a healthy cholesterol level for women only taking lipid lower medication was significantly associated with having unhealthy triglyceride levels this may be picking up women who were on lipidlowering medication because they have been recently diagnosed with a high triglyceride level eating 30 min before the interview was positively and significantly associated with having an unhealthy triglyceride level for women only a number of socioeconomic factors were significantly associated with cholesterol ratio and triglyceride levels being a home owner compared to renting was negatively associated with unhealthy cholesterol ratio in the model adjusted for socioeconomic status and with triglyceride levels in the model adjusted for socioeconomic status and access household income was negatively and significantly associated with unhealthy cholesterol ratio and triglyceride levels in all adjusted models being educated to the college degree level or having some higher education was negatively and significantly associated with having an unhealthy cholesterol ratio in all adjusted models reporting difficulty in accessing sports facilities was positively and significantly associated with an unhealthy cholesterol ratio in the model adjusted for access table 3 displayed the results of genderstratified regressions to investigate the association between selfreported activity rating and the two biomarkers for cvd risk and socioeconomic status reporting being highly active through sport was negatively associated with increased likelihood of having an unhealthy cholesterol ratio and confidence intervals are in parentheses regional dummy variables are included in the adjusted models but not shown p 001 p 005 triglyceride levels this provided evidence that the relationship between activity and cholesterol ratio may be mediated by socioeconomic status for both genders the relationship between triglyceride levels and activity was only mediated by socioeconomic status for men similar to the results found in table 2 age was associated with a higher likelihood of having an unhealthy cholesterol level and triglyceride levels in table 3 the probability was similar for both genders socioeconomic factors were only significantly associated with cholesterol and triglyceride level risk for women the same associations as found in table 2 are also found in table 3 the exception is in table 3 being employed compared to not being in the labour market was negatively and significantly associated with having an unhealthy cholesterol ratio and access to sports facility was no longer significantly associated with cholesterol ratio for women table 4 showed the results from the genderstratified models of the relationship between cvd risk walking and socioeconomic status walking 30 min a week or more was negatively associated with having an unhealthy cholesterol ratio for men in the unadjusted model this association held for all models for women there is some evidence that this relationship was mediated by socioeconomic status for both genders for men in all models there was a negative and significant association between walking 30 min a week or more and triglyceride levels there was no significant association with walking and triglyceride levels for women the significance of the relationship between the variables related to socioeconomic status and cvd risk was similar to those found in table 2 and table 3 as can be seen in table 5 there was no significant association between mild activity and the biomarkers for cvd risk for either gender discussion in a populationbased crosssectional sample of adults we find a significant association between two biomarkers for cvd risk and frequency of selfreported moderate physical activity and selfreported perceived level of weekly sportsbased activity a weaker association was found for walking 30 min or more per week these results are consistent with a large body of literature finding a negative association between physical activity and cvd risk 12519 the findings show that intensity of activity is important 2021 mild activity even if performed as frequently as moderate activity is not significantly associated with a reduced probability of having unhealthy cholesterol ratio or triglyceride levels our results also corroborate findings 4 that traditional lipid biomarker may mediate the relationship between cvd risk and physical activity and provide additional evidence on the mechanisms that may explain the link between cvd risk and physical activity socioeconomic status is likely to be associated with cvd risk through a number of complex pathways that include economic social environmental and biological pathways 22 we find some evidence that this relationship between our biomarkers for cvd risk and physical activity is mediated by socioeconomic status those in lower socioeconomic neighbourhoods may have less opportunities for physical activity 1523 leading to widening health inequalities other lifestyle and healthrelated behaviours such as individual diet may be mediated through socioeconomic status and thereby may have affected our outcome variables there may also be the cumulative negative effect of socioeconomic status on our biomarkers for cvd risk which is being picked up in the analysis 24 variables related to socioeconomic status were associated with our biomarkers for cvd risk for women only the negative associations of socioeconomic status with health are larger for women than for men 25 it is possible that men in lower socioeconomic status may be employed in manual professionals participating in more physical activity which could attenuate some of the negative impacts of lower socioeconomic status on the biomarkers for cvd risk strengths and limitations this study used a crosssection of data from the understanding society survey which is a nationally representative dataset providing a good level of generalisability to the uk population selfreported measures of physical activity which are easy and cheap to collect continue to be widely used in research 26 this study showed that these measures are on average significantly associated with objective measures of cvd risk providing some support of the validity of these measures for future research especially in large scale studies where it may not be practical or costeffective to use objective methods for the measurement of individual physical activity such as accelerometers a key limitation of this study is that only 1 year of data with the required variables for this analysis is available limiting our ability to estimate a causal relationship longitudinal data would allow us to better understand how physical activity and the lipid biomarkers impact on cvd risk and for example account for changes in medication due to a recent diagnosis of high cholesterol levels more detailed information on type intensity and duration of physical activity would also be useful for better understanding the relationship between physical activity and lipid biomarkers there is also a considerable number of missing responses when taking into account all of the requirements required for the statistical model this may have some impact on the generalisability of the results confidence intervals are in parentheses regional dummy variables are included in the adjusted models but not shown p 001 p 005 conclusions this study supports the development of general lifestyle interventions and those targeted at women from lower socioeconomic backgrounds to promote moderate physical activity and incorporate physical activity into individuals daily routine local policy to promote active transportation and public transportation use may be one mechanism to promote physical activity of the required intensity 27 competing interests all authors disclose no conflict of interest ethics approval and consent to participate this project used secondary anonymised data which did not require us to obtain consent from participants respondents provided written consent for their blood to be taken and to be stored for future scientific and genetic analyses 11

background cardiovascular disease cvd is the leading cause of global death physical activity can help individuals reduce their cvd risk however the biological mechanisms explaining the link between physical activity and cvd risk and how they may be mediated by socioeconomic status are not well understood methods we use crosssectional data from 20102011 of the understanding society survey uk to investigate the association between two biomarkers for cvd risk cholesterol ratio and triglyceride levels and four different measures of physical activity moderate mild selfreported activity rating and walking 30 min or more a week using multivariate logistic regression the analysis investigates if this association is mediated by socioeconomic status and difficulty accessing sports facilities results results from multivariate regressions show that moderate and selfreported activity rating are significantly associated with cholesterol ratio and triglycerides for both men and women a weaker association was found for walking 30 min or more a week no association was found between mild physical activity and the two biomarkers there is some evidence that socioeconomic status mediates the relationship between the biomarkers and physical activity a significant association between socioeconomic status variables and the biomarkers was found only for women conclusions we provide some evidence of the mechanisms explaining the link between cvd risk and physical activity by finding an association with traditional lipid biomarkers we also find that intensity of physical activity matters socioeconomic status especially for women is important which may explain some of the inequalities in cvd risk

19818_0

it is undisputable that lifestyle and behavior play a significant role in many chronic diseases such as diabetes heart disease and cancer behavioral and environmental factors account for 70 of premature deaths in the us behavior is difficult to control and predict however it is recognized that behavior including health behavior is multidetermined one of the factors influencing behavior including health behavior is the impact of individuals in ones social network this may be ones friends family peers coworkers social groups or clubs or faithbased groups such social influences may be positive or negative in nature multidimensional theories of social influence it has been proposed that individuals behaviors and choices vary in the extent to which they are influenced by others this influenceability has been proposed to be a trait or personality factor such social influence has also been proposed to differ by culture and societal norms social influence has been recognized as a multidimensional construct bearden and colleagues and mourali and colleagues conceptualized social influence as being comprised of three dimensions including utilitarian influence valueexpressive influence and informational influence utilitarian influence occurs when an individual complies with others expectations in order to receive rewards or avoid a punishment and involves compliance processes valueexpressive influence occurs when an individual wishes to enhance their selfimage or selfconcept by identifying with a reference group and involves identification processes informational influence occurs when an individual looks for information from others to form their reality and involves internalization processes with compliance the individual may act but may not believe in what they have done with identification and internalization the individual actually believes in the behavior social influence and health behavior perceived social influence has been found to be associated with a number of health behavior outcomes including sexual experimentation age of sexual initiation health behavioral intentions and health behaviors other studies report relationships with smoking smoking intentions fruit and vegetable consumption and mammography utilization the present study the present examination reports on the development and validation of an instrument to assess the perceived role of others in the health behavior decisions of individuals an african american adult sample was employed as part of an ongoing national survey examining the role of a variety of cultural factors in health risk and protective behaviors existing instruments examine perceived social norms through a theory of planned behavior or theory of reasoned action context however an extensive search produced no instrument to assess perceived social influence from a trait or individual difference approach particularly within the domain of health behaviors therefore an existing theorybased multidimensional instrument was adapted to suit this purpose an instrument that assesses the perceived role of others in making health behavior decisions has broad utility and could be used in determining the role of social influence in health behavior decision making findings from such studies may have applied value for the development of more effective health promotion interventions particularly those based on theories that incorporate the role of social influence method instrument development and pilot testing the measure identification and development phase involved a series of six systematic steps we used a process similar to that cited by krause involving expert input item revision and iterative piloting the process began with comprehensive literature searches conducted in nine databases an existing suitable instrument to assess the construct was not able to be identified however one was identified that was close but in a different domain that of consumer behavior therefore rather than to develop all original items the team decided that the consumer susceptibility to interpersponsal influence scale could be adapted to the health context the adapted instrument was subject to a full team review on the basis of representativeness of the construct and cultural appropriateness the items were then revised based on the team review using an iterative process and then finalized the finalized instrument was administered by telephone to a national probability sample of 55 african americans to assess testretest reliability no changes were made at this point the piloting was part of a protocol used in a larger study that was developing other instruments de novo the instrument was then administered to another national probability sample of 1006 african americans to assess other psychometric properties telephone survey for psychometric data collection the study was approved by the institutional review board at the university of alabama at birmingham for both the initial testretest sample of 55 and the full sample of 1006 professional interviewers recruited participants by telephone by calling names from a purchased list the sample consisted of african americans age 21 and older living in a private residence with a telephone telephone numbers were randomly selected from the nationally representative pool that was developed based on census tract if interested individuals were screened for eligibility criteria including being an african american age 21 or over testretest samplea gift card of 15 was mailed to each participant upon completing the initial survey the survey was timed and took an average of 20 minutes to complete two weeks later participants were contacted for a readministration of study instruments this survey took an average of 15 minutes and participants were mailed another gift card in the amount of 15 for its completion full psychometric samplethe telephone survey took an average of 45 minutes to complete due to administration of a full battery of instruments used in the larger study instruments related to the current analysis included the perceived social influence on health behaviors instrument additional measures for the assessment of discriminant validity and participant demographics due to the increased time commitment by participants a gift card of 25 was mailed to each participant upon completing the study procedure measures health behaviors alcohol use was assessed using a module from the behavioral risk factor surveillance system the instrument has demonstrated adequate testretest reliability over a 21day period in a sample of african americans the module includes four items breast prostate and colorectal cancer screening frequency were also assessed using items from the brfss the brief version of the international physical activity questionnaire was used to assess participants physical activity in the last seven days the instrument has been validated with african americans the instrument contains seven items that ask participants to report the number of days they performed various types of physical activities to assess fruit and vegetable consumption we used an adaptation of the national cancer institutes fiveaday survey it consists of seven items that assess fruit consumption and five that assess vegetable consumption fifteen different fruits and 18 vegetables are assessed specifically within these items this instrument has performed well in previous work with the study population the testretest reliability over a twoweek period for the both the fruit and the vegetable portions were adequate selfefficacyselfefficacy was utilized to assess discriminant validity being a distinct construct from social influence on health behaviors it was assessed using an eightitem scale that has high internal reliability and testretest reliability analyses to evaluate the internal reliability of the instrument cronbachs alpha was conducted as well as itemtotal correlations pearson correlations were conducted to evaluate discriminant validity and associations with healthrelated behaviors the intraclass correlation coefficient was used to evaluate testretest reliability measurement models or confirmatory factor analyses were conducted using mplus 30 to evaluate the factor structure of the new instrument the dataset was randomly split in half using a computer program the first measurement model was run on one half of the data and then verified on the other half results participant characteristics a total of 1006 individuals completed the telephone interview the response rate is calculated as the proportion of complete interviews to the total number of eligible individuals the overall response rate was 25 as computed from accepted acceptedrefused before eligibility screener 1006 10062992 another 387 individuals were screened but not eligible for various reasons 16 were under age 21 163 refused to provide an age for use in eligibility screening 122 were not african american 86 had a history of cancer only 17 individuals who were screened and eligible refused to participate resulting in an upper bound response rate of 98 a brief refusal survey was conducted to compare responders to nonresponders nonresponders were in general older than responders more likely to be men and less likely to have attended 4 or more years of college to assess testretest reliability a unique pilot sample was examined including 55 african americans sampled nationally using the aforementioned method fiftythree completed the twoweek retest participants in this sample were 34 women and 21 men from 23 states with an average age of 5093 and on average with a high school diploma characteristics of this sample are reported in more detail elsewhere reliability and validity the perceived social influence on health behavior scale consisted of 10 items assessed in fourpoint likerttype format four points were used for ease of telephone administration the instrument has a possible range of 1040 with higher scores indicating higher levels of these beliefs scores in this sample ranged from 1040 with a mean of 2050 and standard deviation of 625 the internal consistency of the overall instrument was α 90 subscale alphas were α 84 for utilitarian influence α 85 for valueexpressive influence and α 81 for informational influence the average itemtotal correlation was 69 and ranged from 60 75 testretest reliability was acceptable during the twoweek interval validity was evidenced through the instrument development process in terms of face validity involving the investigative team as well as discriminant and factorial validity discriminant validity was evidenced by modest negative or nonsignificant correlations with the selfefficacy scale scores measurement model to examine the factor structure of the perceived social influence on health behavior instrument a measurement model was conducted using mplus software as recommended by muthén and muthén an exploratory approach was conducted to determine the appropriate number of factors and identify potentially problematic items a principal components analysis with a varimax rotation was applied this was followed by a confirmatory analysis on a random sample of half of the data and a subsequent confirmation on the other half of the data the exploratory factor analysis suggested a threefactor approach based on the eigenvalues greater than 100 using the kaiserguttman rule and examination of the scree plot a threefactor model is also consistent with previous research using this instrument the confirmatory factor analysis measurement model was developed based on the factor loadings from the exploratory approach maximum likelihood was used as the estimator all item loadings onto their latent constructs were consistent with those found with the original instrument except for one item that loaded onto the first latent construct rather than the second latent construct thus the latent construct utilitarian influence included the first four items the valueexpressive influence latent construct included the next three items and the informational influence construct included the final three items table 4 shows the correlation matrix between these factors this model provided an approximate fit for the first random half of data χ 2 16080 p 001 χ 2 df 503 root mean square error of approximation 09 90 confidence interval 08 11 comparative fit index 95 tli 92 srmr 05 modification indices suggested adding an error covariance between two sets of items items one and two and items six and seven examining the instrument it was determined that items one and two both reflected the concept of approval from others prior to engagement in health behaviors and these items were also in consecutive order on the instrument items six and seven both reflected identification with others by making the same healthy choices that they do using the same phrasing and also falling in consecutive order these factors may cause the errors of these pairs of items to be correlated as such the errors were allowed to correlate which improved the fit of the model χ 2 8738 p 001 χ 2 df 291 root mean square error of approximation 06 90 confidence interval 05 08 comparative fit index 98 tli 96 srmr 04 although the probability value for the chisquare statistic was significant it is recognized that the chisquare value is sensitive to sample size and a recognized measure of model fit is χ 2 df with values in the 200 500 indicating acceptable fit each item was significantly related to the latent variable onto which it was loaded no other residuals or modification indices provided a theoretically defensible modification for further model respecification this model was verified on the other random half of the study sample and provided a comparable fit χ 2 7638 p 001 χ 2 df 255 root mean square error of approximation 06 90 confidence interval 04 07 comparative fit index 98 tli 98 srmr 03 model parameters were also comparable to the first model relationships with health behaviors because men scored significantly higher than women on the social influence subscales correlations with health behaviors were analyzed separately for men and women in general there were more correlations with health behaviors for utilitarian influence than for the other subscales and more correlations with health behaviors for women than for men though this finding is primarily driven by utilitarian influence for men the significant correlations between social influence and health behaviors were all positive in nature for women these correlations were mostly negative in nature for men the correlations mainly involved health screenings while for women they involved physical activity and mixed correlations with alcohol use discussion the present study reports on the process of adapting an existing instrument to assess perceived social influence on health behavior the result is a brief instrument with modest to acceptable reliability and validity that is appropriate for use with african american populations factorial validity was evidenced through the measurement modeling process and was consistent with the theorybased original instrument there was one exception in which one of the utilitarian influence items loaded onto the value expressive influence factor it is possible that this item which involves making good impressions on others reflects more of a process of gaining others approval than identifying with others this would be consistent with utilitarian influence rather than value expressive influence the current findings are largely supportive of the threedimensional model of interpersonal influence that mourali and colleagues reported with the instrument the instrument developed by bearden and colleagues proposed a three factor solution however their data fit a two factor solution better in which the utilitarian influence and value expressive influence factors were combined the correlation between the two factors in that study was r 92 whereas it was r 67 in the present study the difference could be due to differences in study populations or domain differences the bearden study examined adult consumers one item in the current study migrated from the utilitarian influence factor to the value expressive factor which was unexpected and illustrative of the potential for conceptual overlap between these two factors few previous studies have examined the role of perceived social influence among african americans specifically a previous study found that african americans did not report being motivated by social influence to engage in dietary change this finding is comparable to that in the present study as evidenced by means on the psihb scales near the middle of the possible range and nonsignificant or negative correlations with fruit and vegetable consumption these findings have implications for health promotion namely that when promotion dietary change social norms may not be the most promising target for intervention it is proposed that both individuals and behaviors can be subject to normative control this supports the individualdifference view of social influence but also suggests that some health behaviors are more or less susceptible to influence than others this pattern was evidenced in the current data where the psihb subscales were correlated positively negatively or not at all with different health behaviors these findings also have implications for interventions in which health behaviors may vary in their suitability for a social influencebased intervention the patterns of correlations of the psihb subscales with health behaviors for men and women were notable men scored higher than women on each of the subscales suggesting that they tend to follow the indications of others when making health behavior decisions to a greater extent than do women particularly among women utilitarian influence seemed to carry more correlation with health behaviors than did the other types of influence reflecting compliance with others expectations in order to receive rewards or avoid a punishment this process was negatively associated with performance of healthrelated behaviors perhaps reflecting the negative role of social networks or peer influences interestingly for men the correlations with health behaviors were positive it is possible that this process reflects a supportive role of family or friends for men these data are preliminary and warrant further study with more complex modeling including multigroup measurement models limitations the findings of this study should be interpreted in the context of several limitations first as with most research in instrument development we are relying on selfreport data second the data may not generalize beyond an african american sample however much of the instrument development research relies heavily on european american samples including college students resulting in instruments that may not be valid for a mature beyondcollegiate african american population third the current sample included selection bias due to nonresponse however through use of the brief refusal survey we were able to characterize nonresponders as older more likely to be men and less well educated than responders finally for retention purposes there was a brief interval between the test and retest reliability administrations due to the characterization of perceived social influence on health behavior as an individual difference variable it is not likely that this construct would vary significantly if a longer interval had been utilized conclusion the availability of a valid and reliable instrument to assess the role of perceived social influence in health behaviors will help answer some of the questions posed by theorists interested in the role of social networks and social influence processes on health behaviors and outcomes in the context of social networks such as faithbased or secular networks more needs to be learned about the specific nature of their impacts on health behaviors and outcomes this work can inform the development of interventions particularly those targeting such social networks bivariate correlations between social influence subscales and health behaviors among men and women

assessment of social influence on health behavior is often approached through a situational context the current study adapted an existing theorybased instrument from another content domain to assess perceived social influence on health behavior psihb among african americans using an individual difference approach the adapted instrument was found to have high internal reliability α 8184 and acceptable testretest reliability r 6885 a measurement model revealed a threefactor structure and supported the theoretical underpinnings scores were predictive of health behaviors particularly among women future research using the new instrument may have applied value assessing social influence in the context of health interventions

19819_0

individuals with mild cognitive impairment the lack of social connectedness could increase the chances of these individuals progressing to dementia methods we crosssectionally assessed social networking among 122 subjects with mci and 2403 cognitively healthy subjects aged 45 years and above from the srinivaspura aging neurosenescence and cognition study cohort in rural southern india cohens social network index was used to assess social networking wherein three dimensions are assessed network diversity number of people in social network and number of embedded networks the diagnosis of mci was made using the clinical dementia rating instrument this is an extensively validated 5point scale wherein six cognitive and functional domains are assessed memory orientation judgment problem solving community affairs home hobbies and personal care the overall cdr score of 0 was interpreted as cognitively normal and cdr score of 05 as mci the sni dimension scores were compared between subjects with mci and cognitively healthy subjects using ttest and a pvalue of 005 was considered significant results the mean scores of all three sni domains were significantly lower in mci compared to cognitively healthy subjects network diversity number of people in social network and number of embedded networks conclusion aging rural indians with mild cognitive impairment have poorer social networks than their cognitively normal counterparts hence social connectedness should be routinely evaluated in individuals with mci and prompt social interventions should be instituted to enhance their social functioning social isolation may indeed be a contributory risk factor for developing cognitive impairment however causal relationships and reverse causality should be evaluated in further longitudinal studies p90 the indirect role of supportive dyadic coping in the association between selfperceptions of aging and depression authors jose a fernandespires andrés losadabaltar maría del sequeros pedrosochaparro maría márquezgonzález isabel cabrera laura garcíagarcía and guy bodenman objective it has been shown that having negativeself perceptions of aging significantly predicts depressive symptomatology although the partner relationship may have an impact on the effects of perception of aging on distress the number of studies assessing the effect of partner on negative selfperception of aging and mental health is limited the stress of one partner may elicit dyadic coping responses in the other partner the stress of one partner may elicit dyadic coping responses in the other partner depending on whether the responses are positive or negative a close relationship can go along with additional stress or resources and benefits the present study analyzes the relationship between negative selfstereotypes and depressive symptomatology considering the partners dyadic coping as a moderator variable in this association method participants were 365 individuals 40 years or older involved in a maritalpartner relationship participants completed a questionnaire that included the variables negative selfperception of aging positive dc negative dc and depressive symptomatology two moderation models were tested by linear regression the first considered positive dc and the second negative dc as a moderator in the relationship between negative selfperception of aging and depressive symptoms

background verylateonset obsessivecompulsive disorder vloocd is rather rare although vloocd should prompt a thorough workup most cases do not evidence an underlying medical illness nor structural brain abnormality a subset manifests somatic obsessions bringing about diagnostic challenges objective critical literature review based on a case studya 73yearold male patient was hospitalized for intrusive repeated distressing mental images and thoughts about hell describing difficulty to disengage from these obsessions alongside secondary mystical and ruin delusionlike ideas modulated by the pathoplastic effect of core religious beliefs and inflated sense of responsibility he had previously experienced those intrusive mental images yet not in a recurrent nor uncontrollable manner preceding the ocd he presented mild depressive symptoms triggered by financial hardships after the emergence of ocd depressive disorder aggravated with psychomotor retardation hopelessness insomnia anorexia obsessive hyperawareness of autonomic processes distressing bodyfocused preoccupations raised by interoceptive stimuli became noticeable with overestimation of threatening consequences daylong swallowing ritualscompulsions avoidance of nutritional intake general unease and even panic yalebrown obsessive compulsive scale ybocs scored 25 ancillary tests were unremarkable transglutaminase antibodies were negative ruling out glutensensitive enteropathy hence tryptophanserotonin metabolism impairment neuroimaging did not evidence structural disruption of corticostriatal circuitry therapeutic regimen comprised sertraline 200 mgday augmented with mirtazapine 45 mgday aripiprazole 15 mgday additionally trazodone buspirone and benzodiazepines were used to manage anxiety and insomnia at the fourth week of treatment the anxiety burden driven by religious obsessions ameliorated meanwhile lamotrigine 100 mgday and gabapentine 200 mgday were added with further improvement 60 ybocs score reduction at seventh week discussion this case highlights the clinical relevance of the oc spectrum concept wherein at the compulsive end are ocdrelated disorders which feature high degrees of harm avoidance intolerance to uncertainty anticipatory anxiety engagement in repetitive behaviors we hypothesize that somatoform variant of ocd constitutes a distinct phenotypic subtype stemming from a complex interplay of neurobiological substrates psychosocial and genetic factors shared with hypochondriasis this assumption might be addressed in future studies furthermore this case illustrates the fact that vloocd might exhibit prodromic periods of subclinical oc symptoms before the manifestation of fullblown ocd

19820_0

introduction in a series of recent articles margaret kohn has reintroduced many political theorists to the late19th and early20th century french solidarists following leading intellectuals such as alfred fouillée and émile durkheim the solidarists rose in prominence as republican defenders of a third way between capital and labor as the main contending sectors of society and so between respectively laissezfaire capitalism and socialism as the leading ideologies by the time the solidarist former prime minister léon bourgeois published his pamphlet solidarisme this doctrine was considered the official social philosophy of the third republic kohn shows that solidarism retains its critical bite as a theory of social justice against todays ascendant neoliberalism it does so through a moralized political economy that views each person as entitled to a fair return for their labor and views wealth as collectively produced rather than principally the work of private enterprise together these commitments justify returning the products of collective effort to those who produced them this political economy then global justice theory practice rhetoric 2023 issn 18356842 solidarism and the struggle against environmental racism issn 18356842 68 armstrongs resourceegalitarian theory and attachment dovetails with a forwardlooking commitment to our shared fate which justifies the provision of public goods and prevention of excessive stratification these twin moral commitments founded in nondomination and moral equality ground a theory of state action that goes beyond liberal visions of the state as handmaiden of the market or as a mere backstop for resolving collective action problems yet without asking the state to orient itself against capital capital serves an important social function but it does so by building on public goods and it can continue to be a valuable contributor if all who contribute get a fair return notwithstanding this quite compelling portrait kohn confronts without fully resolving an objection to solidarism namely that it is an overly statist ideology this concern has two prongs first its solutions to market depredations rely on state interventions that displace individual initiative and even individual rights such that capitalist domination is just replaced by state domination meet the new boss same as the old boss kohn responds that solidarism does not prioritize state intervention but state support for the civil society organizations that bring each person belonging mutuality social capital and respect plus relief in their hour of need the image that emerges is of a structured common life where individuals most important relationships are horizontal rather than vertical this commitment to subsidiarity higherlevel agencies defer to lowerlevel ones in serving public aims limits the growth and power of the state and if only aspirationally solidarism could support measures such as the partial transfer of capital to organized collectives such as unions and cooperatives enabling a propertyowning democracy rather than a capitalist welfare state the second prong of the statism objection however seems more challenging that is not that the state qua government sector will be too interventionist but that the raison dêtre of the solidarist state is to foster and maintain the solidarity of the leading sectors that make up the polity and that consequently the public interest the interest of the we who are all in this together will come to be identified with the intersection or overlap of these leading sectors interests as a third way ideology solidarism may be forced to subordinate moral equality nondomination and public goods production to the paramount goal of maintaining this intersectoral compromise for instance the overlapping core of labor and capital as leading sectors might include a vision of france as a unitary industrialized nation indispensable to the broader european project and global order and at least in the late 19th century decidedly patriarchal in character consequently the lodestar of solidarism would be the interests margaret moore of the polity so understood rather than the emancipation of individuals whose interests this compromise ignores or steps on in effect notwithstanding its republican bona fides on the level of theory solidarisms effort to articulate a unifying vision of the polity leaves it vulnerable to the limitations of extant interests interests that are bound to be in important respects conservative simply because they are the dominant sectors of society the subsidiarity which allayed the first prong of the statism objection does not help much here for civil society formations tend to be dominated by avatars of these leading sectors prominent businessmen clergy and so on if this concern is on the right track it raises the worry that solidarisms critical bite is more like a nibble its teeth seem big from an early21st century perspective amidst the rubble of the postwar social contract that bound capital to labor from where we sit wresting even a little power back from capital does indeed seem like a major goal but again like other third way ideologies solidarism may not be up to the challenge of realizing nondomination if doing so would destabilize the intersectoral compromise that is its raison dêtre to assess the strength of this objection and hence of solidarism as an emancipatory doctrine of nondomination i want to consider its resources for engaging issues that fundamentally challenge the shared core of commitments that unify dominant sectors the struggle for environmental justice and particularly against environmental racism provides a powerful test case this is for three reasons first in direct contrast to solidarism not just the practice but the theory of ej has developed in deep conversation with and in response to the work of frontline activists particularly women of color ej theorists understand themselves to be answerable to ej activists to a degree that remains uncommon among normative political theories second ej has not sought to be a unifying third way between capital and labor but to fundamentally challenge the contempt and racism of a capitallaborgovernment nexus that dumps waste on people and places that are coded as expendable and which buys the allegiance of white workers by rewarding them with benefits expropriated from nonwhite populations ej forces us not just to blunt the excesses of the market but to address public bads and wrongs when the state deliberately victimizes people to grease the wheels of capital accumulation and third any theory of justice requires not only an account of the currency of justice that is the package of rights and welfare to which each agent is entitled but also of the subjects of justice that is who are the agents whose rights and welfare the state is required to protect and promote but theorists of environ mental racism have shown that a big part of the latter problem is that the range of subjects of justice is contested its not just that some people are not receiving enough things its that some people are perceived as things its not just that some people suffer environmental blight its that some people are perceived as environmental blight a final test of solidarism will thus be whether it can take a sufficient interest in those who for reasons of state or because of pure animus are constructed as a problem to be managed and even disposed of for all these reasons then environmental justice and environmental racism pose important challenges for solidarism the current paper assesses solidarism against this challenge i begin by explicating environmental justice and environmental racism much scholarly work on environmental justice boils it down to three overlapping and mutually supportive core elements distributive participatory and spatial justice to the extent that environmental racism is simply environmental injustice that disproportionately victimizes racialized groups these criteria of environmental justice will suffice but environmental racism runs deeper and the struggle against it requires not just the three elements of environmental justice but a positive repudiation of the assumption that anyone is expendable and an affirmation of the coequal status of each as a subject of justice i then present the intellectual and political outlines of solidarism relying on kohns work contrasting it for expository purposes with the resources available in liberal luck egalitarianism solidarism is a form of neorepublicanism and as such it has a political economy that understands systems and structures not just transactions and choices further it cashes out its concern for each person in terms of nondomination the contrast with luck egalitarianism plays up these features and hence presents solidarism in its best light for responding to environmental racism the next section then discusses whether and how solidarism captures the three aspects of environmental justice and the final section grapples with environmental racism from a solidarist perspective addressing the french solidarists engagement with gender race and eugenics i find that solidarism does not by itself guarantee a dedicated defense of indispensability and affirmation of the equal status of each for this i suggest we need an additional drive toward solidarity in precisely the sense that intersectoral compromises miss a solidarity that expands the range of subjects of justice of people with a stake in the intersectoral compromise by siding with those who struggle against expendability both within a polity and beyond its borders emerging in the 1980s in the us environmental justice brought together activists scholars and community and religious organizations to fight against dumping and degradation that fell disproportionately and without consultation on people of color notwithstanding this reference to disproportion however ej has always been a challenge for liberal philosophers because neither the activists whose work has defined the concept nor most scholars working in this area tend to accept the distributive paradigm from their perspective injustice is at least as much about contempt ignorance misrepresentation and exclusion as it is about maldistribution while maldistribution is an effect of these other attitudes and practices it is neither their cause nor their most outrageous aspect indeed in the canonical statement produced by the first national people of color environmental leadership summit the environmental justice agenda consisted of seventeen points not a single one of which focused on distribution to the contrary if we find ourselves spreading the damage around fairly or unfairly we are already doing injustice1 instead the core of environmental injustice is the disharmony with natural systems evidenced in the production of environmental damage in the first place where such disharmony is suffused with manifest contempt for and lack of recognition of the interests of people of color and indigenous peoples scholarly uptake over the decades has in some respects generalized this concept allowing it to be applied worldwide and studied systematically speaking generally we may see running through this work several hallmarks of environmental justice standardly these conceptions encompass distributive participatory and spatial elements environmental injustice includes the distributive components of greater burdens worse outcomes and lesser remedies the participatory components of exclusion from and marginalization in decisionmaking and lack of political power and the spatial components of negative impacts on individual and community wellbeing and displacement of benefits from burdens however this systematicity and generalizability may have been purchased at the cost of the essential notion of expendability though it has departed from global justice theory practice rhetoric 2021 issn 18356842 72 armstrongs resourceegalitarian theory and attachment a narrow distributive paradigm much ej scholarship still focuses on the currency of justice the things we have legitimate claims upon or interests in such that justice is about how to treat us justly with respect to those things but there is a prior question for theories of justice namely that of the subjects of justice whose claims and interests must be considered if justice is to be done for example famously utilitarians are concerned for all sentient creation whereas kantians worry only about rational agents if anything distinguishes environmental racism from mere environmental injustice it is this problem of subjecthood environmental justice presupposes that we have agreement on what counts as a locally undesirable land use an environmental harm or risk and so on racial disparities then come in as evidence that these harms and risks are unjustly imposed and distributed but in her landmark study of the confluence of environmental racism and mobility in the united states dorceta taylor demonstrates that agreement on what counts as a lulu is precisely what we lack under white supremacy black residency if not black freedom is conceptualized as an environmental harm or risk the toxic communities of her title are not just the environments in which black people live they are the black people themselves in the view of the white supremacist polity this is epitomized in the phenomenon of racializing blight where the mere fact that african americans live in a neighborhood is taken as sufficient evidence that it is a ghetto a slum or blighted discussing the work of we pritchett she writes the term blight was used to describe the perceived negative impacts of some residents of city neighborhoods pritchett argues that the diagnosis of urban decline was used to justify the removal of large numbers of blacks and other minorities from neighborhoods poor whites were also displaced in urban renewal projects environmental racism then is not just racial disparities in pollution exposure it is the white supremacist view that black residents are pollution charles mills refers to this as the problem of black trash in the racialized polity mills argues blacks sic are not part of the we who are facing the environmental problem of what to do with our refuse rather there is a sense in which blacks themselves are an environmental problem which we full humans have to deal with david naguib pellow diagnoses here a logic of expendability which ensnares not just black and indigenous peoples but incarcerated and disabled people elderly people and lgbtq populations all the more so does it apply in transnational contexts where migrants and by default all people of the global south are treated by the global north as utterly expendable their deaths nothing more than a public relations problem if even that pellow argues that the essential norm moving forward should thus be an ethic of indispensability crucially for our purposes environmental racism is perpetrated not by a few villains but by the allied corporategovernmentlaborcivil society nexus that constitutes the white supremacist polity this will color any efforts that wellmeaning officials or even socially responsible businesses might undertake to lessen disadvantage and shore up the basic human rights of people of color a strong civil society is likely to exacerbate the problem because it will be white peoples mutualaid organizations and unions that will turn themselves into the shock troops of white supremacy when challenged indeed even efforts to secure environmental justice become part of the problem for if black people are constructed as pollution then white people will have the cover of environmental justice when they seek spatial justice by limiting their own exposure to black people and preventing black residents from moving to their neighborhoods shopping in their malls and going to school with their children procedural environmental justice will empower white communities and neighborhoods to object to inclusionary zoning and to maintain restrictive covenants even wellmeaning integrators will speak in terms of the distribution of this burden across neighborhoods environmental justice practices so understood would risk driving environmental racism rather than remedying it thus the affirmation of equal subjecthood and indispensability is paramount in the next sections relying on the work of margaret kohn i investigate whether and how solidarism might meet this challenge solidarism as part of her broader project of updating the work of the french solidarists kohn applies the solidarist account of the common good to the allocation of public space such as parks kohn starts from a dispute between silicon valley neoliberals and legacyresident latino youth in mission playground located in a fastgentrifying area of san francisco this synecdochal conflict which encapsulates in its specificity the essential features of a broader social conflict went viral in the summer of 2014 in it kohn system to use the playground at the designated time while the latino youth insisted that their longstanding pickup soccer game should not be displaced even though they could not afford permits kohn shows that the justificatory resources of liberalism fall flat here where the neoliberals can justify the permit system with a vision of government as an agency that regulates conflicts over scarce resources the displaced youth can justify deference to legacy uses on grounds of protecting the vulnerable longstanding occupancy and their desire to maintain a toehold in a place where property values threaten to drive them away altogether the synecdochal conflict encapsulates all three aspects of environmental justice distributive participatory and spatial to overcome this conflict kohn suggests we need a better account of the social good and of the states role in promoting it that account she argues is provided by solidarism solidarists appreciate the wealthgenerating effects of capitalist markets but argue that markets maldistribute the product of labor treating the owners contribution of assets as responsible for all the value that accrues to a product remunerating workers contribution only with what they can command on the market and ignoring the role of natural social and inherited infrastructure in making possible the value that the owner reaps owners make choices that the market rewards but these choices are lucrative only against a backdrop of fortunate or lucky circumstances that the owners cannot claim credit for and yet market outcomes reward them for both choices and luck for instance suppose an entrepreneur identifies a niche in making a new product using the products of governmentfunded research she locates her factory near a logistics hub and hires employees to do the work in doing so she takes advantage of other peoples expenditures including the cost of educating the workers the sponsoring of research the construction of the logistics infrastructure and so on it is thanks to her good fortune that others invested in these things that her choice becomes possible and lucrative there is nothing wrong with taking advantage of these conditions thats what theyre there for but nor should the entrepreneur then suppose that her eventual profits reflect only her own prowess on the market rather her profit is built by incurring a debt the unearned increment which by rights should be repaid to maintain the production of the social goods that make entrepreneurial success possible this unearned increment reflects the owners capacity to benefit disproportionately from third parties inputs but receipt of thirdparty benefits in turn enables the owner to take a disproportionate share of the employees inputs specifically this is because receipt of the unearned increment gives the owner bargaining power in the form of unequal exit potential as the owner meets workers in the labor market she typically has more choice over whom to hire than they have over whom to work for the owners capacity to drop any job applicant in favor of another empowers the owner to set a wage rate in takeitorleaveit fashion owners are therefore to some degree pricemakers not pricetakers in the labor market which violates a core economic assumption of liberal justifications of the market in this way the labor market is skewed in the owners favor and this advantage snowballs this skewing call it the exploited increment is a second way that market relations give owners benefits they did not earn again from a solidarist perspective there is nothing wrong with receiving unearned benefits it is not a basis for condemning the owner but the fact that the benefits are unearned undermines the owners moral claim on them they are social goods serving a social purpose rather than private goods for each to use as they please the justification of social welfare provision then need not lean heavily on a theory of justice but can appeal to a hardnosed analysis of the source of wealth taking for granted the owners preferred norms of rewarding savvy choices the economic analysis of solidarism supports returning to the public and to the working class these products of circumstance the unearned increment and the exploited increment whose initial availability to the owner does in fact serve a social purpose but ceases to do so if the owner is permitted to hold onto them in perpetuity it would however be a mistake to see solidarism as simply a theory of distributive fairness it has spatial and participatory implications as kohn emphasizes solidarist public intellectuals such as bourgeois were not mere social democrats but committed republicans as such they justified socialdemocratic measures such as wealth redistribution in terms of nondomination for instance by supporting civil society smallscale mutual aid and cooperatives so that state provision did not generate the benign despotism of a paternalistic but powerful centralized state these points offer a useful contrast with egalitarian liberalism where the liberal sees the state as an agency for overcoming collective action problems and providing goods that we want but could not secure on our own the republican solidarist sees the state as having both a larger and a smaller role its larger role lies in its responsibility to nonneutrally identify and help us secure goods even if we might not always choose them its smaller role lies in not simply providing those goods but enabling us to provide them for ourselves this ethos is especially evident when we are discussing not the privately owned products of mar ket relationships but the public spaces that make up our shared world these public spaces are the product of government regulation the natural environment and countless laborers and planners over the course of generations but they must also be maintained and cared about by everyday citizens and especially civil society organizations if we inherit goods of this type we are then obliged to cultivate the common world that we inherit this initial contrast points to a second relevant difference between solidarism and liberalism whereas liberals normally strive to be neutral across at least a broad range of conceptions of the good solidarists must not only take an affirmative stance on the social good but their account of the good must also be pluralistic to view market outcomes as takings and to repair them through redistribution solidarists need to impute a social value to inputs and contributions exchange value is not the full story of the social good moreover this theory of value must be pluralistic both because there is a variety of modes of contribution and because some goods are nonfungible and hence takings must be repaid roughly in kind to this end kohn explains the solidarist case for the provision of public parks parks compensate workers for their loss of access to nature from a liberal perspective repayment in kind is normally suboptimal because it imposes a conception of the good on individuals who might otherwise prefer to spend their repayment on something other than say access to nature liberals might still provide goods inkind in the event of a collective action problem ie if individuals inability to coordinate frustrates their preference for a park but the principle at work here for liberals is efficiency not inkind provision or respect for nonfungible public goods worse if the majority would not choose a park even given the ability to coordinate then the liberal state would shun the paternalism or minoritarianism implicit in imposing the park on people for solidarists to choose the park then they must appeal to a pluralistic theory of the social good similarly for housing although it is possible to move ones residence and it is obviously possible to treat ones residence as a commodity homes are much more than that hence ej activists and scholars emphasize that being bought out and relocated due to irremediable environmental blight is itself a spatial injustice as it breaks up communities and social networks solidarism then offers a political economy of shared production which rejects liberal fantasies of individual achievement a pluralistic conception of the good and an affirmative duty to repay ones debts and positively contribute to the public goods and other circumstances that enable collective flourishing through individual success each of these elements departs in important respects from liberalism together they give solidarism a powerful framework for challenging not only distributive but spatial and participatory injustice solidarism is thus promising as a driver of concern for environmental justice in the next sections i shall argue that solidarism does indeed have resources to address the three elements of environmental justice but that the most powerful challenge that of environmental racism and the racist constriction of the scope of subjects of justice poses a distinctive challenge requiring additional resources environmental justice and the diversity of bads the solidarists political economy grounded in nondomination gives them important resources for all three faces of environmental justice first recall that distributive environmental justice seeks to correct greater burdens worse outcomes and lesser remedies because solidarism is initially articulated in distributive terms these three tenets of distributive environmental justice straightforwardly map onto the compensatory conception burdens reflect contributions to the social product and hence ought to be repaid disparate outcomes and remedies would be a sign that these debts remained outstanding participatory and spatial environmental justice may pose greater challenges to the compensatory conception first participation is not something that is taken away or that is produced and then maldistributed to be sure the expansion of economic and governance systems to encompass millions of people leaves each of us qua voter with only the tiniest blip of political influence and makes it difficult for anyone except those with significant resources or antecedent backing to gain a seat at any table of significance however this is not a worsening from any reasonable baseline since most people never had power and the expansion of society to encompass millions and a highly varied division of labor is in many other respects a public good so cannot easily be characterized as a taking this is where solidarisms neorepublican core is particularly helpful the reason to insist on participatory environmental justice is to prevent domination without granting the right people a seat at the table and a voice in the deliberations not only is our water poisoned our air polluted our lives blighted and foreshortened but the people who make the decisions that lie behind these outcomes do so in corner offices accountable only to investors or with backroom handshakes and campaign contributions then the victims testimony is devalued and ignored so remedying these problems requires them to make plaintive appeals for help from credentialed experts living outside the community the basic needs attainment of citizens is subject to the whims and horsetrading of a small number of elite decision makers who see numbers rather than people thus the republican core of a solidarist ethos supports participatory environmental justice on grounds of nondomination nondomination also dovetails with spatial justice and the empowerment of located civil society organizations environmental burdens often limit mobility because for instance no one is willing to buy a house in a polluted area so it becomes impossible to sell declining property values and assets undercut locally owned business and reduce commerce in the neighborhood causing damage to ripple outwards and further reduce the market desirability of real estate in the area this downward spiral reduces residents capacity to marshal media and communication resources to make their case to the broader public even when local media still exist and actually have an environmental reporter to cover the story most often the news staff does not look like the affected community the journalists are uncomfortable walking the neighborhood and meeting people and they often commit testimonial injustices by being overly skeptical of the claims of residents and overly solicitous of responses from perpetrators and officials domination ensues solidarism speaks directly to this problem because it is a theory of political economy and not just individuallevel disadvantage we can adduce further solidarist resources for spatial justice recall that for the solidarist the division of labor is the principal public good that generates shared prosperity and the division of labor is a collective achievement underwritten by the state a division of labor is not just a division across persons the butcher the baker the brewer all trucking in the same market rather a modern division of labor necessarily entails the siting of factors of production hydraulic infrastructure mills farms mines industrial facilities residences schools hospitals waste processing and disposal recreational facilities and so on and the reproduction of the workforce requires that times be set aside and facilities built for investment in children and families for restoration of health and psychological wellbeing and for the success of mutual aid and collective selfhelp organizations the division of labor is thus not just about social organization but about spatiotemporal organization insofar as this spatiotemporal organization consumes the space of our shared world and the labor time of members of our society it should do so in a way that is fair to all and does not drive the concentration of capital or power however markets and the economic policies that underpin them tend to promote just this sort of concentration repairing the spatiotemporal division of capital and labor can be justified by reference to the compensatory logic of solidarism environmental racism and the solidarist track record solidarism sees the state as mediating between labor and capital without decisively taking either side it does so in part by promoting mutual aid organizations so that state action is required more to enable social arrangements than to intervene in them in the context of environmental racism however this solution generates a new problem recall that the hard core of environmental racism is the expendability of racialized populations and their construction as the pollution to be fairly distributed rather than as subjects of justice though the state may in fact be neutral between labor and capital then this neutrality fosters those sectors domination of nonwhite others mutualaid agencies may then be even worse racially restrictive in who can join their neighborhood associations their healthinsurance and utility cooperatives and so on whether unofficially or through their government dominant white interests may make whole regions or countries offlimits or beyond the pale for black indigenous and other racialized outgroups systematic exclusion and discrimination in all spheres of the social world government market and civil society compel racialized outgroups to create their own versions of these spheres but sharply limit their capacity to do so and when the racialized outgroup is successful against all odds in building a base of power or wealth the dominant group often resorts to violence to be sure in the abstract solidarist theory would repudiate such basic violations of nondomination but this ignores a practical dilemma solidarisms paramount goal of unifying the leading sectors of society leads it toward silence about or complicity with these sectors mutual oppression of out groups and the mechanism for avoiding the statism objection is to practice a subsidiarity that empowers civil society organizations that themselves practice racist oppression to rein in civil society is to reassert the dominating state to challenge the laborcapital compromise is to set up solidarism as a third contending party rather than as the peacemaker between them here it is instructive to consider how the solidarists responded to two indicative social challenges in the third republic as the 19th century drew to a close french feminists gained power in demanding rights to work on equal terms legal and economic protection for mothers and children and more karen offen indicates that feminist ideas gained so much traction that they gave rise to a vitriolic antifeminism that forced men to take a position on the woman question antifeminists lined up behind nation or church there was little risk that solidarists would ally with antife but what politics did republican men who were sympathetic to feminism adopt offen shows that they found themselves forced to choose between integral feminism a liberal feminism of thoroughgoing equal opportunity and familial feminism which offered a biologically differentiated familycentered vision of malefemale complementarity … a sexual division of labor in both society and the family … and a positive concept of womens special nature or womanliness … familial feminist s aimed not to overthrow the economic basis of patriarchy but to reorganize the existing society to the greater advantage of women in theory the solidarist case for integral feminism is straightforward the family is a civilsociety organization that helps realize both associative goods for its members and public goods such as hygiene care labor life satisfaction and reproduction mens seizure of the associative goods such as the familys jointly produced income and property as well as womens emotional and caring labor is then a microcosm of capitals selfenrichment through seizure of public goods and of workers industrial labor the moral equality of all not to mention the bedrock value of freedom as nondomination entails that each member of the household should receive their fair share of the jointly produced benefits but it was not to be solidarists egalitarianism bumped up against the crisis of declining population growth and the fear that france was falling behind germany and england the goal of maintaining french cultural and military strength seemed to unify labor and capital not least among those who hoped to export republicanism and keeping up with germany and england in population seemed necessary for that pronatalism was the answer and encouraging women to leave work marry and reproduce seemed to be the mechanism of pronatalism so the solidarists repudiated integral feminism in favor of a tightly circumscribed familial feminism on which moral equality was filtered through an account of natural differences where the natural role of women was to be mothers and wives fouillée wrote what was decided among the prehistoric protozoa cannot be annulled by act of parliament consequently as offen explains solidarists touchstone one that had a long history in republican thought on the woman question was equality in difference they were willing to consider women as moral equals but could not accept members of either sex acting as individuals in disregard of their functional context in the nation which in this case was defined in terms of organic biology and the family for the solidarists then the patriarchal conception of the state unified capital and labor and hence trumped moral equality they turned their backs on the feminists whom they should have allied with and on the egalitarian commitments that should have followed from their republicanism in doing so they aided conservative efforts to shape the family in a patriarchal direction they did this not due to an embrace of patriarchalism for its own sake but because of a conception of state interests that arguably viewed the state as the property of its men its aspirations tied to military prowess and hence requiring a larger population which in turn required families to instrumentalize women for reproductive purposes2 all that was left was to negotiate the terms of womens instrumentalization to be fair the solidarists seem to have acquitted themselves better in another ideological and political struggle of the time namely opposition to social darwinism eugenics and race science jennifer michael hecht explains how at the dawn of the 20th century proponents of rightwing anthroposociology used notyetdebunked pseudoscientific methods such as craniometry to push the doctrine of national racial differences in support of eugenics and eventual extermination the apparently scientific methods of anthroposociology initially wrongfooted the solidarists because they wanted their politics to be grounded in social science anthroposociology forced a choice as hecht explains the solidarists seem to have chosen right their opposition to social darwinism and race science impelled them over time to repudiate appeals to nature as a foundation for their political commitments hence a decade after his appeal to the supposed patriarchy of the prehistoric protozoa fouillée rejected scientific laws as a foundation for society instead he held t he real law of human societies … is not natural selection and the struggle for life but rational choice and cooperation for life the solidarist philosopher célestin bouglé added in declaring men sic to be equal we deliver a judgment not on the way that nature made them but on the way that society must treat them global justice theory practice rhetoric 2021 issn 18356842 margaret moore in opting for equality and against social darwinism the solidarists overrode their scientism in the name of social equality by contrast in embracing familial feminism they sacrificed social equality to pseudoscience about protozoan gender roles what explains this divergence the social darwinists in the former case were a rightwing fifth column the pronatalists and familial feminists in the latter case were the mainstream of the republic itself representing a conception of the state shared by the leading sectors of society as stewards of that compromise the solidarists opted to advance that conception of the state rather than the interests of all its citizens or even of the family conceived as an association of equals environmental racism lies right in the middle of these two kinds of problem because any ideology that could defend it would inevitably be a rightwing fifth column while at the same time environmental racism in practice is so deeply embedded that no effort to uproot it could avoid antagonizing to some degree both labor and capital or challenging the projection of state power beyond its borders for this reason solidarism seems likely to prove a dubious ally in the struggle against environmental racism i propose that the solidarists crucial failure regarding feminism stems from the same reason that they will be dubious allies in the struggle against environmental racism it is not that they were familial feminists per se any more than they are environmental racists on principle its that they sacrificed womens interests in favor of the vision of the state that men had built they failed a test of solidarity with the integral feminists who sought to rearrange the family economy in much the same way that solidarists sought to rearrange the political economy put otherwise the problem lies in the sense in which what the solidarists embraced was an expression of solidarity as has been frequently observed solidarity comes in many forms and each form makes distinct demands upon us solidarism makes a politics out of what sally scholz has called a social solidarity one that holds together a mutually identifying people for a shared purpose in social solidarity we the whole people affirm that we share our fate and agree that we are all in this together on its face social solidarity is a bulwark against too extreme a descent into oppression because rule by violence and fear seems incompatible with viewing our fates as shared instead it reflects a radical break in the fates of those who exercise violence and those who are on its receiving end but this is too rosy a picture social solidarity is perfectly compatible with injustice and oppression provided that the major institutions and practices of the society converge on the unjust and oppressive structures and particularly if the victims of these injustices are subject to adaptive preferences that normalize their oppression and consequently conscript them into aiding in their own bondage this is just what we should fear from solidarisms actual origins as a third way as charles mills warned regarding environmental racism if the we excludes black people then social solidarity will be perfectly compatible with racial oppression indeed it will require it in such an environment sincere egalitarians will not bat an eyelash at status differences or still less raise a finger to repudiate them quite the contrary they might be the strongest advocates of the sharp line between we and they they express the legitimacy of their demands for recognition and redistribution from a ruling elite by affirming their difference from a racialized outgroup social solidarity even in a republican polity is therefore not enough for status equality that requires a political solidarity solidarity with social movements of the oppressed this is what the solidarists showed themselves to be lacking regarding the woman question and it is what a contemporary solidarism must achieve in order to reject expendability and to join wholeheartedly the opposition to environmental racism failing to be in political solidarity with the organized oppressed is an occupational hazard of an ideology that sees itself as the steward of a compromise consensus between contending parties though solidarism has important theoretic resources superseding those available to liberalism for embracing environmental justice then it will reliably be able to stand against environmental racism only to the extent that it is able to suspend its commitment to compromise among dominant sectors and instead sign onto the project of building a social order that manifests the coequal personhood of each although i am partial to a particular account of solidaritywith my aim here has not been to enter that debate but to show that solidarism needs the resources of some account or other of political solidaritywith and the deeprooted problem of environmental racism shows why

margaret kohn has argued that findesiècle french solidarists such as alfred fouillée developed a third way between capitalism and socialism which can be updated to provide a powerful justification for welfare state institutions and publicgoods provision but how would a renewed solidarism respond to demands for environmental justice and the struggle against environmental racism which have emerged in the past 50 years mostly in women of colorled social movements distinguishing three elements of environmental justice and pinpointing the logic of expendability at the core of environmental racism the current article shows that solidarism has valuable theoretic resources to challenge environmental injustice but that as a compromise between dominant sectors solidarism has more difficulty confronting environmental racism in particular after discussing the classical solidarists divergent responses to feminism and social darwinism the paper concludes by suggesting that a political solidaritywith outgroups is an essential complement to the social solidarity across dominant sectors of the state which characterizes solidarism

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background an estimated 578 million people worldwide use opioids of whom 304 million use opiates such as heroin 1 these estimates based on recent epidemiologic studies indicate that the global prevalence of opioid use disorder is significantly higher than was previously thought injection drug use of which opioid use accounts for an estimated 829 represents a major risk factor for poor health outcomes 2 at least 12 of people who inject drugs were living with hiv in 2019 and pwid were 29 times more likely to acquire hiv than people who do not inject drugs 3 moreover 523 of pwid have been exposed to hepatitis c and an estimated 9 have chronic hepatitis b 2 use of other substances is commonplace among people who primarily use opioids worldwide 4 5 6 7 alcohol is the most common secondary substance used among people who use drugs in europe in the united states 35 of people who use heroin meet criteria for alcohol use disorder 57 alcohol use is also prevalent among patients receiving treatment for oud an estimated onethird of patients receiving medication for opioid use disorder have an alcohol use disorder 89 people with oud commonly use methamphetamine as well between 2011 and 2017 concomitant methamphetamine and opioid use in the united states doubled to 342 and prevalence of methamphetamine and heroin couse among those who inject is as high as 50 1011 the overall prevalence of amphetamine use in east and southeast asia is also above the global average and in recent years the region has represented the fastest growing market for methamphetamine worldwide 112 limited data suggests that methamphetamine is the most common stimulant used as secondary drug among people who primarily use opioids in asia with an estimated 33 of people with a history of heroin dependence in china reporting use of amphetaminetype stimulant 13 polysubstance use among people on moud has been associated with lower rates of retention on these medications 14 concurrent use of either alcohol or methamphetamine specifically may decrease the effectiveness of oud treatment among people who primarily use heroin 14 in the united states people who couse methamphetamine and opioids are less likely to receive moud than people who use opioids only 15 alcohol abuse is associated with increased risk of return to opioid use for people treated with buprenorphine 16 among people with hiv methamphetamine use has been associated with increased hiv risk behaviors and transmission 1718 higher hiv viral load lower cd4 t cell counts hivrelated neuronal damage and increased antiretroviral resistance 19 20 21 22 alcohol too is associated with behavioral and biological risk factors for hiv infection and progression including highrisk behaviors related to sex and injection drug use lower adherence to antiretroviral therapy increased hiv viral load and hivrelated central nervous system effects 23 24 25 26 27 alcohol is also known to potentiate the respiratory depressant effects of both opioids and opioid receptor agonists 28 patterns of polysubstance use among people who primarily use heroin may relate to underlying motivations for using other substances but remain understudied with regards to methamphetamine couse of a different stimulant cocaine has been described as being either simultaneous to enhance the effects of heroin or sequential to mitigate undesired effects including withdrawal 29 these rationales may help to explain different patterns of heroin and methamphetamine couse including coinjection and separate use 11 a growing body of qualitative literature has described key reasons for methamphetamine use among people with oud these include a desire to attain a synergistic high balance the two substances relative effects or mitigate the risk of withdrawal or overdose 103031 moreover methamphetamine use has been described amongst people receiving moud in order to provide an alternative high to opioids andor to mitigate sedating effects of moud 3132 vietnam is home to an estimated 189000 pwid of whom 52200 received methadone maintenance therapy in 2020 3334 injection drug use remains a main driver of hiv transmission in vietnam with pwid accounting for 36 of new hiv diagnoses in 2015 35 between 2005 and 2019 coverage of art in vietnam expanded to an estimated 70 of people living with hiv many of whom have a history of oud 3336 recent evidence suggests that polysubstance use is common among patients receiving moud in vietnam consisting primarily of alcohol tobacco and ats 37 estimates of the prevalence of methamphetamine use among patients receiving moud in vietnam range from 24 to 51 3839 a study of pwid in northern vietnam showed a prevalence of daily alcohol consumption of between 20 and 30 in line with global estimates 40 understanding polysubstance use which may influence outcomes of moud and art use is therefore important for managing vietnams burden of both oud and hiv the objective of this study was to add to the literature regarding how and why people with oud use methamphetamine and alcohol specifically within the context of a developing nation where use of ats is increasingly prevalent results may hold implications for future efforts to address sud and hiv in vietnam as well as throughout southeast asia and beyond methods we conducted a qualitative study of participants enrolled in the buprenorphine to improve hiv care engagement and outcomes study which compared substance use and hiv outcomes among people with hiv and oud randomized to receive hiv clinicbased buprenorphine or referral to methadone maintenance therapy treatment strategies for oud in six hiv clinics in northern vietnam the bravo study did not exclude participants with other drug use but did exclude participants with ast or alt greater than five times normal qualitative baseline interviews were conducted shortly after participant enrollment with a subset of participants purposively sampled to achieve approximate balance in assigned treatment groups and to maximize diversity of insights based on continuation on moud marriage status and employment status selected participants were initially approached by a research assistant during clinic visits to receive moud hiv care or bravo study procedures all participants were informed of the study aims during the recruitment phase and completed written informed consent the aim of this qualitative study was to describe the perspectives of people living with oud and hiv with regards to polysubstance use institutional review boards at oregon health science university and hanoi medical university approved the study interviews were conducted by trained qualitative interviewers with at least a masterslevel education who were employed fulltime as research staff during the bravo study one of two interviewers conducted each interview no relationship between researchers and participants existed prior to study commencement interviews were conducted facetoface in vietnamese in a private clinic room interviews lasted between 30 and 60 min and were digitally recorded interview topics included generaldemographic information substance use and currentprior substance use treatment participants received 200000 vietnamese dong for each interview field notes were recorded during each interview to supplement recordings at the end of each interview participants were provided with an opportunity to further clarify or amend earlier statements between december 30 2015 and april 27 2018 interviews of 44 participants were conducted interview recordings were professionally transcribed in vietnamese thematic analysis was employed using a semantic inductive approach to identify themes related to methamphetamine and alcohol use as well as other areas of interest three researchers developed a list of preliminary codes after reading interview transcripts in vietnamese with codes grouped into overarching themes an intercoder reliability process was conducted in which the vietnamese transcripts were coded by two coders using atlasti software with discrepancies adjudicated by a third coder ten percent of all transcripts were doublecoded to achieve an intercoder reliability rate of 85 codes related to alcohol and methamphetamine use were translated into english along with select quotations major themes related to methamphetamine use and alcohol use were described along with minor themes and significant deviations from major themes results participants were 95 male 39 were employed and 36 were married any history of prior or current methamphetamine use was reported by 68 of participants either on a written questionnaire or in response to interview questions while any history of prior or current alcohol use was reported by 75 of participants five major themes emerged regarding use of methamphetamine and alcohol among study participants theme 1 methamphetamine and alcohol were perceived to have lower addiction potential than heroin most participants with a history of methamphetamine or alcohol use did not perceive themselves to be addicted to either substance which they explicitly contrasted with heroin in drawing a clear distinction between heroin and methamphetamine or alcohol participants tended to normalize their use of methamphetamine and alcohol and discounted potential harms compared to their use of heroin because ice methamphetamine is not as addictive as heroin methamphetamine users do not depend on it as much as they do on heroin users dont have to use it regularly they maybe use it today but in the next days they can stop using it without any withdrawal and pain symptoms as is felt with heroin deficiency this ice doesnt produce withdrawal unlike heroin so that i can do it as i want to feel better to avoid thinking i can cease to use it if i wish similarly participants tended to frame their alcohol use as being within their conscious control in contrast to methamphetamine however participants describe use of alcohol as a normal part of life rather than as a substance used intermittently or on special occasions drinking two to three bottles of beer every day is for refreshing refraining from alcohol is unnecessary because i am not addicted to alcohol you have to be addicted to heroin then you have to try to quit it but why do you have to refrain from alcohol if you only drink one to two bottles every day theme 2 social settings were key facilitators of alcohol and methamphetamine use most participants who used methamphetamine reported doing so in social settings especially among groups of friends this was reported for both introduction to methamphetamine as well as continued use i tried it around 2016…2017 around the tet holiday i remember it was new years eve some addicted friends invited me to use ice with them it was the first time i ever tried it yes i do ice sometimes its so common now you can find it everywhere its like water pipe you offer others a few smoke if i like it id smoke more participants reported not only social drinking but social pressure to consume alcohol examples included alcohol use related to work and traditional patterns of alcohol use such as regularly drinking ricebased medicinal alcohol before meals particularly strong social pressure was experienced on ceremonial occasions such as weddings death anniversaries and tet when it could be socially unacceptable to refuse alcohol in general alcohol brings nothing but for work and when in contact with people i have to drink i cannot refuse it participants reported alcohol and methamphetamine use both inside and outside the home methamphetamine was used in the company of friends or wider social circles while alcohol was additionally used around immediate family every day i drink one and a half liter of wine dividing for three meals at home my wife and i both have friend gatherings once or twice a month we will drink there then i do not drink much… i drink three to four times day if i am out with some friends i will drink or when i am with my family i also drink it is kind of a habit when it is time for a drink and if i have not drunk it yet then i will drink it at a mealtime … and another thing is now many drug users like to go to the discos and bars so they normally use an amphetamine type stimulant like methamphetamine… sometimes i went to my friends house and in here we used ice together i did not consume it so frequently when we gathered together for fun we used ice theme 3 some participants but not all used methamphetamine to help quit heroin participants reported a range of experiences with methamphetamine and heroin use across various stages of use or disuse of both substances several participants reported that using methamphetamine helped them to use less heroin or that it provided an alternative way to experience a high without using heroin first people who are taking methadone stop using heroin and change to using ice because now heroin does not give them as much high as before they started taking methadone which weakens the effect of heroin therefore seeing this people would not choose to use heroin and they would try to find some other substance which brings them a different feeling because methadone does not seem to affect ice for methadone patients using ice brings the feeling as same as for people not using methadone i just think i give up one substance i will use a different substance honestly heroin was more harmful so i quit it i like ice but i am not addicted to it i have used it for a long time i am still using it now… i do not feel high or anything i think i am a man and if i give up all these it will be so humdrum however even while acknowledging that many of their peers used methamphetamine in this way other participants reported that methamphetamine actually increased their desire to use heroin many people say that methamphetamine use can help with quitting heroin you understand however personally i do not think like that… because i used it and i knew using ice cannot help quit heroin because it only makes us want to use heroin more… for me after i used ice i wanted to find heroin it is really like that theme 4 consuming alcohol blunted the effects of heroin while paradoxically serving as a catalyst for heroin use many participants reported trying to avoid consuming alcohol with heroin as alcohol blunted the effects of heroin however several participants paradoxically reported that consuming alcohol made them want to use heroin more when i used heroin i did not want to drink alcohol because drinking alcohol dampened heroin …i do not dare to drink because every time i drink i will end up using heroin after drinking alcohol i tend to lose control think about heroin and really want to use it theme 5 use of methamphetamine was perceived by many participants to be incompatible with treatment for hiv participants relationship with methamphetamine varied with treatment for hiv prior to participating in the bravo study some recalled having missed outpatient hiv care appointments as a result of their methamphetamine use yes it using methamphetamine makes it easier for me to forget some things using ice leads me forget the appointments with the clinic then the healthcare providers have to make a phone call to me for reminders maybe now i think about it at that time when i used it methamphetamine i did not think about it however now i quit it i usually think back maybe sometime in the past i did not take the medication art on time when i still used it i was into it so i could not remember if i took the medication or not so i might take the medication late or i might forget taking it discussion polysubstance use in vietnam is best understood within the context of overarching substance use trends as well as policy changes related to treatment for oud and hiv since the passage of the law on hivaids prevention and control in 2006 the government of vietnam has facilitated treatment implementation aimed at controlling the spread of hiv including provision of moud to pwid and scaleup of art 41 this has given rise to a new and growing population of people living with hiv who have a history of oud many of whom are receiving longterm moud in addition to art during this same period use of methamphetamine has increased significantly in vietnam 42 while heroin is used by 68 of the total population of people who use drugs during the first 6 months of 2018 more than 60 of newly identified people who use drugs in vietnam used methamphetamine while fewer than 40 used heroin 42 percapita alcohol consumption has also increased in vietnam over the past 15 years doubling among men and growing sixfold among women 43 multiple studies suggest that binge drinking increased during this time with current estimates of the prevalence of binge drinking or hazardous alcohol use ranging from 317 to 529 among males 4344 against the backdrop of a growing number of people receiving longterm moud and art in vietnam this increasing prevalence of methamphetamine and alcohol use has the potential to adversely affect treatment of oud and hiv in the country our qualitative study population was made up almost entirely of male participants reflecting not only the composition of the overall bravo study population but also the demographic makeup of people receiving treatment for moud in vietnam 34 substance use is widely believed to be a predominantly male phenomenon in vietnam perhaps due to traditional gender roles in the culture of vietnam however little data exists to substantiate this belief and it is possible that current treatment efforts are failing to reach significant numbers of females with sud in vietnam 34 most participants in our study felt unambiguously that their use of alcohol and methamphetamine did not constitute addiction this may be related to broader societal views of these substances although little research has been conducted into public attitudes towards alcohol and methamphetamine in vietnam in the case of alcohol few policies have been implemented to minimize public consumption of alcohol or to mitigate associated risks 43 to the extent that such policies may reflect andor shape social perceptions of alcohol their relative absence in vietnam may indicate limited social awareness of alcohols addictive potential similarly traditional perceptions of illicit drug use as a social evil tend to emphasize the role of personal choice rather than addiction in popular conceptions of methamphetamine use 41 when experiencing symptoms of withdrawal following use of multiple substances people holding such beliefs may tend to disproportionately attribute their withdrawal symptoms to the specific substance which they believe a priori to be addictive thus participants who used both heroin and methamphetamine or alcohol may have blamed their withdrawal symptoms largely upon heroin and failed to fully consider the possibility that they were simultaneously withdrawing from methamphetamine or alcohol in addition to these cultural factors for nearly all participants initial methamphetamine use was relatively recent compared to much longer histories of opioid use it is possible that these participants were relatively early in the course of their methamphetamine use and had not yet developed a dependence that would be perceptible to them in the context of their coexisting oud participants enrolled in the bravo moud treatment trial reported both methamphetamine and alcohol use as part of the social fabric of their daily experience moud has been associated with increased rates of loneliness among people with oud and it is possible that use of methamphetamine and alcohol in social settings may be a strategy for coping with loneliness 45 alcohol has a longestablished place in the culture and social life of vietnam and is thought to have traditionally served to smoothover intergroup tensions a role for which social pressure to drink to excess is integral 46 it is possible that alcohols traditional role in temporarily levelling otherwise rigid social hierarchies may serve to help pwid overcome stigma and maintain social connections with people who do not use drugs an additional possibility is that a deeply ingrained social dynamic surrounding alcohol consumption whereby individual members of a group are pressured to engage in binge drinking may have been transferred to newly arrived psychoactive substances such as methamphetamine the importance of methamphetamine and alcohol use in social settings in the current study also suggests that interventions addressing polysubstance use might target family and friend social networks in vietnam such interventions are particularly needed for alcohol which is an essential aspect of social and business life for many people in vietnam our study identified complex interactions between methamphetamine alcohol and heroin use which are consistent with results seen elsewhere as well as with proposed underlying mechanisms for example our study findings in vietnam are similar to qualitative data from people who use drugs in rural communities in the united states who believed methamphetamine could decrease heroin cravings and overdose risk as well as alleviate opioid withdrawal symptoms 30 in china moreover people who previously used heroin reported switching to methamphetamine with the goal of transitioning to a drug with lower perceived addiction potential 47 methamphetamine use is hypothesized to alleviate physiological symptoms of opioid withdrawal through activation of different dopamine reward pathways than those inhibited by moud 1048 suggesting a potential neurobiological basis for the perception that methamphetamine might be helpful for quitting heroin multiple genetic risk loci have been associated with heroin use methamphetamine use and heavy alcohol use yet little is known regarding their interaction and behavioral correlates 49 studies demonstrating decreased injection frequency among pwid with increased alcohol consumption suggest that a relationship may exist between heroin and alcohol use 40 a similar causal hypothesis between heroin and methamphetamine use may also exist our study should be interpreted in light of potential limitations though lack of generalizability is not a threat to validity in qualitative research study participants were people with hiv participating in a trial of two moud treatment strategies in urban vietnam hiv clinics exclusion of people with significantly elevated liver enzymes from the main bravo trial may have limited the voice of people with more serious alcohol use still our findings inform the relationship between methamphetamine alcohol and heroin use in the context of continued growth in methamphetamine prevalence and ongoing hiv transmission associated with injection drug use in vietnam and throughout southeast asia and the us 42 conclusions further work is required to better elucidate the relationship between methamphetamine and alcohol in people who use opioids in both behavioral and basic science domains a crucial first step is for oud treatment trials to include measures of polysubstance use and analytic plans that assess relationships between complex use patterns and study outcomes as the population of people receiving moud increases in vietnam and globally a better understanding of such relationships will be necessary for clinicians and policymakers to develop and implement effective interventions to treat patients with polysubstance use manuscript kh coordinated coding and data analysis and was a major contributor in writing the manuscript dtt conducted qualitative interviews data codinganalysis and translation of selected quotations ppm nth ttk and ntt were major contributors to investigation and analysis lk provided project administration and resources lmg contributed to conceptualization methodology supervision and manuscript revision and editingtk was primarily responsible for conceptualization methodology supervision funding acquisition and manuscript revision and editing all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background heroin use continues to drive hiv transmission in vietnam but methamphetamine and alcohol use are growing rapidly and as in other countries polysubstance use is widespread the objective of this study was to understand the interplay between heroin methamphetamine and alcohol use among people with opioid use disorder oud and hiv in vietnam methods we conducted 44 indepth facetoface qualitative interviews with people with oud and hiv who participated in the bravo trial of buprenorphine versus methadone in five vietnam hiv clinics interviews probed participants experiences of heroin methamphetamine and alcohol use and their interplay with hivoud treatment interviews were professionally transcribed and analyzed using a thematic analysis approach results of 44 participants interviewed 42 were male on average 388 years of age with 30 reporting a history of methamphetamine use and 33 reporting a history of alcohol use several themes emerged 1 methamphetamine and alcohol were perceived to have lower addiction potential than heroin 2 social settings were key facilitators of alcohol and methamphetamine use 3 some participants but not all used methamphetamine to help quit heroin 4 consuming alcohol blunted the effects of heroin while paradoxically serving as a catalyst for heroin use 5 use of methamphetamine was perceived by many participants to be incompatible with treatment for hiv conclusions participant experiences reflected a significant impact of polysubstance use on treatment of hiv and oud patterns of polysubstance use are subject to common preconceptions of alcohol and methamphetamine as having a low addictive potential and these substances are deeply enmeshed in the social life of many people with oud in vietnam interventions to address complex social norms and potential harms of polysubstance use are urgently needed as the population of people receiving medication for oud moud increases in vietnam and globally

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introduction gender stereotypes have deep influences on how men and women are perceived and perceive themselves on their attitudes and preferences and on their choices common gender stereotypes include the association of men with professional life and women with domestic life as well as the association of men with math or science and women with arts or liberal arts these biased associations act as an unseen force steering men and women to different behaviors roles and activities and contribute to gender imbalances at home at school in educational choices and in the labor market having cultural foundations gender stereotypes should vary in strength across countries and an analysis of their variations across countries can help us better understand and reduce gender imbalances besides an analysis of gender stereotypes in a crosscountry context could shed some light on the gender equality paradox this paradox is the now wellreplicated fact that gender differences in a large number of domains are not reduced but greater in countries with higher levels of economic development individualism or gender equality first results were provided by the largescale study showing that gender differences in personality traits were larger in more individualistic and affluent countries similar results were subsequently obtained for gender differences in values preferences tastes or choices of occupations possible explanations for the gender equalitydevelopment paradox include among others the existence of innate gender differences that can be more easily expressed under more favorable social and economic conditions or the presence of gender stereotypes that could be more prevalent and readily expressed in individualistic and developed countries 9 12 13 14 15 these lines of explanations being not mutually exclusive an analysis of the crosscountry variations of gender stereotypes and in particular of the variations of gender stereotypes with indicators of country economic development individualism and gender equality would help to better identify the possible role of stereotypes in the gender equalitydevelopment paradox and more generally to gain a deeper understanding of the paradox gender stereotypes are difficult to measure especially in a crosscounty context word embeddings are a recent natural language processing tool that has shown validity and reliability in measuring gender stereotypes even in a crosscountry context word embeddings are numeric representations of meaning derived from word cooccurrence statistics in corpora of humanproduced texts by capturing semantic similarities between words of the corpora on which they are trained word embeddings can serve as a powerful tool to detect gender associations at a societal level of analysis on a large scale in this contribution we attempt to analyze crosscountry variations in gender stereotypes by relying on publicly available embedding models pretrained on text corpora from more than 70 countries we consider gender stereotypes that have been robustly documented in previous literature on both explicit and implicit measures specifically we examine the stereotyped malecareer femalefamily association as well as the malemathfemaleliberal arts and the malesciencefemalearts associations for a review see we expect that these stereotypes will vary in strength across countries but the way they should vary with country level of economic development individualism or gender equality is not clear first lay expectations suggest that gender stereotypes should be less pronounced in such countries where there are fewer disparities in vertical opportunities such as educational attainment and labor force participation and where men and women are considered and treated more equally due to prevailing gender egalitarian values in support of these arguments inglehart and norris suggested in their rising tide theory that development induces systematic changes in gender roles toward greater gender equality in any society more recently higher levels of gender equality at the country level were shown to be associated with reduced male dominance in google image search results for the gender neutral keyword person however the gender equalitydevelopment paradox reveals strong gender imbalances in traits values or horizontal opportunities in more economically developed countries these imbalances could be associated to the presence of stronger gender stereotypes in these countries either as a cause or as a consequence in line with this argument williams and bests seminal international study on gender stereotypes in personality traits across 26 countries reveals that men and women are perceived as relatively more different in more developed and individualistic countries p 27 a recent study uses students questionnaires in the program for international student assessment to propose a nonstandard measure of the stereotype that math is not for girls and shows that this stereotype is more prevalent in more developed countries could the same pattern be observed for gender stereotypes about career math and science embedded in natural language our findings show that gender stereotypes about career math and science indeed vary across countries and are all stronger in the text corpora of more economically developed and individualistic countries gender stereotypes embedded in natural language are also stronger in more gender equal countries in particular in countries that endorse more gender egalitarian values but the relation seems weaker than with countries wealth or individualism we discuss the possible mechanisms connecting economic development or individualism to gender stereotypes by drawing upon previous research in sociology that emphasizes the multidimensional nature of gender equality and allows us to suggest possible explanations for the fact that in more wealthy and individualistic countries men and women can be considered as both more equal and more different regardless of the origin of these stronger gender stereotypes their prevalence should be noted since they are likely to impact gender imbalances we finally discuss the implications of our results as well as their limitations in particular we emphasize the importance of exercising caution when interpreting our results as they are based on big data analysis in an international context and may involve various underlying mechanisms results descriptive statistics our approach is similar to the one in and detailed in the materials and methods section and in appendix a we summarize the main steps here as in we rely on publicly available word embeddings pretrained on text corpora from wikipedia and from the common crawl project using the fasttext algorithm a variant of word2vec the wikipedia and common crawl corpora are organized and split by language and our sample of text corpora includes 82 language corpora from wikipedia and 75 language corpora from common crawl we consider linguistic stereotypical gender associations about careerfamily mathliberal arts and sciencearts for each stereotype we choose stimuli ie sets of words representing the categories men and women as well as sets of words representing the attributes careerfamily mathliberal arts and sciencearts we essentially adopt the same stimuli as in for the english corpus which are the stimuli of the implicit association test and translate these stimuli for all other language corpora as in our measures of gender stereotype denoted by gs rely on the word embedding association test which tweaks the iat for word embeddings for each corpus the measures gs represent the extent to which male words are more similar than female words to career versus family words to math versus liberal arts words and to science versus arts words we also consider a measure of aggregate gender stereotypes by collapsing the three stereotypes tables s1 ands2 provide the three gender stereotypes measures gs by language corpus as well as the effect sizes the average effect size varies from 035 for careerfamily associations to 057 for mathliberal arts associations the measures of stereotypes are positive in most corpora reflecting biased associations in favor of males for career math and science but there is variation in the level of biased associations across corpora and there are language corpora where the association is biased in favor of females figure s1 provides the histograms of the three gs we analyze in table 1 the relations between gs measures across corpus sources and across stereotypes concerning corpus sources the correlation between the measure of aggregate stereotype from wikipedia and that from common crawl is significant but not perfect with r 059 figure s2 illustrates this result for the three stereotypes taken individually we get r 066 for careerfamily gs r 049 for mathliberal arts gs and r 042 for sciencearts gs gs measures are consistent but slightly different across sources plausibly due to the variations in content wikipedia being more specific and considered more objective and fact based the correlation across different stereotypes is also significant with r 052 between career and math stereotypes r 051 between career and science stereotypes and r 075 between math and science stereotypes this means that corpora that exhibit stronger biased gender associations of one type are also those that exhibit biased gender associations of the other types these corpora are altogether more gender stereotyped gender stereotypes are stronger in the text corpora of more economically developed and individualistic countries we now examine how gender stereotypes gs vary across countries and in particular how they vary with levels of economic development and individualism we use gross national income to measure economic development and hofstedes index of individualism versus collectivism to measure individualism since these indices are calculated per country and gender stereotypes are available by language corpus we followed the approach of and used data from wikipedia which outlines the relative contribution of residents from each country to each language corpus in our main specification we consider for each language corpus the country that contributes the most to the corpus this amounts to assuming that the stereotypes embedded in a corpus reflect the stereotypes of the residents of the country that contributes the most to the corpus as robustness checks we consider alternative ways to match corpora with levels of economic development and individualism in particular in proportion to countrys relative contribution to the corpus as in we first observe that the level of aggregate gender stereotypes is on average twice as large in the text corpora of oecd countries which are mostly economically developed countries as in the corpora of nonoecd countries figure 1 provides a comparative analysis of careerfamily stereotypes embedded in the text corpora of two countries an oecd country known for its economic development and individualism and a nonoecd country characterized by lower economic development and individualism we observe distinct patterns in the semantic similarity of career and family words to male versus female words in these two corpora specifically in the us corpus all careerrelated words except business show a stronger semantic similarity to male words than female words with the strongest male biases observed for the words career and salary in contrast the bangladesh corpus displays more balanced semantic similarities to male and female words for careerrelated words resulting in a slight female bias turning to familyrelated words a similar trend emerges in the us corpus all familyrelated words except relatives exhibit a stronger semantic similarity to female words than male words with wedding and children showing particularly strong female biases whereas the similarities to male and female words are more balanced in the bangladesh corpus as a consequence the careerfamily gender stereotype is notably more pronounced in the us corpus than in the bangladesh corpus more precisely table 1 and 2 and table s3 provide the relation between our gs measures and country level of gni and individualism for the wikipedia source a 1 sd increase in country level of individualism is associated with an increase of 056 sd of the level of careerfamily gs and a 1 sd increase in country level of gni is associated with an increase of 047 sd of careerfamily gs figure 2 and figure s3 illustrate this result for math and science the increases in the level of gs associated with a 1 sd increase in country level of individualism or gni vary between 026 sd and 041 sd and are all significant if we consider the three stereotypes together we find that a 1 sd increase in country level of individualism is associated with an increase of 066sd of the level of aggregate gs in the common crawl corpus source collapsing both sources we obtain in table 2 that a 1 sd increase in country level of individualism is associated with an increase of 067 sd of the level of aggregate gs figure 2 illustrates this result finally table s3d suggests that the impact of individualism seems stronger than the impact of gni on aggregate gender stereotypes gs in the sense that if both indices are introduced simultaneously as explanatory variables in the regressions only the index of individualism remains significant singlecategory biased associations as the standard iat the weat measure hence our gs measure makes it impossible to disentangle the various associations and to determine whether the stronger gender stereotypes in more individualistic and economically developed countries are primarily related to male or to female words and whether they are primarily related to a stronger relative similarity of careermathscience words to male versus female words or to a stronger relative similarity of familyliberal artsarts words to female versus male words as the single category iat the single category weat introduced in makes it possible to quantify each association separately table s4 shows first that the relation between gs and country individualism and gni is primarily related to female words a 1 sd increase in the level of individualism is associated with a decrease of 043 sd in the similarity of female words to career versus family words figure s4 illustrates this result the relation for male words is not significant the pattern is robust to the consideration of aggregate stereotypes and of the common crawl source concerning attributes table s4 shows that careermathscience words are more similar to male words versus female words in more individualistic and economically developed countries a 1 sd increase in the level of individualism is associated with an increase of 044 sd in the similarity of careermathscience words to male versus female words figures s4 and s5 illustrate the result table s4 further shows that there is a lower association of family words to male versus female words in more individualistic and economically developed countries for the wikipedia corpora this relation is however not robust to the consideration of the common crawl corpora robustness checks and complementary analyses robustness to other stimuli since our analysis relies on word embeddings and word similarity the choice of the stimuli is important and we verify the robustness of our results to alternative stimuli we consider as alternative stimuli for the careerfamily dimension and for the sciencearts dimension the stimuli adopted in for these dimensions table s5a provides descriptive statistics the average gs computed for these alternative stimuli is very similar to the average gs in our main analysis for both stereotypes table s5b shows that for both dimensions the correlation between our main measure fig 1 linguistic gender stereotypes about career and family embedded in the us and bangladesh common crawl text corpora the figure presents measures of the relative semantic similarity of career and family words to male versus female words in the us and in the bangladesh common crawl text corpora the words stimuli to represent career and family attributes are the stimuli used in the iat and the same as in and ie eight careerrelated words business career corporation executive management office professional and salary and eight familyrelated words children cousins family home marriage parents relatives and wedding the left figure represents the relative level of similarity of career words to male words versus female words positive values represent a male bias ie a greater similarity to male words than female words the right figure represents the relative level of similarity of family words to female words versus male words positive values correspond to a female bias details about methods and data are provided in the materials and methods section and in the supplementary material and the measure obtained with the alternative stimuli is strong with r 080 for the careerfamily dimension and r 074 for the sciencearts dimension table s5c shows that the main result of our analysis remains valid with these alternative stimuli a 1 sd increase in country level of individualism being associated with an increase of 035 sd of careerfamily gs and of 038 sd of scienceart gs robustness to other measures of individualism and economic development we have considered so far gni as a measure of economic development and hofstedes index of individualismcollectivism as a measure of individualism we verify the robustness of our conclusions to alternative measures of country individualism and economic development we consider as an alternative measure of individualism the opposite of the measure of collectivism of the globe survey which is more related to family collectivism than the measure of hofstede as alternative measures of country economic development we consider the gross domestic product as well as the human development index which incorporates measures of education and life expectancy on top of economic wealth the definition of these measures and data sources are provided in appendix b table s6a shows that a 1 sd increase in these various measures of individualism and economic development is associated with an increase of aggregate gender stereotypes of 038 sd for hdi 048 sd for gdp and 056 sd for the opposite of the collectivism measure of the globe survey similar results are obtained when considering each stereotype and each source of text corpora separately table s6b shows that our results are fully robust to the consideration of historical measures of economic development the number of observations is sometimes reduced for these historical measures but table s6 shows a systematic significant relation with gender stereotypes taken individually or collapsed into an aggregate measure of stereotypes which indicates that the relation between stereotypes and country levels of individualism and wealth is historically founded consideration of country gender equality and ecological stress we have focused so far on country individualism and economic development because these dimensions are considered as main drivers of cultural variations and because they are the most frequently considered indices in the literature related to the genderequalitydevelopment paradox numerous works however have related the gender equality paradox directly to the level of gender equality of the countries or to their level of ecological stress and we now examine the relation between gender stereotypes gs and these constructs table s7a first shows that the relation is significant in most specifications for the gender gap index which synthesizes the position of women regarding education economic opportunities politics and health and has been shown in to be related to sex differences in stem fields a 1 sd increase in the ggi is associated with an increase of aggregate gs embedded in both data sources of 03 sd this means that gender stereotypes embedded in languages are stronger in environments that are more gender equal in the sense of the ggi since the ggi is a composite index it is useful to consider specific dimensions of gender equality the relation is not robustly significant with measures of gender equality that are specifically related to career or family issues like female fertility rate or female labor force participation the relation is on the contrary strong and robustly significant with measures of gender equality in values a 1 sd increase in the level of gender equality in values concerning politics education or occupations is associated with an increase of aggregate gs embedded in both data sources between 052 sd and 062 sd the relation of gender stereotypes with ggi or measures of gender equality in values is however weaker than with measures of individualism or gni in the sense that the relation mostly disappears when controlling for either of these measures note that for stereotypes about math the relation with the ggi and especially with gender equality in terms of values is more robust when controlling for gni or individualism compared with the other stereotypes which suggests that the impact of gender equality per se is greater on mathrelated stereotypes than on those related to career or science ecological stress has been shown to be related to collectivism and also to sex differences in eg personality traits in when controlling for confounds only the impact of ecological stress and of individualism remained as in we consider the two most prominent sources of ecological table 2 regression of linguistic gender stereotypes about careerfamily mathliberal arts and sciencearts on country individualism and gross national income s7b shows that the relation is significant in most specifications a 1 sd increase in the level of lack of nutrition is for instance associated with a decrease of aggregate gs embedded in both data sources of 048 sd for contemporary estimates and 039 sd for historical estimates for both sources of ecological stress the relation seems however to disappear when controlling for the levels of country individualism or gni in summary gender stereotypes are stronger in the text corpora of more gender equal countries or countries facing lower ecological stress but these relations seem to be weaker than those observed with country level of individualism or gni dependent variable is language gender stereotype about careerfamily mathliberal arts sciencearts careerfamily mathliberal arts sciencearts careerfamily mathliberal arts sciencearts careerfamily mathliberal arts sciencearts additional robustness checks table s9 shows that results remain the same when considering normalized measures of gender stereotypes ie effect sizes results also remain qualitatively and quantitatively valid if we restrict our sample of text corpora to the largest contributors to the wikipedia data source or to oecd countries that are mostly economically developed countries defranza et al have shown the relation between genderedness of languages and the strength of gender prejudice since individualism and economic development may be related to the genderedness of languages we verify if our results remain valid when controlling for genderedness table s10 shows that it is indeed the case table s10 further shows that results are robust in controlling for a metric of countrylevel interdependence such as continent and language family discussion relying on word embeddings from two different data sources each comprising around 80 text corpora we have found that gender stereotypes embedded in natural language are stronger in the corpora of more individualistic and economically developed countries gender stereotypes are also stronger in the corpora of more gender equal countries although the relation seems weaker than with individualism or economic development these results hold true for gender stereotypes about careerfamily mathliberal arts and sciencearts in this discussion we aim to provide an interpretation of our findings explore their implications and acknowledge the limitations of our approach interpretation of our findings we interpret our result as reflecting the presence of stronger gender stereotypes in more economically developed and individualistic countries which may initially seem surprising as mentioned in the introduction section this finding is however in line with the few previous empirical works on the variations of gender stereotypes across countries identifying the exact mechanism leading to stronger gender stereotypes in more developed individualistic or gender equal countries is beyond the scope of this work but there are theoretical foundations to both interpret and explain why in these countries higher formal procedural equality can coexist with stronger stereotypes of gender differences prominent theories of social norms propose that dominant social groups utilize norms to distinguish themselves they highlight how eliminated sources of social differentiation are likely to be replaced by other type of norms to sustain social hierarchy this can explain why in more individualistic and progressive countries in which male primacy is reduced an equal but different ideology can be reinforced moreover according to social dominance theory the most culturally valued traits in a society are attributed to more dominant social groups which are usually men thus stereotypes about men and women will change with the core values of a given culture which can explain for instance why in more individualistic and progressive countries in which individualism is more valued career is relatively more associated with men this interpretation is also supported by recent research in sociology on gender norms that emphasizes the role of gender as a fundamental cultural tool for framing social relations and the resistance to any real reduction in gender differentiation this research argues that gender differentiation is maintained and rewritten into new socioeconomic arrangements even under an altered form in particular it underscores the significance of distinguishing between two dimensions of gender ideology the belief that men and women are unequal and the belief that they are on balance different the former has declined in developed and individualistic countries but it has been replaced by various forms of egalitarianism with the emergence of a new frame denoted egalitarian essentialism combining support for traditional differentiation between men and women with an individualistic and feminist rhetoric of choice and equality it denies implications of lower status for women and can claim to be egalitarian since men and women have equal opportunities and can make counterstereotypical choices if they want to while still reinforcing traditional gender stereotypes of complementarity research on the gender equalitydevelopment paradox also provides interesting insights into the factors that can contribute to the endorsement of stronger gender stereotypes in individualistic and wealthy countries first the impact of individualism and economic development on gender stereotypes can be indirect acting through strong existing gender imbalances within these countries indeed the gender equality paradox highlights the presence of strong gender differences in preferences behaviors and choices in individualistic and wealthy countries these differences may arise because men and women can better express their innate preferences or due to variations in socioeconomic and cultural environments therefore the strong biased gender associations observed in the natural language of these countries may simply be the reflection of these strong existing gender disparities in preferences behaviors and choices however individualism and economic development may impact gender stereotypes more directly first as noted by charles and bradley individualistic and wealthy societies emphasize the importance of the individual highlighting individual personality traits and preferences as well as the idea of an individuals true self as underlined in these notions of self are in fact largely socially constructed drawing from traditional gender stereotypes which can lead to the reinforcement of such stereotypes in individualistic societies another and perhaps most plausible explanation relies on attribution processes as suggested by costa et al the idea is that in individualistic and wealthy countries where men and women are considered and treated more similarly the fact that women spend more time with their children than men or neglect math fields may be seen as a free choice reflecting their preferences whereas the same behaviors in a more collectivistic and traditional country might be seen as mere compliance with sex role norms and requirements differences in behaviors will then be attributed to differences in preferences and traits rather than constraints and roles which can contribute to the reinforcement of standard gender stereotypes in more individualistic and progressive societies we emphasize that these explanations are not mutually exclusive and can complement one another to contribute to the reinforcement of stereotypes in wealthy and individualistic countries implications of our analysis whatever the underlying mechanism our analysis highlights the presence of stronger gender stereotypes in the natural language of more individualistic and wealthy countries which has both practical and theoretical implications our analysis first emphasizes the importance of trying to reduce gender stereotypes in wealthy and individualistic countries or at least to minimize their impact or to be aware of their presence to allow more gender equality this is true of stereotypes embedded in language but more generally of stereotypes embedded in society that the word embeddings reflect this would be beneficial to both women and men directly attacking gender stereotypes is difficult but being aware of the presence of strong gender stereotypes in developed countries is important when considering possible gender equality policies for example easier or longer paternity or maternity leave may backfire and reinforce labor market imbalances if due to the presence of strong stereotypes women make more use of it than men or if fathers use it for purposes other than childcare our analysis also has theoretical implications it shows that in more individualistic and economically developed countries more gender egalitarian values and practices can coexist with stronger gender stereotypes which supports the growing literature underlining the multidimensional nature of gender equality besides our analysis provides new insights into the gender equality paradox it does not invalidate existing explanations and these explanations probably complement one another however in line with our analysis suggests that stereotypes are likely part of the explanation as regardless of their origin the mere presence of more pronounced stereotypes in individualistic and developed countries should lead to greater gender imbalances this is all the more true as more developed and individualistic countries make the expression of gender stereotypes into free choices easier more generally existing and future possible explanations of the paradox should be analyzed in terms of their consistency with the fact that gender stereotypes themselves seem more marked in more developed countries a final implication is directly related to our method of measuring stereotypes through word embeddings the fact that word embeddings trained on wikipedia and common crawl corpora napp 7 exhibit gender stereotypes in wealthy and individualistic countries is concerning because as underlined by bolukbasi et al due to their widespread usage as basic features word embeddings not only reflect gender stereotypes present in broader society but can also perpetuate and amplify these stereotypes this is particularly worrying with their widespread use in nlp applications such as decision tools or the ongoing development of generative artificial intelligence limitations of our analysis first our analysis is correlational it shows that individualistic and wealthy environments are associated with stronger gender stereotypes embedded in language but cannot make any claim about causality even if we have provided possible explanations however note that whatever the cause of these stereotypes it is important to identify the presence of strong gender stereotypes in individualistic and wealthy countries to better understand and reduce gender imbalances second we relied on word embeddings to measure gender stereotypes and while word embeddings have been shown to be a reliable method to detect biased associations and cultural beliefs in a society they are not without limitations in particular their capture of gender stereotypes may be noisy especially in a crosscountry context the measure of biased associations may be influenced by corpus selection and specific stimuli choices additionally due to diverse languages in the corpora we had to rely on a translation tool introducing some noise even if we have confirmed the robustness of the results to various choices of corpora stimuli and translation tools regarding the relation with macro variables each corpus does not univocally correspond to a single country and we had to choose a procedure to associate a level of individualism and wealth with each text corpus which may also introduce noise even if we verified the robustness to different matching procedures moreover the volume of wikipedia or common crawl data can be influenced by factors like internet usage which is related to economic development similarly the volume of data related to gender or related to careermathscience in a country can be influenced by economic development and impact the measure of gender stereotypes even if the nature of this impact is not clear gender stereotypes themselves may be more openly discussed in western countries and there may be a greater volume of research in social psychology there which could affect the dataset furthermore specific linguistic features that may vary with countrys level of individualism or wealth could potentially introduce bias into the measurement of gender associations all of these limitations emphasize the need for careful interpretation of the results based on word embeddings and in future research it would be valuable to assess the robustness of our analysis using alternative measures of gender stereotypes third we have focused on gender stereotypes that have been robustly documented in the literature namely stereotypes about careerfamily and about math or sciencearts or liberal arts while these are common gender stereotypes in western countries there may exist other stereotypes like eg stereotypes more directly related to a gender hierarchy that could be stronger in less wealthy and individualistic countries for instance bailey et al have recently shown by using word embeddings trained on the common crawl corpus that the concept personpeople prioritizes men over women and this biased association could be stronger in less affluent and individualistic countries note however that these stereotypes would be less directly related to the gender imbalances that satisfy the gender equality paradox that are mainly horizontal finally word embeddings relying on largescale corpora such as wikipedia or common crawl make it impossible to distinguish between stereotypes endorsed by men and stereotypes endorsed by women such a distinction can be useful in particular to examine the relationship between gender stereotypes and gender differences in individual choices and could be made by relying on other measures of stereotypes such as the iat or by relying on word embeddings trained on other text corpora such as books as in or song lyrics as in materials and methods word embeddings and text corpora we used publicly available word embeddings pretrained using the fasttext algorithm on two different data sources with each more than 100 text corpora corresponding to different languages the first data source consisted of data from the free online encyclopedia wikipedia and the second was from the common crawl project which contains snapshots of all the text that can be scraped from the publicly facing internet since 2013 we kept the text corpora whose language is an official language of at least one country and for which the contribution of each country is available see the supplementary material for more details our final sample included 82 corpora for the wikipedia project and 75 corpora for the common crawl project word embedding association test we used the weat to obtain measures of gender stereotypes from word embeddings tweaking the iat the weat measures the association between two sets of target words x and y and two sets of attribute words a and b the weat measures the difference between the two sets of target words in terms of their relative similarity to the two sets of attribute words the level of similarity between two words w 1 and w 2 with word embeddings w 1 �→ and w 2 �→ is defined as the cosine similarity cos w 1 �→ • w 2 �→ ∥ w 1 �→ ∥ ∥ w 2 �→ ∥ measures gs of language gender stereotypes to measure gender stereotypes we consider as sets of target words a set x of male words and a set y of female words the sets of attribute words change depending on the gender stereotype under consideration with a set a of career words and a set b of family words for gender stereotypes about careerfamily for each stereotype represented by the sets we take as our measure of gender stereotypes gs ≡ s higher values of gs correspond to stronger gender stereotypes for example for gender stereotypes about careerfamily then a is a set of career words b is a set of family words srespectively smeasures the relative higher similarity of male wordsrespectively female wordsto career versus family words and gs measures the differential similarity between male and female words to career versus family words ie the level of gender stereotypes about careerfamily note that unlike the normalized measure es the measure gs is linear and permits to easily collapse different gender stereotypes or data sources since gs gs gs 2 and this is one of the reasons why we favor this measure in our analysis in robustness checks we verify that our results remain valid for effect sizes es stimuli concerning the choice of stimuli we adopted the same sets as in and as in the iat for the english text corpus except that we kept the same sets x and y of male and female words for the three different stereotypes this permits to avoid sets including proper names for which there is no direct translation equivalent in other languages as in more precisely we took x male man boy brother he him his son and y female woman girl sister she her hers daughter in all settings for stereotypes about careerfamily we took a executive management professional corporation salary office business career and b home parents children family cousins marriage wedding relatives for stereotypes about mathliberal arts we took a math algebra geometry calculus equations computation numbers addition and b poetry art dance literature novel symphony drama sculpture and for stereotypes about sciencearts we took a science technology physics chemistry einstein nasa experiment astronomy and b poetry art shakespeare dance literature novel symphony drama in robustness checks we considered as alternative stimuli those adopted in see supplementary material for details about these stimuli for all text corpora in languages other than english we translated the words in x y a and b from english to the considered language and used these translations to compute gender stereotypes gs ≡ s embedded in each corpus in the main specification we used google translate to obtain translation of the words in x y a and b and we verify in table s11 the robustness of the results to using chatgpt instead of google translate singlecategory weat to quantify how masculine or feminine attribute words are we define the relative similarity of an attribute word w to the target set x versus y by s mean x∈x cos mean y∈y cos the relative similarity of the attribute set a to the set x versus the set y by s mean a∈a s and the relative similarity of the attribute set b to the set x versus the set y by s mean b∈b s for instance for gender stereotypes about career and family s represents the strength of the relative association of career words with male versus female words note that for all stereotypes our score of gender stereotypes gs represents indifferently the difference s s s or the difference s s s while the effect sizes differ which is another reason why we favored nonstandardized measures in our analysis match between corpora and levels of individualism and economic development finally to analyze how gs vary with country level of individualism and economic development we relied on available data from wikipedia outlining the relative contribution of each country to each corpus in our main specification we essentially considered for each text corpus the level of individualism or of economic development of the country that contributes the most to the corpus in robustness checks we considered alternative specifications and in particular a specification where we adopt for each corpus the weighted average of the levels of individualism and development of the countries contributing to the corpus based on countries relative contribution to the considered corpus as in and a specification where we limit the sample of corpora to those for which one country contributes to more than 50 table s10 shows that our results are robust to these various matches between corpora and macro variables data availability we used pretrained word vectors which were generated by training on wikipedia and common crawl datasets using fasttext these word vectors are publicly accessible and can be found at the following links html and all the codes used for our main analyses are publicly available via the open science framework and can be accessed at osfiogkmv4 supplementary material supplementary material is available at pnas nexus online

gender stereotypes contribute to gender imbalances and analyzing their variations across countries is important for understanding and mitigating gender inequalities however measuring stereotypes is difficult particularly in a crosscultural context word embeddings are a recent useful tool in natural language processing permitting to measure the collective gender stereotypes embedded in a society in this work we used word embedding models pretrained on large text corpora from more than 70 different countries to examine how gender stereotypes vary across countries we considered stereotypes associating men with career and women with family as well as those associating men with math or science and women with arts or liberal arts relying on two different sources wikipedia and common crawl we found that these gender stereotypes are all significantly more pronounced in the text corpora of more economically developed and more individualistic countries our analysis suggests that more economically developed countries while being more gender equal along several dimensions also have stronger gender stereotypes public policy aiming at mitigating gender imbalances in these countries should take this feature into account besides our analysis sheds light on the gender equality paradox ie on the fact that gender imbalances in a large number of domains are paradoxically stronger in more developedgender equalindividualistic countries

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background mental health disorders are a public health issue most mental disorders begin during childhood and adolescence epidemiological studies regarding the diagnosis prevalence and access to treatment by children and adolescents are scarce especially in portugal this research protocol aims to characterize the referral process and waiting times for these consultations at a portuguese local health unit between 2017 and 2022 and to identify barriers to adequate health care for children and adolescents from the perspective of healthcare professionals from the hospital and primary care units methods we used a mixed methods study qualitative data allowed interpretation and reflection of quantitative data with validation and integration of results we conducted a descriptive analysis of the variables obtained through the local health information system and semistructured interviews with a sample of healthcare professionals involved in mental health care for children and adolescents at the hospital and primary care unit levels results preliminary results show a break in the number of consultations in 2018 due to the lack of professionals and a yearly increase after covid19 followup appointments and evaluation processes have long waiting times since there is a focus on ensuring shorter waiting times for the first consultation and there is a shortage of professionals in mental health teams the staff identified the need to integrate schools into care referral and evaluation and to promote communitybased programs that train skills in children adolescents and caregivers conclusions health indicators allow the assessment of epidemiological data and access to care yet it is fundamental to listen to the professionals in the field to identify barriers needs and possible actions that more effectively promote mental health in this population key messages mental health disorders in children and adolescents are a significant public health issue in portugal yet there are scarce epidemiological studies on diagnosis prevalence and access to treatment there is a need to address the shortage of mental health professionals and integrate schools and communitybased programs into mental health care to improve access and promote mental health abstract citation id ckad1601540 addressing influenza outbreaks in schools regina sa ŕ sa ´1 s garganta 1 c borges 1 m correia 1 d emilio 2 ap rodrigues 3 1 public health unit algarve i health center grouping faro portugal 2 family health unit osso ´noba algarve i health centre grouping faro portugal 3 epidemiology department national institute of health doutor ricardo jorge lisbon portugal contact the public health unit of albufeira received a communication from the director of the a public school about the occurrence of flulike symptoms in a large number of students no response protocols were in place for laboratorial analysis and control measures in this specific situation the phu started the necessary procedures to assess the situation and act according to the information obtained in collaboration with the school control measures were implemented a communication network was established and informative materials such as leaflets on preventive measures against the flu were produced and distributed as well as pediatric masks and hand sanitizer in partnership with the national network of sentinel flu doctors five nasopharyngeal samples were also collected for laboratory analysis epidemiological investigations have identified 4 confirmed cases of influenza b 17 probable cases and one case with missing information the attack rates were found to be high with 95 of both students and teacher becoming ill

fertility rates have been declining globally since 2010 also in the nordics in finland this decline has been steep and the country has now hit lowest fertility level ever changes in fertility rates often occur with economic status and life expectancy improvements in a population in finland delaying childbearing is a major cause for declining fertility rates the aim of this study was to examine how ethical economic and societal factors affect having childrenin total 65986 randomly selected adults living in finland were invited to answer the healthy finland questionnairebased survey in 20222023 subjects n 28480 participation rate 323 males 421 and females 579 aged 20 to 54 years were asked questions on childlessness and infertility results 176 of subjects reported not wanting more or any children while 93 wanted to have more children 147 reported never wanting to having nor wanting to have children 42 reported having had an experience of infertility and 31 reported receiving fertility treatments currently 05 were expecting a baby and 15 actively trying for a baby in the sample population most common reasons for not having children were economic situation 62 never wanting to have children 61 relationship situation 59 and work or studies 56 other reasons included capability issues 43 ecological or environmental reasons 41 other miscellaneous reasons 40 and loneliness or lack of social network 39 lack of societal support 32 and own spousal or family illnesses 29 while childlessness may be a temporary state in many peoples lives close to every seventh person chooses it permanently several external reasons affect voluntary childlessness ranging from ethical to practical further data is needed to evaluate the societal and economic obstacles to make childlessness a truly voluntary choicethe healthy finland population survey provides information on the major causes of voluntary childlessness including economic reasons and never wanting to have children in this population every seventh person did not have nor ever want to have children

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where d denotes the number of deaths y denotes calendar year x a vector of predictor variables and y the vector of coefficients that need to be estimated predictor variables were dummy variables indicating educational class and interactions thereof with age and calendar year to control for confounding a set of dummy variables for each year and age were added to the model furthermore to account for selection bias by education in the lfs data a variable measuring the length of followup time in the lfs and an interaction thereof with age were added to the model second these relative risks were then used to decompose mortality rates from the total population by exploiting the following relationship ða2þ mða t eþ ¼ rrða t eþ â mða tþ p e rrða t eþ â pðeja tþ where mða tþ denotes total mortality rates for age a calendar year t as published by statistics netherlands and mða t eþ denotes mortality rates for age a calendar year t and education level e equation states that mortality rates in a particular year at a particular age are the weighted average of the mortality rates of the different educational subgroups note that pðeja tþ denotes the proportion of individuals at an education subgroup at a particular age in a given year and was taken directly from the lfs data background overall decreased socioeconomic status has been linked to increased stroke incidence and mortality questions remain regarding whether these relationships persist into older age and apply to stroke sequelae it is also unknown whether the influence of ses on absolute riskthe metric of most importance for population healthdiffers by age methods a nationally representative crosssectional survey conducted in 2009 in france involved 26 000 participants 1653 of whom declared previous stroke we identified stroke with sequelae and stroke with dependency ses was characterized as low medium or high education we compared the prevalence of stroke outcome across education within age groups results prevalence of stroke was 238 per thousand 651 of patients had sequelae and 196 were dependent variations in the prevalence of stroke and of stroke sequelae were statistically significant only in the youngest generations a significant education gradient for stroke with dependency was apparent in all three generations although the prevalence ratio was highest in the 4059 compared with that in the 80 conversely the absolute difference was of much greater magnitude in the oldest vs youngest generation conclusions ses disparities in the older age group were significant and large in absolute terms when considering more severe outcomes such as stroke dependency these findings question the ability of universal health care systems to answer equitably the need of the aging population background a s for most diseases higher frequency of stroke has been shown to prevail among individuals with lowsocioeconomic status 12 whether these disparities affect all agegroups equally is unclear specifically some studies suggest that the steepness of the gradient may decrease flatten or even reverse when age increases 34 however these results are mostly based on the analysis of stroke incidence and stroke mortality whereas the spectrum of stroke outcomes also includes varying levels of disability consideration of disability outcomes is quite important as nearly half of stroke survivors are dependent 1 year after stroke occurrence 5 socioeconomic disparities in stroke consequences have been little investigated 12 however as suggested from a study examining disabilityfree life expectancy ses gradient related to disability may be more pronounced than gradient based on mortality alone 6 another limitation of previous research is the frequent use of relative measures of association relative indicators are useful for exploring and expressing statistical associations but absolute indicators such as socioeconomic disparities in stroke risk differences are better for assessing the population health impact 7 absolute differences may be as or even more meaningful in older ages when disease prevalence is higher and relative risks are attenuated in this study we aimed to examine how the educational gradient of stroke and its consequences varies across age groups using both relative and absolute measures of inequalities methods disabilityhealth survey data are from the disabilityhealth survey a french national crosssectional survey with two components first a representative sample of people living in households second a representative sample of residents in institutions a detailed account of the twostage stratified sampling design for the household arm of the survey is provided elsewhere 8910 in brief at stage 1 a preliminary filter survey was conducted to classify 141 138 randomly selected persons from the 2006 national census into four levels of disability at stage 2 a random sample was selected from this population with higher sampling fractions applied to those with disability response rates to stages 1 and 2 were respectively 791 and 766 so that a total of 29 931 subjects were enrolled the sampling strategy for the institution component of the survey was also multistage first a sample of 1567 institutions was drawn from a sampling frame of 12 000 records of nursing homes long stay hospitals homes for adults with physical or mental disability and sheltered housing among those 1519 agreed to take part to the survey next six to eight residents from each selected institution were invited to participate a total of 9104 subjects were finally involved in this arm of the survey for both the household and the institution arms of the survey information was collected during inperson interviews at the participants place of residence between 2008 and 2009 when participants were unable to answer responses were provided by a household member or a proxy the disabilityhealth survey was conducted by the national office of statistics with ethical approval from the national institute of statistics and the national agency for data protection stroke and stroke consequences participants were asked whether they were affected or not by various chronic conditions from a list of 52 conditions in case they indicated stroke the presence of sequelae and of disability were ascertained during the interview interviewers inquired about the presence of motor or sensory loss aphasia difficulty to swallow balance problems and cognitive difficulties for this analysis we identify the subgroup of stroke patients that declared at least one sequel level of dependency was assessed with a scale based on katzs activities of daily living this explores six functions bathing dressing toileting transferring preparing meal and selffeeding we define patients with dependency as those with at least one sequel and unable to perform at least one of these functions alone because stroke is rare in early life we restricted our analysis to participants aged 40 years in order to study variations of the ses gradient with age we split participants in three generations defined as those aged 4059 6079 and 80 years at the time of the survey definition of ses out of several socioeconomic indicators we chose educational attainment to define participants ses this is because unlike occupation and income educational level is usually established in early adulthood and is therefore unlikely to be affected by the occurrence of stroke education level was collected in 14 categories education level was significantly higher in younger generations making it difficult to compare the gradient across generations on the basis of absolute attainment to counter this difficulty we devised a threelevel relative education variable using specific cutoff points for each of three age groups this ensures that in these three generations 30 of participants belonged to the loweducation group and 22 to the high education group statistical analysis we first compared the distribution of all participants and of those declaring stroke according to age and gender across education levels we used linear and logistic regression to test for trend across education levels we then calculated and plotted prevalence and 95 confidence intervals of each outcome for the nine groups of participants defined by generation and education level we used generalized linear modeling to analyze disparities in the prevalence of stroke and its consequences across education levels for each generation from the models we derived firstly prevalence ratios therefore expressing the disparities on the relative scale and secondly prevalence differences representing them on the absolute scale analyses were conducted for the whole sample and for each gender in order to test for the hypothesis of varying ses gradients across generation we looked for statistical interaction between education and age for each outcome we also looked for interaction between education and being institutionalized for each outcome in each agegroup in all analyses we applied weights reflecting the sampling probability of each participant and accounting for nonresponse data were analyzed with stata using the survey commands results out the 26 251 participants aged 40 years 26 154 provided information on educational attainment mean age decreased but the proportion of males increased from the low to the higheducation groups a total of 1653 declared having had a stroke which corresponds to a prevalence of 238 per thousand there were marked contrasts across education groups in the prevalence of stroke the proportions of cases with sequelae and the proportion with dependency all being higher in the loweducation group and declining thereafter cases from the loweducation group were more than twice as likely as other cases to reside in care setting and presented more often with other comorbidities figure 1 and tables 2 and 3 present the ses disparities across the three generations since no interaction was found between education and sex we present results for the sample as a whole the prevalence of stroke and strokerelated outcomes all rise sharply with increasing age higher education is strongly related to all stroke outcomes in the two youngest generations while among individuals 80 years higher education is only associated with strokerelated dependency test for interactions suggested that the effect of education varied significantly across age groups for the outcome stroke and stroke with dependency whereas there were no significant interaction for stroke with sequelae table 3 presents the contrast between low and higheducational levels regarding stroke outcomes on both relative and absolute scales overall the relative measures of association between education and stroke outcomes are strongest among the younger vs the older age groups while the reverse is true for absolute measures of association this is particularly so regarding stroke with dependency where the pr in the group aged 4059 years suggests an 8fold increase in prevalence in the low compared with the high education group the corresponding prevalence difference is quite small however compared with differences observed in the 6079 and 80 years or more since patients with low education declared more comorbidities we introduced this variable in the models but found no significant changes in the pattern of associations we found no evidence of statistical interaction between education and institutionalization for any outcome in any agegroup except regarding stroke with dependency among the older figure 2 shows that no significant ses disparities existed among those residing in care setting whereas the educational gradient was clear among patients residing at home to explore this further we looked at the proportions of older participants residing in care setting this was much higher in the loweducation group compared with the medium and high education groups most probably because as stroke does other disabling diseases affect this population more often as a consequence although the prevalence of stroke with dependency rose in institution for all participants it did not rise as much among the low educated which explains the flattening of the educational gradient discussion although socioeconomic disparities have been shown to persist in older age for a variety of health outcomes previous studies suggested that this may not be the case for stroke our results based on prevalence suggest that the gradient is pronounced even in older age groups when considering stroke consequences such as dependency as opposed to stroke per se the ses gradient expressed in the relative scale was steep and statistically significant in the younger agegroup whatever the outcome regarding the outcome stroke with dependency however the gradient expressed in absolute differences across education levels were of much greater magnitude among the older generation although some of our prevalence estimates lack statistical precision because of small numbers of cases the ses gradient for stroke in the younger group and the gradients for stroke with dependency in all age groups displayed high level of statistical significance patient level characteristics such as the initial severity of stroke and the frequency of preexisting comorbidities may explain these findings variation in access to health and social care may also contribute to these disparities although the gradient of higher stroke incidence in lower socioeconomic groups is well documented available evidence is unclear as to whether a similar gradient applies to initial stroke severity for instance no variation of severity measured at hospital admission according to residential ses was found in two studies from canada and france 1011 whereas stroke patients living in poorer neighborhoods were more likely to need help to walk at admission in a study from scotland 12 or to display higher severity score in a sample of us ischemic stroke patients 13 since some of this evidence is based on retrospective estimation of initial stroke severity analysis of prospectively collected data might help to clarify this issue however factors other than the initial stroke severity may explain ses disparities in stroke consequences variations in access to care may be one of those the entire stroke care pathway involves a number of components and actors from the health and social sectors whose involvement and coordination are likely to determine middle to longerterm outcome for instance a registrybased study in france found no disparity in poststroke mortality while patients were in acute care setting but a strong ses gradient thereafter 11 a similar finding applied to a large number of canadian patients followed by kapral et al 10 the transition between acute and postacute care and disparities in the quality of the latter could therefore account for part of the longerterm ses gradient subtle differences in the process of acute care such as the timeliness of procedures may also contribute and have longerterm consequences since lowincome patients in denmark received less optimal care 14 we found that the ses gradient in stroke with dependency only applied to those residing at home in the older age group but that this was a consequence of a higher proportion of loweducated people being admitted into care for other reasons than a dependent stroke the leveling of the ses gradient for a specific cause such as stroke is therefore a consequence of this selection process it is worth stressing that this finding does not mean that institutionalization tends to reduce ses disparities in old age first because the higher admission under care among lower educated individuals reflects in itself a disadvantage also the quality of the setting and of the care provided to institutionalized older patients may vary across ses groups education level as ses indicator is readily usable as an ordered variable and is also available for both genders even in older generations in most instances education is also completed before the age of 40 therefore could not be affected by the occurrence of stroke which could be an issue with both occupation and income higher education is likely to improve access to information to better material conditions and to be associated with health behaviors conducive to better health it could also help being geared toward better care pathways involving for instance rehabilitation services once stroke has occurred 9 there is some evidence that higher ses individuals in france have more social ties 15 this could be an asset at the time of key decisions regarding the care pathway as well as a resource for coping with the consequences of the disease although it has not been observed specifically for stroke care there is evidence that at equal needs higher education is associated with higher use of specialist care in france 16 education may finally enhance individual resilience toward adverse health events occurring in later life a strength of this study is that it is based on a large and nationally representative survey involving both noninstitutionalized and institutionalized individuals our analysis also benefits from observer collected key information on education and disability although less valid than clinically ascertained events selfreported stroke has been shown to be a useful outcome indicator in epidemiological studies 17 it is also likely that lower education is related to more severe stroke and reduced recall of medical history a pattern that would have biased our results toward and not away from the null due to the crosssectional design of the national disability survey we have compared prevalence indicators which reflect both occurrence and survival survival after stroke has been shown to be higher in higher ses as a result the gradients that we identified are likely to underestimate the overall disparities and particularly so in older age groups we found that taking into account the trend of more comorbidities as education decreased did not affect our results however number of participants did not allow a refined adjustment for this it is therefore possible that part of the extra burden of dependency identified among older low ses stroke patients is due to one or more other invalidating pathologies such as diabetes coronary artery disease or dementia the analysis of prospective datasets would help to clarify this issue it would also allow more robust ascertainments of stroke and its consequences as well as measurements of social mobility along the life course 18 in conclusion this study shows that ses disparities regarding the burden of stroke consequences remain significant in old age these are large when expressed on the absolute scale and translate into a high population impact at the time of the survey more than 143 000 patients were affected by a stroke with dependency in metropolitan france had the prevalence of the highly educated applied to all more than 77 000 strokes would have been averted most of them in the two older groups it is worth noticing that this impact is observed in a country which endeavors to provide universal access to health and social care the results of this study suggest that france falls short of this objective providing seamless stroke care for all patients is likely to be a challenge everywhere which raises questions about the size of disparities in countries with less socialized health and social care finally our results certainly suggest that attention to equity in access to health and social care should be part of a policy addressing social health disparities but also that focusing on the wider determinants which govern the occurrence of chronic diseases may be both more effective and fairer introduction b oth individual factors and environmental factors contribute to the risk of cancer and the prognosis for affected patients in cancer epidemiology the impact from socioeconomic status on incidence rate and prognosis is increasingly recognised high ses has been linked to a higher risk for breast cancer and malignant melanoma whereas low ses is associated with adverse prognosis in for example stomach cancer lung cancer prostate cancer and ovarian cancers 12 incidence case fatality and mortality rates are affected by both illegitimate factors of inequality circumstances and legitimate factors of inequality effort circumstances are factors exogenous to the person including age access to health care and childhood ses while efforts are factors that can be influenced by the person including lifestyle factors such as smoking alcohol use and physical activity 3 policies of equalopportunity requires an understanding of how circumstance and effort contribute to observed inequality it is especially hard to identify factors of effort and how these are influenced by circumstance for instance it can be argued that smoking attributed to family background is a circumstance and hence an illegitimate factor of inequality 4 breast cancer is the leading cause of female cancer in europe is estimated to affect more than one in 10 women and accounts for 288 of female cancer 5 individual factors eg ethnicity family supplementary data supplementary data are available at eurpub online conflicts of interest none declared key points stroke prevalence has been shown to increase as ses decreases some studies suggest that this ses gradient flattens in old age accordingly we found marked variations of stroke prevalence across ses among the younger age group but none in the older however the ses gradient was steep and significant among older when considering stroke consequences ses needs to be taken into consideration when organizing postacute health and social care for older stroke patients

of the reference educational class age a year t to estimate rr ate we fitted a poisson regression model with the exposure as offset and the expected number of deaths by year age education class and calendar year as outcome variable eðda e t yþ ¼ expðy 0 xþ

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for barrientos et al promoting participation requires assuming that the goal of education is none other than to ensure that children develop the competencies established in the curriculum recognizing that respect for cultural diversity is essential for building an effective relationship with families contributing to the construction of educational conditions in which all people and groups can promote shared activities and valuing the contributions of external professionals and families these contributions can be a reference that allows us to know if the practices that are developed in classrooms are shared and are part of a collective identity and above all are oriented under the principles of equity and social justice however these principles do not make sense if they are not linked to the recognition of the value of differences and greater representation in social and school life theoretical framework the field of leadership has advanced by following several models in recent years instructional leadership has put the responsibility for school improvement on the shoulders of the principal distributed leadership emphasizes the role of teachers and those who take both a formal and informal role in creating change moral leadership calls on schools to be places of community and trust transformational leadership moves beyond management to make fundamental changes in people and organizations kouzes and posner helped to popularize burns concept of transformational leadership in the world business they defined a transformational leader as one who inspires a shared vision encourages collaboration and the creation of effective teams promotes high expectations and recognizes the work of the members of the organization this type of transformational leadership requires a higher level of interaction among the members of an organization da costa et al described transformational leadership as a result of increased motivation and commitment on the part of managers and professionals at the center they argue that it is necessary to enhance the participation of all and work together cornejo et al emphasize that it is fundamental to guide teams in a particular direction toward excellence and organizational learning they point out that strategic management communication delegation negotiation conflict resolution teamwork and the participation of families open new possibilities transformational leadership has had a major impact in business and education being a successful manager is no longer considered to be an adequate profile for a school director this change from static directives to negotiation and inspiration has opened the way to influence both leaders and followers to think in new ways and reflect on their own moral convictions while laudable transformational leadership falls short because it can be carried out without reference to conditions of social justice in the broader community for example a school director might inspire teachers to implement reading programs that give students greater levels of skill and help them reflect on their own moral behavior but there might still be no reference to the social conditions in which students live and the historical conditions that keep them in poverty for these reasons shields concept of transformative leadership goes wider because it includes a more critical perspective and equitable change in social conditions she argues that leadership requires moral courage and activism shields inspired a line of research that focuses on social justice dematthews et al studied a school leader mrs donna who established a school in mexico along the border with the usa she exhibited transformative leader practices which included leadership oriented toward the lived experiences of marginalized communities a connection of school lives to community lives commitment to a view of schooling that included more than academic achievement a priority of interaction with the community and most importantly for transformative leadership a challenge of dominant ideologies another school leader in northern california in the usa provided safety by protecting undocumented parents and students from the threat of deportation she was sensitive to the culture of the community she communicated regularly and had developed a critical consciousness the transformative practices reported by de matthews et al and crawford were related to the practices of culturally responsive school leadership described in a recent review of literature by khalifa et al culturally responsive school leadership included critical selfawareness culturally responsive curricula and teacher preparation an inclusive school environment and engagement with students and parents transformative leadership is perhaps best exemplified by santamarias concept of acl it includes aspects of transformational and transformative leadership in the context of social justice acl is defined by the following practices conducting critical conversations assuming a critical race theory lens building consensus addressing stereotype threat promoting academic discourse honoring all constituents leading by example and establishing trust acl served as a guiding theory for this study because the above practices resonated with transformative social justice leadership we were looking for attitudes and actions that represented these practices the transformative social justice leader would confront moral issues when necessary with critical conversations a critical race theory would be applicable in the usa where santamarias research was conducted but we looked more broadly for oppression of any group particularly those newly arrived in the country we were particularly alert for subtle threats to the identity of immigrants that would affect their achievement the leader would also have the skills of transformational leadership to build consensus of families and teachers promote academic discussion of the mission of the school honor all constituents lead by example and establish trust methods this study looked for signs of transformative social justice leadership by examining the views of school directors teachers and parents we chose two schools that were undergoing major demographic changes because of increased immigration into catalonia spain they were both classified as schools of maximum complexity because of their socioeconomic characteristics to determine the level of maximum complexity the following criteria are taken into account diversity of the school family background socioeconomic and educational level of families and academic results these schools receive a higher level of resources the schools were located in the cities of santa coloma de gramanet in the province of barcelona and in the city of lleida the two are located in the autonomous community of catalonia spain the schools were selected for their diverse migrant populations principals and teachers participated voluntarily and teachers recommended parents to be interviewed the santa coloma school is located in a lowermiddle class urban area it provides services to families in disadvantaged socioeconomic conditions there are three groups of preschool and six groups of primary school with 254 students and 20 teachers in total there are 12 different nationalities 10 of the students are native to spain and 90 are children of migrant families of these some were born in catalonia but did not have contact with the catalan language until they entered school students are predominantly of moroccan origin but there are also romanian indian pakistani bangladeshi chinese ecuadorian bolivian honduran dominican republican and nigerian students school two is located in the center of the city of lleida traditionally it was a school that served people of the neighborhood with a high economic and social level now it is a different school hardly recognizable due to the change it has undergone it provides services to families in disadvantaged socioeconomic conditions there are three groups in preschool and six in primary school with 235 students 22 teachers and three specialist teachers there is a psychologist from the psychological support team and a social worker who attends the school at specific times there is a turnover of between three and four teachers each year there is free lunch for all students who request it in total there are 46 different nationalities 8 of the students are native to spain and 92 are children of migrant families like the school described above some were born in catalonia but have not had contact with the catalan language and culture until they entered school the students are mainly of senegalese cameroonian algerian or moroccan origin they also have students from south america the school also is classified as of maximum complexity sample school one the principal has 20 years of teaching experience he has 12 years in management positions he previously served as head of studies and agreed to serve because the former principal became ill and retired from school the teacher has 15 years of teaching experience he has worked in several schools teaching first second fifth and sixth grades currently he teaches first grade the mother is a woman who is 33 years old she is a single parent who lives with her son she is from morocco and moved to spain 20 years ago her son is 7 years old and was born in barcelona after several changes of address they have lived in santa coloma for 6 years her son is in precarious health and has had difficulty in behavior at school he has attended the school for the last 4 years he currently attends second grade of primary school school two the principal has 25 years of teaching experience she has 10 years in the center four of them as director she has experience in instructional management and was appointed by the inspector the teacher has 30 years of teaching experience he has spent 9 years at the school and is currently head of studies a position he has held for the last 4 years the mother is a woman who is 39 years old she has two children of school age she is from romania and has been living in lleida for 15 years she is unemployed and receives family help each month from the government her husband works in a fruit company the oldest of her children is in secondary school and the second is in fifth grade research design with this sample we carried out an exploratory case study that is an examination of preliminary issues of social justice leadership that are just beginning to be defined the results were intended to achieve greater clarification rather than to lead to conclusions it was characterized by the search for understanding social justice from the point of view of the participants through the systematic analysis of their narratives the methods used in this study are similar to those of theoharis who studied principals in the usa who showed commitment to social justice the research questions were how were the beliefs of school leaders related to transformative social justice and how were the actions of school leaders related to transformative social justice an indepth interview was used we wanted to know the background and the reasons why the participants were interested in issues related to social justice the interviews were transcribed and sent to the informants so they could validate the content we used the constant comparative method of coffey and atkinson two researchers read each transcript twice and developed an initial list of codes they compared the codes and agreed upon a common list of 20 codes then they applied the codes to each transcript and compared their results this coding process led to themes related to each of the research questions for the beliefs of the leaders the themes were the needs of families migration of students student needs and the principle of treating students fairly for the actions of leaders the themes were teacher learning relations with the community and social cohesion results in this section we present the beliefs and practices of these two schools that serve as a basis for identifying elements related to transformative social justice and acl they are organized according to each of the research questions how were the beliefs of school leaders related to transformative social justice we wanted to know how people we interviewed gave meaning to social justice we were interested in knowing their reasons and what motivated them to continue this pursuit the following participants wanted to honor all constituents of the school particularly families who had recently migrated to spain and their children who needed personal attention as well as students with physical handicaps or autism needs of families principal montse expressed interest by looking at the context and needs of families my interest in social justice was much more awakened when i took over the leadership i think ive always had sensitivity for others in this school what drives you is the need you are in a neighborhood of people who have many social needs the vast majority of students as you know are in a precarious social context they are not native families they come from many countries especially from north africa latin america and above all china this neighborhood contains the largest chinese community in catalonia migration principal albas reasons stemmed from the change brought about by migration she noted that the students uncertainty and lack of adaptation to their new environment made her aware of being involved in a new project i would say that what made me change was the attitude of the children when i arrived at this school children had symptoms of sadness you never saw them smile they were never happy and they were a little suspicious of the attitude of the teachers instead they are much closer now always looking for your support your love student needs teachers sergi and lluís were aware of the context they worked directly with students who needed personalized attention and the effort they made to get ahead made them realize that it was essential to provide adequate attention to students and their families a couple of experiences that caused me great impact arose with disabled children the first experience was with a girl who despite having undergone several operations to be able to speak and only be able to use two fingers of each hand tried to be like others and do exactly the same as they did despite her disability the second experience came from an autistic student who overcame his physical barriers to achieve an outofschool success both experiences made me see that despite the limitations that one may have if he strives he can achieve many of the things that are proposed these experiences made both teacher sergi and teacher lluís realize how important it is to work under the principles of equity and social justice fair treatment of students honoring all constituents was also expressed in terms of fairness parents and teachers felt that all students should be treated the same parent fatija acknowledged that the performance of faculty showed fair and equitable treatment for all students at school they treat all children and families equally i have not seen that they treat one or the other differently regardless of origin parent nicole pointed out that the treatment had been very fair and had met what she expected from the school and its teachers she believed that you should treat people well no matter whether they are foreign or fat or whatever they should not be treated badly they are all the same these ideas are confirmed by the opinion of principal montse in school for sure we have inequalities because students come from different cultures here there are no differences because they do not consider them so for they are all from here children feel this more than their parents most of these children do not want to go back to their country the parents do these children do not conceive of differences in any way indeed we do not demonstrate them or emphasize them on the contrary we always use cultural differences to integrate in all cases they emphasized their belief that it is important to attend to students in the same way recognizing that change of context is very difficult and that children require special attention has allowed teachers and managers to ensure equitable treatment a concept that mothers point out with the expressions such as all are equal or treat all children and families alike sense of responsibility and action the experience of teachers has led to the need to assume more responsibility for their work ensuring that all students are able to study and have the necessary resources is to ensure equal opportunities for all children in school principal alba described her approach to education in the following words i believe that the basic thing is to act every day every moment every minute to act with justice and not only at a certain time in a special circumstance but every minute it has to be a foundational job working and trying to make everyone happy everyone has a pencil or an eraser parent fatija agreed with this idea i think the materials are different they worry about the children having all the materials pencils notebooks in other schools that i know they do not worry so much we pay 60 euros a year for all the materials and the child needs thats very good in other schools they pay 200 or more in both schools there were critical conversations among teachers to challenge their own practices and find new ways of doing things there was an explicit identification of the need to challenge traditional practices and begin to do things differently the needs of families motivated teachers to orient their work under just principles when they first arrived the directors confronted teachers with the need to change the need to do things differently was never seen by the two directors as overwhelming but rather as a challenge and an opportunity when i arrived the teachers did not assume that there would be a new reality they did not want to see change and their lack of understanding of these children was the first things that caught my eye confronting new challenges was also mentioned by teacher sergi and parent fatija it coincided with a new management team arrival and they began to act in another way with affection with attention with service and the teachers began to realize that many more things were gained from this at school they have information about the child that is communicated from the social worker from the cap the hospital they know everything they quickly know everything that happens to them yes they communicate quickly between them the directors described the difficulties that the teachers faced has been hard since many teachers did not understand the changes we were experiencing we went through many things for example difficulties like students who arrived without books students who came without the minimum qualifications who had not eaten who did not bring basic school material such as a case a pencil an eraser there were some teachers who resisted and did not understand when teachers were confronted they felt uncomfortable in their attempt to address the needs of a new immigrant population and in that time what i observed was a great discomfort on the part of the teaching staff because just as the population began to change until then there had been an immigrant population immigrant but migrated from other parts of spain these were people who had been here for some years and were already quite adapted working people people within a normal area of the outskirts of barcelona the foreign population was just beginning to arrive in large numbers of course nothing like the present the assessments of the two directors were not unfounded because in fact there were uncertainties in the teaching staff they were facing a reality that they had never lived and for which they were not prepared evans concluded that educational leaders have a social and moral obligation to confront inequitable practices and create more equitable processes and outcomes for students of different racial socioeconomic gender and cultural groups palacín states that teachers invest all their energies in order to work coherently and effectively in such a complex context but the working methodologies that they usually use are not always effective in the new reality in our study these ideas about the back and forth struggle to confront inequities were confirmed the teachers and the directors despite the changes experienced have been concerned with promoting new actions and trying to change the institutional culture and promote new projects the two cases that we present coincide with browns and hafners who suggest that leaders for social justice help students overcome school failure by helping them to make decisions and to implement actions to improve their own achievement this is a process of deconstruction and reconstruction which could also be understood as reflective practice that is akin to santamarias practice of building consensus from their experience of a critical situation experienced in the school teachers have been able to overcome fears and uncertainties and to rebuild a new educational project that benefited students by giving attention and honoring families and including them as the focus how were the actions of school leaders related to transformative social justice the analysis of the professional practices of teachers and managers showed the relationships established with students and their families changes in context challenged teachers to broaden their professional practice to adopt other principles in teaching the faculty developed consensus about what needed to be done through promotion of academic discourse promotion of academic discourse zaretsky raises some concerns about the absence of practical guidance for school leaders and santamaria adds the need for academic discourse as a foundation for practical guidance our study coincides with these authors because teachers in both schools recognized that they did not have the tools to meet the needs of children teacher sergi said the main obstacle that i saw was the vision of the teaching staff they did not know how to act principal montse said the first thing we did was to get two years of training in emotional education because many students arrived with many problems that they did not understand why they had been uprooted from their natural environment and entered a school in a country they did not know in a society that they did not know and usually with parents who were both working and those children were immersed in a different world and that caused many of them to have emotional problems which were then reflected naturally in the day to day life of the school at the first meetings in september we always explain the attitude that the teacher has to take trust with the community barrientos et al point out that school management must base its functions in two relevant dimensions on the one hand manage all areas of institutional activity focusing on students and on the other hand promote a culture of participation with families and the community this participation had trust as its foundation this idea emerged clearly from the results of our study i also connect social justice with the participation of citizens and decisionmaking it is fundamental there is no social justice if there is no active participation and communication of people the family has an important role to play without the support and involvement of parents the student will probably not succeed our priority now is the families we want them to become support for the institution we have to focus on the emotional side of the student and his family we do not want parents to only come forward when there are complaints or difficult situations but feel part of the institution we need to make links with parents parent fatija and parent nicole mentioned how the principals led by example and established trust by reaching out to parents the principal always greets you even if you do not have an appointment you go without a date and they always take care of you you have to wait a little while but you enter and listen mothers who do not understand what the teachers and the director tell them received explanation many times little by little especially the chinese emphasis on social cohesion the educational administration of catalonia considers social cohesion to be a policy priority several schools have incorporated it as a priority of their educational project social cohesion means establishing trust among all groups action in this direction is expected to reduce social inequalities widespread vulnerability and social exclusion in terms of social cohesion we realized that we needed to do a very important job with families and we got families involved more with all the artistic activities because we knew that if families were involved with the school they were getting involved with society they left their familiar social surroundings and integrated into a much more mixed much more varied environment which was the environment offered by the school all this also coincided with the fact that most of the parents remained unemployed support for families has resulted in lunch grants and specific grants or savings in the purchase of books through socialization if you have to pay something to go on an excursion they allow us to pay it little by little so that the child does not stay home without a trip for the last three or four years we have had used books and that helps us a lot communication is a key to trust and it becomes particularly challenging when working with people of multiple languages in some cases the schools receive help to strengthen communication incorporating families into school life is not easy language is an aspect that can generate difficulties to avoid them schools have translators another of the things we get is to have a chineselanguage translator to do interviews with chinese families that was very important its still important now but now we do not have the money to pay it despite insisting on the importance of school education many parents because of their particular situation have not tightened the link with the school and that translates into little support for activities discussion the social justice leaders in this study were motivated by seeing the needs of migrant families and students with special needs programs for parents and interaction with them were judged in terms of social cohesion they exhibited many of the practices of acl they confronted structural and pedagogical issues related to serving a new immigrant population they promoted academic discourse and worked to build consensus on a direction for their schools they honored all constituents through the establishment of trust they believed that students should be given the same opportunities and all should be treated fairly the principals wanted to guide teachers to see their work in new ways and develop practices to address the needs of a changing student population however the directors teachers and parents in this study did not develop a critical perspective they expressed their commitment to improve the lot of their students through an education that would meet their needs they did not attempt to educate students about the broader reasons that caused families to flee from their homeland they advocated for more resources but did not question the system that gave them less in the first place they reached out to involve parents but they did not provide opportunities to raise their consciousness and act politically our research questions reflect the strength of these schools to accommodate a new immigrant population as well as the limitation of helping them only to adjust to their place in society how do social justice leaders make sense of social justice shields conception of transformative leadership and santamarías acl come from studies of socially just leaders critical leadership argues that people should engage in frank conversations and analyze differences the principals and teachers in this study were committed to improving the lives of students they took action and they achieved some degree of academic success because first they cared for their students and in the end we have raised the academic level of this school and we are very happy and we have received many congratulations because they begin to notice that we are at the same level of other schools of catalonia we know it because the tests of competences have shown us that we have gradually been putting ourselves on the same level but of course we have had offer care first it is a word that would not have to be used in school but here is primordial performance is only understood if it is accompanied by affection and understanding what do social justice leaders do in school teachers and principals interested in social justice adopt practices that have been widely described in leadership literature as transformational such as building trust and challenging the process the principals and teachers in this study exhibited these practices the development of social justice leadership and advocacy may occur in stages at first teachers were stunned by the changing world conditions that brought large numbers of immigrants to their classrooms some resisted and wanted to return to the past in a stage of reaction then they began to accept the new conditions but were unsure of what to do they had entered a stage of inaction the next step was to advocate for children and families and seek out resources in a stage of action they took small steps and began to wonder if they were making progress and if their efforts were making a difference this was the stage of evaluation they did not achieve the last stage which would be to reflect on the connection between their daytoday problems in the school and the larger social system this is the stage of reflection to develop a critical perspective conclusions in this paper we have provided an account of the relationship with social justice of a group of people from two schools in catalonia it adds to those developed in other contexts the teachers parents and principals in this study were motivated by beliefs about the needs of families concerns about increased migration of people to spain individual student needs and a commitment to the general principal of fairness this sense of responsibility led to action teachers assumed more responsibility for their own teaching and wanted to make sure that students had the resources that they needed they were at times confused and uncertain when faced with challenges of a new student population and they longed for greater preparation despite their doubts they tried new projects and began to change the institutional culture the themes of these projects were academic discourse to determine how to accommodate immigrant students outreach to the community and promotion of social cohesion we recommend the alignment of social justice with the improvement of the school the training of teachers and managers to face the new challenges arising from the new social composition and the analysis of implications for management to move towards the goals of social justice in catalonia paying attention to professional practices has allowed us to investigate how leaders take action and position themselves in relation to families and social justice issues the results show that if one is interested in achieving social justice good institutional management is essential it is difficult to imagine a successful school that does not consider all the people involved in the educational task the management team must take the lead to promote energize and support all processes aimed at promoting social justice the priority is to exercise transformative social justice leadership that includes critical leadership that is sustainable over time with this background we are convinced that public schools are the first and most important social institutions that can help make social justice possible they are organizations that provide a universal service sustained and extended over time a service that is common for all citizens without exception practically from the first months of life until the end of compulsory schooling usually at 16 years schools therefore are challenged to help ensure that all students without exception have the same opportunities to develop their competencies especially those who are in personal and family situations more precarious and at risk of falling into social exclusion in this context it is not enough for a leader to promote equity within the school and treat students equally rather there are obligations to address the marginalization of students resulting from injustices in society to address them in all areas and to require a greater level of interaction among all constituents declaration of conflicting interests the authors declared no potential conflicts of interest with respect to the research authorship andor publication of this article author biographies patricia silva is lecturer at the department of pedagogy and psychology faculty of education psychology and social work university of lleida spain email she is a member of the consolidated research group edoudl and she is an author of scientific papers related to school organization and management and online teaching she is an instructor in subjects related to management and teacher training she was honored with the jaume vicens vives

this study investigated social justice from the point of view of school directors teachers and parents we chose two schools that were undergoing major demographic changes because of increased immigration into catalonia spain they were both classified as schools of maximum complexity because of their socioeconomic characteristics the research questions focused on how directors teachers and parents give meaning to social justice and what actions they take to achieve it teachers and principals adopted practices that have been described in leadership literature as transformational such as building trust and challenging the process they only occasionally showed transformative practices like those described by santamaria 2014 as applied critical leadership acl they were motivated by seeing the needs of migrant families and students with special needs they seriously considered social cohesion and believed that all students should be given the same opportunities and treated fairly while these principals wanted to guide teachers to see their work in new ways and develop practices to address the needs of a changing student population they did not reflect on the connection between daytoday problems and the larger social system this critical perspective is essential to acl

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introduction this paper brings the issue of community engagement in design to the fore by looking at how technology designers work with communitybased partners going beyond simple definitions of participation to regard such production as social structure meeting shared process understanding motivation is key to cooperation especially when working with groups that adhere through interest rather than formal organization 15 so we ask how to inspire motivation and encourage plural ownership of our projects hirsch 12 suggests technology practitioners and scholars alike rarely reflect on what is intended when the word community is used despite making decisions based on beliefs about the communities they and their users inhabit but once the idea of community is invoked social and relational factors are surely paramount for the difference between working with individuals and with the diverse tiers of society that make community must be one of engaging with existing social structures and interwoven motivations nonetheless researchers who go into the field are criticized for arriving investigating and leaving without care for the impact of intervention 4 cases of research fatigue and resistance to participation are growing 4 a danger with extractive research where experts visit a community do their study and take away data to write up is that the study subjects feel treated as instruments of the research not people with agendas of their own and value to their time instrumental use of communities against their interests is noted in clark 4 as a factor in research fatigue our discussion of the dynamics of ownership is in part then a means to look at practical and ethical matters that arise in working effectively with communities to develop technology and its uses it is also a way to consider judgment and what it means to give responsibility to others for a shared outcome inspired by goodman et als 9 work on professional judgment in interaction design practice and rogers call to show how theoretical concepts can be utilized in practice 20 we explore how ownership can impact during designing our first example concerns a university research team commissioned by architects and a swedish municipality to collaborate to make innovative use of media technologies for public display to enhance the municipal environment and thus community wellbeing 13 the architects and municipality operate in formal stable structures supporting community in its most abstracted sense in the second example we turn to the grassroots and look at practices where small groups with informal and evolving structures form partnerships with researchers to look at how learning takes place in situations where there is little reflection and much makingdo at this end of the scale relations are not predefined and little process exists to deal with civil society as lived in a tier between state and individual households the two projects thus differ with regard to scale focus and type of participant in one experienced professionals collaborate harmoniously on media facades in the other community volunteers confront professionals in the production of internet radio programs both contexts foreground complex shifts of responsibility background and related work the authors habitually use participatory design approaches in their work 17 in other words it is not enough that beneficiaries are part of the process the process must enable them to take action and influence the design this in turn implies and requires that they feel some motivation 15 however we can go further and ask what if the researcher is the invited participant what if the power lies sometimes with the community sometimes the researcher and the action is not principally initiated by one party who can be said to lead participatory design then we regard this issue from two directions writing here about a brief given and one taken and the play of initiative that follows ownership we understand ownership here as having an agentic stake in the process and outcomes of a multipartner project this kind of ownership describes relations where an individual or group feels a thing is mineours linked to matters of meaningfulness identity responsibility and control and extending to immaterial entities such as ideas words and artistic creations pierce et al 18 give a summary of research into attachment and the growth of these feelings noting the topic interests anthropologists geographers historians philosophers artists animal and consumer behaviorists and social psychologists yet little attention has been paid to it in the technology design process it is assumed to sit with whoever is responsible for commissioning and briefing as pierce et al define it 18 this form of ownership a is grounded in motivation to be efficacious in relation to ones environment b helps people come to define themselves express their selfidentity to others and maintain the continuity of the self across time and c emerges from the need to have a place their research proposes three major experiences through which it emerges controlling the ownership target coming to know the target intimately and investing the self into the target noting that people come to find themselves psychologically tied to things as a result of active participation or association with those things 18 while we cannot consider pierce et al 18 exhaustively here we note that pierce et al 19 relate these findings to work contexts and find psychological ownership of ones job to be mediated by the experience of control studied in the contexts of technology autonomy and decisionmaking in development studies ownership is a key research topic identified as a major determinant of whether a project will succeed and change take place locally for instance world bank guidance on capacity development 21 is devoted to fostering stakeholder ownership stating it to be essential and noting several major crosscountry studies provide evidence supporting the development community consensus that stakeholder ownership is critical to the success of development programs here ownership involves the ability and willingness of beneficiaries and also other actors inside and outside government to express and facilitate demand so as to influence achievement of the development goal donais 7 regarding local ownership draws a distinction between a strong and a weak sense the strong version implying that recipients drive the process while the weak is convincing or cajoling local actors to accept the wisdom and utility of what remain externally defined policy prescriptions namely to do what is advised but to do so voluntarily within design research bratteteig and wagner 1 look at power and decisionmaking in a participatory project observing the factors mediating control and reflecting how implemented decisions lessen the room for negotiation the power to allocate resources may rest in the project leader but it is driven by research commitments and the fact that some solutions have already been made material hence irreversible from this perspective prototyping becomes a decisionmaking process that closes the design space here we can note the high authority of a research question and how material considerations bring a temporal aspect once a thing is made it becomes a fixed aspect now acting as a constraint and resource to inform decisions this manipulation of material also points to the importance of knowledge judgment and competence 9 we note too that allowing people autonomy to develop and use their expertise emerges as a critical component in pierce et als analysis of what encourages ownership how might such concepts so important in development contexts allow us to explore our relations in designing technology with communities here we start this enquiry by offering an account of our work in two contrasting projects two studies of engagement are presented here as author narratives stressing chronology so that we are able to consider ownership as fluid in the following discussion we review four dynamics that seem particularly pertinent to these projects what motivates ownership how ownership transitions structures to support ownership and what facilitates efficacy among participants in doing so we relate design research to development research in considering the value of a body of knowledge about how to create meaningful intervention in others lives the odenplan project the odenplan project is an effort to realize an interactive led media façade integrated into a projected metro station in stockholm sweden the project is currently in the planning stages several suggestions for potential designs have been submitted by the research team to the architect collaborators the partners involved at this stage are cavi the architectural firm 3xn the city architect of stockholm and the municipality of stockholm representing the citizens of stockholm along with visitors and other potential users who influence appropriation of the metro station it is not a direct collaboration with anticipated users cavi currently only collaborate directly with 3xn who are responsible for negotiations with the municipality who answer to the citizens as voters and as users of the metro we give an author account here of how this responsibility was delegated in doing so we go into the main junctures where decisions were made and negotiations took place as experienced by the designerresearchers at cavi the initial contact with 3xn in spring 2008 aarhus university launched a new center to conduct research into forms of living reflecting the societal and technological development of the experience economy the center encompassed many kinds of partnership using a researchbased userdriven innovation explorative casebased activity model one of these partnerships was developed with 3xn who was interested in working on advanced projection technologies however the actual odenplan project did not take off for several years starting the odenplan project the work we report on here was conducted in 2012 the break between initial contact and project start can be attributed to the long process of negotiation between 3xn and the stockholm municipality and city architect as 3xn submitted a proposal and won the privilege to design the metro station of odenplan as such when we started on the project 3xn stockholm municipality and city architect had already agreed on both some fixed conditions and some more flexible ones and negotiations were already mature we kicked off our part of the project by meeting 3xn who briefed us on the specifics of the building they came to the meeting with an agreement with the other partners already in place 3xn were representatives for the municipality of stockholm who had accepted their architectural proposal and were open to considering using the building as a media façade but the municipality had left the task of suggesting what form this could take to 3xn thus 3xn came to us with permission to take ownership of the details of the building and the ensuing design aspects of this were then offered to us as designers through a verbal briefing and some design materials we were told that the shape and materials of the building as well as the placement budgets and such were already agreed meaning that there was no flexibility granted us to change these factors other partners controlled these parts of the project since the building was located in sweden there were specific legal requirements for indoor lighting and similar issues which none of us controlled further constraining aspects of the building thus the option for us to take ownership for creating façade designs came with conditions already in place as part of good practice these were made clear to us at outset manifesting constraints and opportunities at the meeting we were presented with a physical scale model of the odenplan building as well as examples of the materials that the building would be made from in this way 3xn on behalf of the other collaborators transferred ownership to us in the form of written verbal and physical accounts of the project 3xn stated their desire to use lighting to shape the space we considered this statement as a sort of flexible demand from them it was stated as a desire but was clearly at least at that point up for negotiation this indicated to us that 3xn respected our ability to make design judgments we did not need to demand some scope they knew that we needed some leeway in order to user our professional competence and create the best work possible however we liked the idea of using leds and agreed to do this similarly it was left to us to determine what the exact experience and usage of the leds should entail meaning that we now had ownership of the nature of the interaction which was a key interest for us and thus a motivation to be involved in conclusion the initial meeting left us with ownership of specific parts of the projected building leaving it equally clear that other parts lay in the hands of others before parting we knew that we had to design for the front of the building using leds and somehow use lighting to shape the space thus the façade was handed over to us to work on while the architects handled the building itself through reflection we can observe that at this meeting we and 3xn had common ownership of the façade and collaboratively drove the process forward this highlighted the value of a good grasp of the dynamics shared well collaborators are able to align their efforts within a project drawing on their individual strengths by accepting one part of a project through agreement a stakeholder in the project can have a relatively free hand to develop for this part while still ensuring that the ideas fit the overall strategy for the rest before the meeting we had indirect ownership of the project we were recognized as partners but had no direct influence over anything after the meeting we were excited to feel a stake in the work meeting and designing locally after agreeing on the details of our role in the project with 3xn it was up to us as designerresearchers to take initiative to move the interactive lighting part of the project forward we did this through a series of design workshops where we played with lighting to shape the space these workshops were conducted without reference to partners apart from sporadic coordination with 3xn underlining that while we ran this design process we still respected that 3xn was the source of wider authority and we thus could benefit from aligning our work with them during this period we generated ideas by working with the 3d model that 3xn had given us having transformed it ourselves for use in unity3d so that we were able to work with the model façade in our 3d cinema the 3d model acted as a mediating artifact transferring ownership to us while still enabling 3xn to have some control over our ideation process the 3d model albeit transformed acted as a constant reminder of the agreement we had made to develop ideas that followed the shape of the building as well as to work using lighting to shape the space furthermore as the shape of the building was itself the result of negotiation between 3xn and the other project partners they too had indirect influence on our work in this phase in that light the handing over of this 3d model to us was a sign of trust which inspired our sense of ownershipothers outside the project did not have our access and could not have done the same work that we did by having access to the resources of the other partners by giving out their resources the others recognized us as partners respecting our knowledge and competence we did not generate any fullblown ideas in this phaserather we tried out alternatives by discussing technologies we had experienced using including sensors and camera tracking we worked to connect our wider research interests with the parts of the project we had responsibility for this can be seen as our way of navigating the design space set up collaboratively and finding our own pleasure in doing the work we wanted to create a solution with which we felt comfortable as researchers and designers for instance we have previously focused on emergent behavior in public space 2 so this became one of our focal areas by the end of these sessions we had transformed the design space the initial desire to use lighting had evolved into a more specific understanding comprising four key themes we wanted to explore emergent behavior public space optical illusions and persistence while we felt ownership of this part of the project we still considered our themes flexible since we had not returned to 3xn for approval main ideation workshop close to the end of the current project iteration we had our pivotal ideation workshop discussed in 13 we used the 3d model provided by 3xn in our 3d cinema to sketch out different design concepts our four key themes could be said to inhabit the design space intersecting our research interests and our design ideas based on these we generated ten ideas that all in one way or another adhered to our partners desire to use led lighting to shape the space of the projected building as such we enacted our ownership of this part of the process working in the design space we had ourselves formulated in the previous phase with each idea being an interpretation of possibilities in the design space our ten concepts acted as interpretations and translations of what we could do again we still considered these ideas to be flexible in that they were interpretations of the brief to be presented to 3xn for further development then presentation to the municipality and city architect concept videos for the architects as the last part of this phase we selected three design ideas to realize as virtual video prototypes 11 showcasing the different concepts these concepts were selected for several reasons first we considered them to be representative of the possibilities of the odenplan façade as a platform for social interaction in public space second the technical implementation of these ideas would enable us to realize easily the rest of our ideas and last but most interesting here they were easy to communicate and had discernible qualities we knew would sit well with 3xn we found the partners roles reversing as we contemplated another transition we used our control at this point as well as respect for 3xns knowledge and competence to create a set of design materials that would work well when responsibility for the façade elements was transferred back to 3xn we tailored our work with the virtual video prototypes to ensure that our views would be represented loyally onwards in the process all of the three design concepts interested us as designers and as researchers and thus our selection was both for pragmatic and political reasons this meant that when the proposals were discussed by 3xn and the stockholm municipality and city architect we could feel confident our own research interests would still be represented enabling us some degree of control over the proceedings of this part of the process in the same way that giving us a constrained design space at outset enabled 3xn to ensure that our work would be valuable to them we were able to reciprocate at the end of this phase again a transfer of artifacts captured the interests of the partners and made them material however whereas the 3d model we received showed nonnegotiable elements the videos represented our suggestions constrained but not final the carm project we now turn to look at the issue of ownership from the side of those setting the brief in a small british ahrcfunded project under their connected communities program community groups were invited to participate and one success criterion would be the extent to which ownership devolved away from the academic research team the author account this time comes from the project initiators the carm project asked how communities might use podcasts and community internet radio to reflect on their own and others achievements and learn from each other set in the context of the uk governments intentions to devolve social care and community affairs to the third and voluntary sectors we sought to address how knowledge might be made and shared using new forms of media to compensate for the shift from a centralized administrative network to a less integrated grassroots approach although networks and their power to connect have been observed as an outcome of the information age analysis has centered on new communities of interest gathering across space and how this changes relations between individuals or at a broad political level there is less research exploring impact on communities negotiating physicallylocated services such as care environment and cultural heritage though light et al 14 looks at how to turn social media back to the local context and gilchrist 8 addresses networks of groups at community level and use of media carm raised questions of learning across different communitybased organizations as people come together locally a further research goal was to explore how locals might work with community radio stations as a vehicle for sharing insights british community radio only started formally in 2004 most stations are internetonly run by volunteers and serve a very small catchment area little programming is produced ahead and then aired shows are live talk andor music some of these shows are then podcast and offered on the stations website participating groups partnered with a local station who committed to play the research output in their schedule and then offer the program as a podcast this context partly defined what was useful to produce requiring local interest enduring relevance and brevity process to investigate the potential of making media together three community leaders we were acquainted with each agreed to introduce the idea of participation to a group that might be receptive in a oneyear study they were given funds to make a program and commission any support they needed with a simple brief make at least one 15min program and capture the groups purpose and achievements beyond interviews about individuals and their interests guidance was given on how to reach consensus about the content and a deadline was agreed by which time each program would be ready for others to listen to the first test then was whether any programs would be made for several months three community groups in different parts of england worked on their themes reflecting on their group and its value all chose to recruit external support to record and edit their programs despite the offer of media training no group wished to make their program alone and the subsequent degree of editorial control varied the final outputs were as follows 1 a craft group of older people spoke about the different crafts they follow how their fathers were a major influence on them in pursuing craft and the social and emotional support that the group offers them 2 two groups of museum volunteers interested in the oral history of their villages came together to share practices of testimony collection and develop a project capturing and comparing their high streets through sound 3 a newlyformed womens group talked together about the experience of being mothers and daughters using drama methods to raise sensitive issues and discuss what cohered the group as people shared their feelings at deadline there was at least one program per group at special listening events the groups heard their own work among that of the two other groups and by the end of the project they had also been heard by an advisory group of hyperlocal media experts and groups with similar pursuits outside the study at each event group discussions were initiated after each piece and chance for some solo reflection to gain feedback on making them andor hearing them in groups this did not resemble normal listening but raised the possibility of new forms of listening together as groups it also gathered responses from interested parties of three kinds media specialists those who had been through the process and people we might expect to find the content interesting summary feedback was given each group the programs were reedited broadcast on radio and stored as podcasts thus the material became public raising issues of group authorship identity control voice and authority which we can only touch upon here this speedy introduction conceals many negotiations our formal outcome was insight into the potential that groups have to learn about themselves and others in the reflective practice of mediamaking introducing a new structure of program and some guidance about what was found to work to achieve this outcome ownership of the process went through several transitions in all cases the most interesting tensions arose between group leaders and media production specialists and we focus on just one of these relationships to examine wider issues of constraint and control and how meaningfulness identity responsibility and efficacy related to ownership in the project especially as regards outputs negotiating ownership in the womens group the womens group organizer sue was invited to join the project having participated in a previous community coresearch study she is a drama worker with access to many suitable groups at the launch meeting sue asked whether she might set up a new group for this work explaining an unmet intention to launch a womens group we asked her in turn whether she was confident she could meet the program brief and the deadline which were nonnegotiable criteria we were able to align her existing agenda and interests with those of the project and she took over the brief and most of the decisionmaking for many weeks the academic team had no more responsibility for shaping outcomes although we did visit to learn how things were developing sue invited a number of women to join her and put out a call for others she worked to form the group using the radio project to focus participation though keeping this distinct from the wider group goal to share womens issues people could attend without being part of the broadcast all organizers found that while some participants wanted to make a broadcast others were nervous and reluctant to be recorded in sues group the discussions had potential to be highly personal and this added to peoples unease but it also helped to illustrate the journey ahead the group would work best if people were open with each other and made each other feel comfortable participants were shown that the group was theirs the topics chosen and discussed were theirs and that they had control of their comfort and consequently a share in that of others sues facilitation of the group and elicitation of common themes brought and kept together a disparate group of women a few with their daughters some women came and went however a frank and collaborative culture quickly established itself and as the interest in the topics being discussed grew so concern about being broadcast lessened until everyone who attended regularly felt part of both the discussions and the making of the program about them sue recorded details of what was covered in the sessions as notes on a scroll of wallpaper no audio was used until the group had been meeting for months meantime the group agreed how they wanted to proceed they unanimously felt that they wanted a woman to work with them and equally that they had no interest in the mechanics of making the program but they were also clear that they wanted control of the content after checking with the research team sue invited a local radio producer to make recordings and edit them into the groups program she also consulted her chosen community radio station about any constraints who gave her a blank canvas ie permission to experiment since the researchers had also adopted a handsoff role this left design and production to the group indeed the research was to see what value it acquired for the group if any and intervention would not be helpful either to how the group viewed its role or to the analysis possible but when the radio producer began her work the academic lead on the project was invited back into the process because of conflict between the producer and the group whose project is it anyway tensions arose shortly before the deadline the extracts below come from emails between sue and the academic team as sue directs the radio producer to edit the material she has gathered in the way that the group has chosen by and the group also warms to it sues report of the listening event the women were so so proud as was i and felt that the piece really did reflect the group one woman described the difference between the first edit and this one as transformative the final piece was played to various audiences with a mixed response at one end it elicited empathic emotion in presenting women talking together about family relations and inspired others to want to do likewise at the other there was tightlipped dismissal as too intimate and vulgar it was felt not to be a subject for people to share let alone record sharing interestingly the hyperlocal media experts were able to pinpoint the tensions in its production in their reviewing they note a lack of clarity about what happened at group meetings while applauding the energy fun frankness and group spirit they could hear that it had been recorded with a different idea in mind if we relate what happened here to experiences in the other two groups we see a pattern radio producers who brought familiar genres to bear found themselves being directed away from their ideas with more or less success towards expression of group identity in each genre expectations hampered the making of an enduring group piece to share and learn from leading to power struggles we conclude that a new subgenre is needed if groups are to be able to express and share their community identity since the work is not timely or about individual or family stories it points to the need for technicalcreative support that is sympathetic to the endeavor given that there seemed value in attempting it analysis of ownership tensions and transitions our theme is ownership and we can see that many aspects of it meet in these tensions about editorial control if we now look more closely as the play of ownership in the account above we see the dynamics have significance both in how we executed the research project and in what we learnt from it not least about communities and media meaningfulness in the initiation of the project we see briefsetting where the constraints are spelled out length of program need to involvereflect group deadline budget but as with the odenplan project there is also room for the local team to appropriate it this is made clear sue has the discretion to choose the group she is given a budget to organize the programmaking and bring in whoever is needed to support this based on her judgment and the response of the group and sue takes this latitude and makes it fit her agenda and sense of rightness she carries the constraints and opportunities of the project to a set of people she can see as benefiting from a chance to reflect on their lives but simultaneously she is able to make the task meaningful for her life and work too identity sue uses the project to build a group she already wants to establish as a group it will have its own identity distinct from a series of individuals as a new group this nascent identity is still being determined but reflection becomes central both in the radio project and in the groupmaking project running alongside questions about who owns the radio project are then questions about who owns the group sue knows this and defines it enough for others to join but leaves space for appropriation members contributions are crucial not only in attending and following sues lead but in shaping goals and setting a tone for the reflective work light et al 16 note the semi arbitrary nature of codesign where the group determines the themeproblem and this then determines the group we saw this process here sues group defines itself through practices of discussion improvisation theme setting and recording insights on the wallpaper scroll at this point the research intention of making a reflective program becomes adopted locally the group is now making a program to express itself and has invested self into the target 18 a group is looking to sue to manage the process of group representation media are very interesting in this respect since representation and ownership are highly linked in pierce et als definition ownership helps people define themselves express selfidentity to others and maintain the continuity of the self across time 18 media record us in the act of definition and expression allowing us moreless interpretation over it depending on who edits the version that others see so once the group has adopted the program as theirs ownership of the process and of what is expressed are tied together in sues negotiations with the producer ownership of the programpodcast is seen in the emails the women were so so proud… we also see it in sues response to the research team stepping in thank you for your support in articulating what we need where we refers to her indignant group the group has seen the value of working out what members would and wouldnt say publicly about their lives and requires control this is now a very different issue from the participation politics of who runs the project in terms of idealized democratic principles relating producers to users it has become an issue of how the project overall deals with power and representation responsibility throughout sue takes responsibility we see in her emails that she has become accountable to two parties the research team and group eg when i told her what i needed and wanted holding ultimate responsibility the research team decides to prioritize the concerns of the group about representation over keeping out of the action efficacy and control why has a struggle arisen the producer introduces a contrasting set of editorial values launching this battle for control of representation we hear this in the reported comment whos going to listen to that sue is shocked but the rudeness also shows the producers dismay the group has not granted her any efficacy 18 by respecting her judgment she assumes she has ownership of her usual territory and misjudges the importance of the groups suggestions in fulfilling her brief but despite the warning that the output will not interest a national audience sue and group ignore her advice and push on with a different style to them she is commissioned to help make their community project a creative instrument not the owner of the content both sue and the producer find themselves puzzled by their lack of control sue turns to the academic team to resolve it the result is an enactment of power the research lead does not wish to assume direction but intervenes following sues invitation to support the organizer and resolve the issue before deadline sue and the lead collude to maintain sues control deferring to the ultimate authority of the research project using it to confront one professional authority with another the tone of the leads email is authoritative implying sues role is also only instrumental but this is employed to return control to her and the group the resumption of ownership is evident in sues email thank you for your support in articulating what we need sue is again efficacious as director as well as consummate manager and her ownership persists so we have evidence that sue and group took ownership and some idea of why it was possible clear boundaries for nonnegotiable elements explicit openness for flexible aspects that could be appropriated as a chance for local efficacy and identification and support to maintain it the requested output was defined enough to be absorbed into existing structures and aligned with others motivations but then defined no further although boundaries changed a little as we learnt more on the ground most academic intervention was to protect autonomy not to marshal it this is shown in how the radio producer was managed however this raises another domainrelated issue which is that communities seeking to make media by harnessing professional expertise need to choose their sources so that they receive support rather than control who has editorial control on matters of representation is not trivial the media industry is used to being the authority on broadcast even if genres are changing with new democratizing production processes and hyperlocal reporting this case study shows how much resistance may be needed to be listened to and as the media specialists on our peer review panel noted the product showed lack of sympathy between group and producer in some lack of narrative clarity even though the group won the day on theme and balance discussion it would have been possible to ask all stakeholders in both projects whether they felt ownership during the process and when motivation for ownership in a project involving multiple partners interests differ and it is not surprising that motivation for participating differs too leading to more interest in taking ownership as interests are reflected and agendas acknowledged 15 speaking as the commissioned the odenplan researchers were motivated by several factors initial involvement was inspired by the high profile of the work it meant exposure which enables the research team to attract new interesting collaborators they were motivated by their history of collaborating with 3xn with profitable results a state of affairs they wanted to continue but they were only able to take ownership as academics when their need for flexibility to conduct research into both media facades and design processes was acknowledged and met further they were treated as experts 3xn saw them as helping to differentiate the firm from other architectural firms 5 they were allowed to exercise their professional judgment for the greater good of all aligning both sets of interests within the frame of the odenplan project this alignment was made simpler by the socioeconomic structures in which they are working which both protect and define each party and the lengthy duration over which trust was built in carm a cascade of newlyengaged stakeholders with less formal structure contrasts dramatically with the odenplan example and shows the work of aligning in progress sue organizer of the womans group offers a rationale for becoming involved to set up a new group which is not originally on the research teams agenda but is accepted since motivation is known to be decisive in asking someone to accept responsibility for an untested and difficult activity on agreeing she could use it to her own ends sues rise in motivation was palpable she then sought out people motivated to experiment in a sensitive emotional space and the dynamics of the group worked to reinforce motivation for those who enjoyed it this time there was little in the way of professional kudos as a spur but participants personal investment with the theme of mothers and daughters was high and there was joy in breaking personal taboos which the broadcast elements reinforced again sues expertise was acknowledged and she was trusted to do her job without interference we note in passing that the womens group has continued to meet in sues care independent of the project and its finances transitions in ownership as is evident then from the description in the section above several transitions of ownership took place during the projects as responsibility for different parts was shared or changed hands only where two partners felt outright ownership of the same aspect of the work at the same time the editorial shape of the program was there conflict and this occurred not because the boundaries were unclear but because one partner was surprised by them with odenplan these transitions can particularly be seen in the passage of designed artifacts used to support verbal communication but also used as definitions of the design space as it evolves as bratteteig and wagner 1 observe prototyping narrows the options remaining and gives decisionmaking control to the makers this device is deliberately exploited by both the architectural and research teams to indicate constraints these transitions in ownership carried with them a material representation of opportunities in carm artifacts were also used as a site of negotiation after the initial brief enabled them to come into existence the controversial second edit is given the group listened to forwarded to the research team discussed and then heavily criticized as a forerunner to a final version none of the ensuing renegotiation between partners would have been possible without it had the producer followed normal professional broadcast practice and made a program without consultation the group would have had no clue as to direction ownership would have unilaterally shifted to the media expert such unilateral behavior was outlawed by the terms of the commission from sue and yet even so we see a struggle for control emanating from the producers failure to share responsibility for content whereas the shift of control from research team to sue and from sue to the group works smoothly the antagonism with the producer and the flurry of email this produces makes apparent many things • how much work can go into making transition smooth • how frequent and important these transitions can be • how too much ownership at the wrong moment may be as bad as not enough structures supporting ownership much of the discussion so far has referred to opportunities and constraints to nonnegotiable elements and by comparison those aspects that are not predefined it has already been noted that one reason for the transition to a shared sense of ownership in both contexts was because the teams began with clear boundaries for nonnegotiable elements and explicitly stated flexible aspects that could be appropriated giving space for localized meaningmaking identification responsibilitytaking and efficacycontrol sue similarly gives her group structure and choice in some contexts there may be no nonnegotiable elements and all aspects of process and outcome are to be agreed but mostly there are some fixed constraints such as externally granted budget and someone with responsibility for it in fact constraints help give definition which speeds up peoples sense of what they can contribute facilitating efficacy irrespective of where the brief began all partners described here showed initiative and made contributions based on what they felt was needed within their area of influence this relates to feeling efficacy in efficacy we can divine two complementary aspects of involvement in a multipartner project personal efficacy when an individual feels that they are controlling their environment 18 and by extension the power to act effectively in driving the agenda forward according to pierce et al 18 people seek ownership to feel efficacious and that feeling control over a target and investing the self in it leads to feeling ownership we observe the role of respect in allowing partners to exhibit efficacy and thus experience the loop implicit in 18 of feeling in control and therefore feeling more ownership etc if judgment is a major part of the design endeavor 9 then we can also see roomrespect for judgment as part of the virtuous circle of building a good collaborative project we observe how stung sue feels when the radio producer is dismissive of her groups views throughout other aspects of the project everyone makes space for the contribution of other partners although the project calls for the producer to create the program using the instructions of sues group an interesting clash ensues it is the lack of negotiation not the difference in values that strikes us while opinion may differ based on different knowledge and expertise it is the culture of the media that appears the villain here where the programmakers authority is beyond question in this light the producer is merely doing her job in both odenplan and carm the commissioned party spends time managing the way that control rests with them to increase their efficacy the cavi researchers describe how they found a way of reaching out through the use of politically chosen artifacts to continue to take initiative even once the next stage in planning the building happened without their presence in this way their careful choice of video concepts gave them efficacy beyond direct action in carm the community organizer managed the matter of negotiating with the producer to ensure that she and the group continued to drive the process even though it meant a short loss of initiative while the academic lead stepped in and reminded everyone of the ultimate authority of the research question which as bratteteig and wagner 1 point out becomes a factor with its own agency these acts of benign manipulation as agency is extended beyond direct control perhaps show most clearly how ownership has become of value to the commissioned partners this is as true when the researcher is the invited participant and challenges our whole understanding of participatory design conclusion we have highlighted how ownership unfolds in a dynamic way throughout two projects that are different with regard to participation relation to community and context across a spectrum in both a project with no direct community activity where researchers are commissioned by civic representatives for the community good and one that is so participatory that it might be deemed coresearch we have explored ownership not as a static phenomenon but by scrutinizing the dynamics as reflected in transitions of ownership and shifting patterns of initiative and efficacy similarly rather than seeing transitions of ownership as the abstract handing over of control we have shown how collaboration can hinge on materialization of transitions we began by looking at contrasting meanings of ownership in the development literature and compared this with the relative neglect of the idea in technology design research into the design of technology prizes the effective production of solutions and though this is not regularly a matter of socioeconomic change both research communities are typically engaged in evaluating managed change the means to make that change and the means to evaluate it design withfor communities differs from more usual design contexts since in bringing in the wider social context we are acknowledging that design has social impact and that we are shaping lives and milieus as we start to work with and for communities we move closer to development goals and the related pragmatic and ethical concerns that emanate from embracing social processes pragmatically if we are to research these milieus we need cooperation not research fatigue ethically if social change is on the agenda it merits asking how best might subjects of that change make it for themselves knowing how to speak of generate nurture and share ownership then has its value this paper hopes to support these goals

this paper contributes an exploration of ownership as a dynamic process in communityoriented projects we use case study accounts of two design projects to consider participation in contexts where social structure is relevant to design outcomes in studying these dynamics we consider four aspects what motivates ownership how ownership transitions structures to support ownership and facilitating efficacy among participants specifically we study the contribution of a danish research team to the production of a media façade for a swedish municipality and how british researchers engaged community groups in making internet radio podcasts to share insight we examine the complexity of the social process involved and trace patterns of change before concluding with pragmatic and ethical reasons for technology design to pay attention to ownership issues

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introduction in this article we explore the attitudes towards democracy which are seen as a contested and complex issue in a world of increased uncertainties massmediated reality and unprecedented technological development in recent decades human societies have been marked by incomprehensible structural and cultural changes which are undermining fundamental building blocks of social institutionsincluding democracy according to the democracy report in 2022 the level of democracy enjoyed globally by the average person had fallen to 1986 levels it continued to stagnate in the following year 1 this means that the progress of the recent years of democratization has diminished in addition the number of countries leaning toward authoritarianism is three times higher compared to the democratic ones 2 although some authors 34 warn about the crisis of liberal representative democracy it is still considered to be the principal form of government which is at least comparatively more likely to secure human rights and civil liberties peace 56 and overall human development 7 it requires and provides grounds for public and civil consent and active participation within social and political spheres where multiple voices can be heard and considered what is good for society is or at least should be depending only on what freely organized people choose 8 as such it is also claimed to be a universal value 9 even in the comparatively stable democracies in the european union the attitudes and perceptions of democracy have therefore become a burning topic and the utmost important research problem several authors write about the democratic backlash in europe in the sense of the deterioration of the rule of law 10 civil and political liberties accountability and political participation 11 12 13 they observe the changing attitudes towards democracy in certain countries 14 fading trust of people in public institutions 15 and the rise of populism that is often associated with it 16 these issues are related to another problem that needs to be addressed modern democracies strongly rely on ongoing public deliberations that are conditioned by normative consensus as well as the consensus on the basic claims about reality the exchange of rational arguments is only possible when people can agree on the basic criteria for considering different claims as true or false the lack of such consensus significantly contributes to the erosion of modern democracies both the dissonance in these basic claims as well as the ultimate skepticism and distrust towards the modern democratic systems is clearly embodied in the support for conspiracy theories which makes them another obstacle to the functioning of democracies 1718 several researchers have sought the roots of these problems in the significantand often increasingsocial inequalities and exclusion in developed democracies lind 19 describes a new class war between the global managerial elite of collegeeducated professionals with significantly more influence and the workingclass majority they have different world views and political preferences which leaves a significant group of people unheard 20 babones similarly names this the tyranny of experts 21 guilluy 22 illustrates these dynamics in the case of france and the division between winners of the global economy living in metropolitan areas and the losers pushed to the periphery of the big cities left behind excluded and inaudible however empirical research does not offer consistent findings on the relationship between inequality and democratic backsliding 2324 nevertheless various authors observe the associations between social exclusion and the challenges democracies face spruyt et al 25 have thus found support for populism among the social groups who face difficulties in finding a positive social identity and manunta becker easterbrook and vignoles 26 have connected it to the feelings of relative deprivation that lead to frustrated belonging it is noteworthy that those studies observe limited populations in flanders and france respectively furthermore researchers have observed the influence of social exclusion on political preferences and political participation subjective status in terms of social position influences political preferences such as support for redistributive policies and ideological principles 27 attitudes toward inequality 28 and meritocracy 29 researchers have found similar connections when researching beliefs in conspiracy theories biddlestone et al note that conspiracy theories are especially attractive to those that feel excluded and isolated and are seeking social connections and bonds 30 belief in conspiracy theories is also associated with a lack of agency low feelings of control in the sociopolitical domain and feeling underprivileged 31 this suggests that the prevalence of belief in conspiracy theories which is emerging as a pressing problem in contemporary societies could be observed from the same point of view as the attitudes toward democracy the existing literature offers a great amount of discussion on the role of inequality and social exclusion in attitudes toward democracy and democratic behaviors however it often provides rather generalized explanations focused on class dynamics andor focuses its findings on only one aspect of attitudes and empirically observed it on a smaller scale this article contributes significantly to the existing literature in three ways first it empirically explores attitudes toward democracy in relation to social divisions in a more comprehensive manner by focusing on several aspects of attitudes toward democracy in the european union drawing on the data from the european social survey we observe how people can be categorized in terms of different kinds of attitudes toward democracy and conspiracy theories second our study is not limited to a national or local case but applied to the european union thus enabling far broader generalizations about the challenges to modern democracies finally the attitudes towards democracy are placed in a wellestablished and elaborated theoretical framework of social fields provided by bourdieu 32 and further conceptualized by fligstein and mcadam 33 we therefore observe how to designate people in different groups based on their different positions within the social structure related to the possession of key resources this approach enables us to comprehend the differences between groups of people and to discern underlying factors conditioning their emergence and maintenance bourdieu claimed that society is composed of different intertwined fields which are organized in terms of their own logic of operation the functioning of the field and the interactions within it are prescribed by the type and amount of resources that agents possess and execute bourdieu called those resources economic cultural social or symbolic capitals fields can be seen as a set of everexisting and obligatory frames that shape our experiences each field has specific operating rules they can be defined as local orders where interactions between more and less powerful collective groups according to rules and shared meanings take place 34 all participants seek to enhance their capitals and related positions within a field according to their interests however the primary distribution of capitals defining ones initial position in a field is of great importance which can be observed in distinctive cultural tastes persisting social inequalities and marginalization for example observe similar social class inequalities can be observed in the educational attainment of children among rather different western countries which can be explained by the fact that it is not only parental economic capital but also their cultural and social capitals that influences childrens educational attainment 35 in this paper we address the national environments of eu countries as a complex system of strategic action fields 33 which are nested not only within national social frames and boundaries but also within european political settings it is therefore a european political field which we observe as a place of conflict where actors possess certain types and amounts of capital exercise specific habitus and related actions and on that basis strategically attempt to improve their position their strategic actions are however conditioned by the comprehension and understanding of the feel for the game within the field as bourdieu would describe it which is dependent on the capitals and habitus that one has the national political fields nested within the european political field are organized according to the logic of representative democracy and individuals can either accept and support this logic or they can challenge it on that basis we propose the following research questions • what is the role of ones positioning in the field in the categorization of different attitudes toward democracy • what is the role of particular capitals in those categorizations • what is the relation between ones positioning in the field and hisher inclination toward conspiracy theories based on the theoretical premises we hypothesize that individuals deprived in terms of various types of capital are more likely to challenge modern democratic systems being deprived of certain resources they feel excluded and disorientated they are less equipped for the symbolic battlefield and as such less likely to participate in political activities actively extensive literature connects different forms of capital with the individual traits we observe for instance lower levels of cultural and social capitals have been associated with lower levels of political participation 36 37 38 39 and dissatisfaction with democracy 40 while lower levels of economic capital have been connected to the belief in conspiracy theories 41 we address these issues more comprehensively with the aim of categorizing different kinds of attitudes and designating different groups of people on that basis more specifically in our empirical research we test the following hypotheses h1 being endowed with more economic social and cultural capitals makes one more likely to support the existing conception of democracy based on representation and the rule of law h2 individuals who are deprived of capitals are more likely to support conspiracy theories materials and methods we use the dataset from the european social survey round 10 democracy digital social contacts collected from september 2020 to may 2022 42 we use the data from the 25 european countries in the survey until may 2022 while we use this complete sample to develop our categorization of the perspectives towards democracy our further analysis is limited to the political field of the european union for this purpose we apply them to the 19 eu member states in the sample the survey assesses the attitudes towards democracy mainly through the following items with 010 likert scale responses • how important is it for you to live in a country that is governed democratically • how acceptable for you would it be for country to have a strong leader who is above the law • how important do you think it is for democracy in general that the views of ordinary people prevail over the views of the political elite • how important do you think it is for democracy in general that the will of the people cannot be stopped we analyze the responses to these questions through principal component analysis to identify the key latent variables summarizing the attitudes towards democracy including the role of the people the elites the rule of law and the idea of a strong ruler these latent variables are then applied in the kmeans cluster analysis to distinguish between the key categories in the population regarding the attitudes toward democracy to assess the resources available to individuals in terms of capitals we apply the following approximate measures from the ess questionnaire • the highest educational level achieved by the respondents to indicate their cultural capital • households total net income after tax and compulsory deductions from all sources to indicate their economic capital • respondents generalized trust to indicate their social capital to identify the tendency of respondents to accept conspiracy theories the level of agreement with the following statement is used a small secret group of people is responsible for making all major decisions in world politics the fivelevel likert scale for this purpose ranges from agree strongly to disagree strongly to test our hypotheses we apply multiple correspondence analysis this enables us to check how the categories endowed with certain types of capital correspond to the categories based on attitudes toward democracy participation and conspiracy theories results challenging representative democracy populism and authoritarianism the principal component analysis of the variables referring to the attitudes towards democracy extracts two components of major significance explaining 412 and 297 of the variance respectively after the orthogonal rotation the two components can be interpreted as populist and authoritarian the first component or dimension can be called populist as it is strongly related to the belief that it is important for democracy that the views of the ordinary people should prevail over the views of the political elite and that the will of the people cannot be stopped the second dimension can be called authoritarian since it is closely positively related to the belief that living in a democracy is not that important and that a strong leader who is above the law is acceptable since liberal democracy in europe is based on the principles of representation and the rejection of authoritarian leaders above the law both populism and authoritarianism can be seen as challenges to the existing order in the political field the results of the principal component analysis are presented in table 1 based on the pca results as far as attitudes toward democracy are concerned the respondents can be roughly positioned in the political field in a twodimensional space combining their scores on the dimensions of populism and authoritarianism on this basis using these scores we apply kmeans cluster analysis that enables the distinction between four groups we call those with high scores for populism and authoritarianism authoritarian populists their direct opposite namely the people with low scores on both dimensions can be called democratic elitists as democracy is the opposing concept to authoritarianism and elitism is typically seen as opposing to populism in addition we can note the two other combinations namely democratic populists and authoritarian elitists it should be stressed that the designations of these four groups should be taken in relative not in absolute terms respondents in the eu typically object to a strong leader above the law and support the idea that the views of ordinary people prevail over the views of the political elite with a mean score of 73 the terms authoritarians and elitists thus imply those with a less decisive rejection of the authoritarian leader and those who show less enthusiasm for the prevalence of the views of the people over the views of the elite for example among the authoritarian populists the mean support for an authoritarian leader is 52 for the views of the people prevailing over the elite it is 53 with 413 democratic populists are the most common category in the european countries included in our study they are followed by democratic elitists while authoritarian populists and authoritarian elitists are somewhat less frequent the combination of authoritarianism and populism seems to be connected to the belief in conspiracy theories while the spearman correlation coefficient between the dimension of authoritarianism and belief in the global conspiracy is a rather modest 023 the connection becomes clearer when combining it with populism and comparing our four groups in this regard in other words 366 of authoritarian populists agree or strongly agree with the claim that a small secret group of people is responsible for making all major decisions in world politics the prevalence of these groups and some of their features are presented in table 2 we apply mca to analyze the relationship between the four categories of attitudes toward democracy as well as economic social and cultural capital most of the variance in the model is explained by the first dimension while the first two dimensions combined explain 874 of the total variance thus providing a rather comprehensive insight the results are presented in figure 1 for peer review 7 of 12 as the political field of the european union involves people from different nationstates with their own specific features this diversity should also be noted to maintain clarity we project the three groups of the eu member states as a passive variable to the mca coordinate plot the results indicate a highly unequal distribution of economic cultural and social capitals between the citizens of different member states and substantial differences in attitudes towards authoritarianism and populism the citizens of european old democracies lean comparatively more towards support for democracy and those from new democracies are relatively more inclined towards authoritarian populism respondents from the middle groupor medium democracies are not connected to any particular attitude towards democracy but they are more likely to correspond to relative deprivation in economic social and cultural capitals deprivation of different capitals corresponds to the beliefs in conspiracy theories the belief in conspiracy theories indicated by supporting the claim that a small secret group of people is responsible for making all major decisions in world politics should not be underestimated as 263 of european union residents in the sample agree or strongly agree with it they also closely overlap with the believers in the claims democratic elitism clearly corresponds to higher amounts of resources in terms of capitals they are more likely to belong to the wealthiest pentile in terms of income have a graduate or postgraduate tertiary education and tend to have very high trust in people in general authoritarian populists in contrast are the closest in relative terms to the 2nd pentile of the income groups and are rather unlikely to have any tertiary education or a high level of generalized trust authoritarian elitists again are negatively related to tertiary education and higher income levels while they correspond closely to low and very low generalized trust finally the democratic populists have a significantly less distinctive social basis they comprise a wider variety of social groups than the other three categories the results speak in favor of h1 which states that being endowed with more economic social and cultural capitals makes one more likely to support the existing conception of democracy based on representation and the rule of law which is most consistent with the position of democratic elitism which is most typically supported by people with the highest amounts of resources the results are rather robust even if one applies alternative indicators such as participation in voluntary associations instead of generalized trust as a measure of social capital parents education as an indication of cultural capital or occupational positions as approximations of goldthorpes class model as the political field of the european union involves people from different nationstates with their own specific features this diversity should also be noted to maintain clarity we project the three groups of the eu member states as a passive variable to the mca coordinate plot the results indicate a highly unequal distribution of economic cultural and social capitals between the citizens of different member states and substantial differences in attitudes towards authoritarianism and populism the citizens of european old democracies lean comparatively more towards support for democracy and those from new democracies are relatively more inclined towards authoritarian populism respondents from the middle groupor medium democracies are not connected to any particular attitude towards democracy but they are more likely to correspond to relative deprivation in economic social and cultural capitals deprivation of different capitals corresponds to the beliefs in conspiracy theories the belief in conspiracy theories indicated by supporting the claim that a small secret group of people is responsible for making all major decisions in world politics should not be underestimated as 263 of european union residents in the sample agree or strongly agree with it they also closely overlap with the believers in the claims that groups of scientists manipulate fabricate or suppress evidence in order to deceive the public or that the coronavirus is the result of deliberate and concealed efforts of some government or organization the results of correspondence analysis between the belief in a small group taking all major decisions and the economic cultural and social capitals are presented in figure 2 the twodimensional model provides a very good explanatory mechanism as its first dimension explains 801 of the total variance while the two dimensions combined explain 849 again significant correspondence can be noted people with vocational or lower education belonging to the lowest income pentile and with very low generalized trust are much more likely to agree strongly with the conspiracy claim with secondary education low or medium generalized trust and shifting to the second income pentile the agreement with the conspiracy claim becomes more moderate tertiary undergraduate education and the fourth income pentile correspond to moderate disagreement regarding the global conspiracy a strong disagreement finally corresponds to the high or very high generalized trust the highest income pentile and graduate and postgraduate tertiary education x for peer review 8 of 12 again significant correspondence can be noted people with vocational or lower education belonging to the lowest income pentile and with very low generalized trust are much more likely to agree strongly with the conspiracy claim with secondary education low or medium generalized trust and shifting to the second income pentile the agreement with the conspiracy claim becomes more moderate tertiary undergraduate education and the fourth income pentile correspond to moderate disagreement regarding the global conspiracy a strong disagreement finally corresponds to the high or very high generalized trust the highest income pentile and graduate and postgraduate tertiary education projecting the distinction between old and new democracies to the mca plot as a passive variable indicates a correspondence between the member states and the belief in a world conspiracy together with the territorial disparities in economic cultural and social capital as confirmed above respondents from the old democracies are far more likely to reject conspiracy claims than those from more recently democratized countries the results support h2 which states that individuals deprived of capitals are more likely to support conspiracy theories discussion the recent decline in democracy can be seen in the context of contested and uncertain social conditions due to unprecedented social transformations conditioned by digitalization and signified by various crises people often feel disorientated and lack agency and control of their own life situation they often distrust established social institutions and their representatives and are more prone to endorse conspiracy theories accordingly they can deny support to democratic leaders and seek the solution from strong authoritative political figures in contrast people can also become more empowered and perceive the existing political order in terms of the advantages for their own life situation projecting the distinction between old and new democracies to the mca plot as a passive variable indicates a correspondence between the member states and the belief in a world conspiracy together with the territorial disparities in economic cultural and social capital as confirmed above respondents from the old democracies are far more likely to reject conspiracy claims than those from more recently democratized countries the results support h2 which states that individuals deprived of capitals are more likely to support conspiracy theories discussion the recent decline in democracy can be seen in the context of contested and uncertain social conditions due to unprecedented social transformations conditioned by digitalization and signified by various crises people often feel disorientated and lack agency and control of their own life situation they often distrust established social institutions and their representatives and are more prone to endorse conspiracy theories accordingly they can deny support to democratic leaders and seek the solution from strong authoritative political figures in contrast people can also become more empowered and perceive the existing political order in terms of the advantages for their own life situation in the context of the eu countries we can observe that the important factors conditioning ones attitudes toward democracy are related to ones access to and possession of economic social and cultural capitals by drawing on the theory of social fields 3343 we can show that the attitudes towards democracy are intertwined with ones positioning in the national and european political field which reflects the ways that people perceive and respond to social reality those ways of perceiving and acting can be defined by using bourdieus concept of habitus which is conditioning how we respond to the field settings and relations within it the attitudes toward democracy and related issues are therefore ensuing from ones habitus in bourdieus 32 sense habitus is a schema of dispositions imposing the structure of the field and orienting a routine action habitus is therefore the social structure imprinted in individuals cognitive dispositions which entail the subjective framework for actions it signifies and influences not only how we think about the world but also embodies the system of dispositions that we bring into the field it underlines the way we walk the way we talk and how we think and speak 43 although individualized throughout habitus reflects a shared cultural context the shared culture of the specific group is inscribed into the individual mindset and reproduced through interactions in the field which is always a constitutive response to preexisting social conditions 44 a habitus thus ensues from the social world and simultaneously represents a foundation for the creation of the social world the relationship between the field and the habitus is dialectical while certain habitus can be formed function and be valid only within a certain field 32 in this paper habitus is a puzzle of different dispositions gained in different life stages according to participation in particular fields each part of the puzzle is activated in different social contexts and triggers are considerations of the social context and concrete actions in that regard we see that habitus plays a crucial role in the ongoing battle between actors for improving their position within a field in addition to the capitals which define ones initial position and consequent actions attitudes towards democracy are related to specific habitus which is conditioned by the cultural social and economic capitals one possesses based on ones position in the fields the related attitudes are either challenging or support existing representative democracy the implementation of the principles of representative democracy and the rule of law can be seen as the operating rules of the political field in the european union liberal democracy inevitably implies at least some elitist elements its representative nature rule of law and separation of powers give a significant role to the elected and appointed decisionmakers in the legislative executive and judicial branches of power in addition the effective participation of an ordinary citizen beyond simple voting requires certain competencies that are far from selfevident these established rules can be challenged from various perspectives authoritarians may see democracy as irrelevant and unnecessary perhaps even harmful due to its presumed ineffectiveness antielitists may object to its representative nature as it seems to give the main say to the elites not the people both however may question the rule of law because in some situations they might place either a strong leader andor the will of the people above the law in addition a common implicit populist belief in the form of a unified will of the people may favor authoritarian tendencies despite such potential common points authoritarianism and populism should be clearly distinguished as separate dimensions on the conceptual level some populists may support an autocratic leader seeing him as an embodiment of the will of the people against the presumably evil and conspiratorial elite other populists may instead embrace a radical vision of participatory democracy undermining elites and leaders in general our results show that the distinction between the two dimensions underlining the four categories of attitudes toward democracy is not only conceptual but also empirical our results support a growing body of recent research that connects the democratic backlash and the rise and persistence of figures such as former us president trump or hungarian prime minister orban to the problems of social deprivation and exclusion 21222526 the finding that the operating rules of the political field are particularly challenged by the groups lacking economic social and cultural capitals is consistent with the recent critique of the gap between the welleducated cosmopolitan elite particularly rich in cultural capital and those who feel left behind 192022 we further extended the same logic to the question of belief in conspiracy theories as it is a pressing problem that can have a severe influence on social and political processes while there are various individuallevel factors and motives believed to be causing belief in conspiracy theories the literature suggests that the question also needs to be addressed from the structural level 45 our research supports this as we find a clear connection between individuals positioning in the field and their support for conspiracy theories in other words individuals deprived of social cultural and economic capitals are not only more likely to have challenging attitudes toward existing representative democracy and the rule of law but are also more likely to believe in conspiracy theories these findings also align with a considerable body of recent research that connects attitudes toward democracy with populism 46 47 48 49 individuals more inclined to conspiracy thinking are those more likely to reject the political system and feel distrust towards public officials 50 in line with this drochon 45 sees conspiracy theories not as a cause but as a symptom of disappointment over democracy furthermore belief in conspiracy theories has often been associated with an individuals feelings of exclusion and isolation 3150 our research also shows significant territorial disparities within the eu political field there is a correspondence between living in new democracies lacking economic social and cultural capital inclining towards populism and authoritarianism and believing in a global conspiracy the key resources needed for successfully playing in the political field instead of challenging its principles are far from equally distributed within the eu this also aligns with some existing research observing the differences in attitudes towards democracy between central and eastern european countries compared to northern and western european countries 51 52 53 54 consistently with some historical experience younger democracies may be at greater risk of falling back to authoritarianism and populism as demonstrated a century ago with the autocratization after the first world war and in recent decades with the rise of populism and still weak constitutional liberalism and the rule of law 55 this article offers novel and more generalizable empirical evidence in comparison to the existing literature that observed similar connections in specific environments it offers a consistent and comprehensive theoretical interpretation that sheds light on some of the aspects connected to the attitudes towards democracies and belief in conspiracy theories often overlooked instead of simply condemning or even expressing disgust about populism authoritarianism and conspiracy theories a better way to protect our democracies is to improve the understanding of the grievances related to a series of corresponding deprivations and deficiencies of resources and address them more systematically data availability statement all data are obtained from a freely and publicly accessible database of european social survey round 10 democracy digital social contacts

we explore attitudes toward democracy in relation to social divisions by focusing on the european union member states and the corresponding eu political field positioning in the european political field is addressed through the theory of social fields as provided by bourdieu and further conceptualized by fligstein and mcadam drawing on the data obtained from the european social survey we conducted a principal component analysis of the attitudes toward democracy and a correspondence analysis between these attitudes and social cultural and economic capitals we demonstrate that attitudes toward challenging the existing representative democratic order can be seen in terms of two distinct dimensions authoritarianism and populism the presence of both corresponds to the lack of ones possession of economic social and cultural capitals and the related political habitus those who lack these forms of capital are more prone to support strong authoritarian leaders and are also more likely to endorse conspiracy theories we can relate this to the problems of exclusion and deprivation related to the lack of political habitus required for effective agency in the political field

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they finance their college education we examine how classbased differences influence how students finance college education we draw on concepts from economic sociology and sensemaking to examine how class backgrounds shape students meaningmaking of finance and funding their college education through interviews with 56 community college students we examine what money means to students and how that varies across classes with implications for transfer decisions and outcomes we surface important implications for students behaviors and decisions in college keywords community college student financial aid social class economic sociology higher education community college transfer el dinero importa cómo la clase social influye en las percepciones de los estudiantes sobre la financiación de su educación resumen la educación superior es cada vez más costosa y existen disparidades de acceso por raza y clase social sin embargo carecemos de matices en la literatura académica sobre la comprensión de los estudiantes sobre cómo financian su educación universitaria examinamos cómo las diferencias basadas en clases influyen en cómo los estudiantes financian la educación universitaria nos basamos en conceptos de la sociología económica y la creación de sentido para examinar cómo los antecedentes de clase dan forma a la creación de significado de las finanzas de los estudiantes y la financiación de su educación universitaria a través de entrevistas con 56 estudiantes de colegios comunitarios examinamos qué significa el dinero para los estudiantes y cómo eso varía entre las clases con implicaciones para las decisiones de transferencia y los resultados destacamos implicaciones importantes para los comportamientos y decisiones de los estudiantes en la universidad palabras clave colegio comunitario ayuda financiera para estudiantes clase social sociología económica educación más alta transferencia de colegio comunitario o dinheiro é importante como a classe social influencia a percepção dos alunos sobre o financiamento da educação resumo o ensino superior está cada vez mais caro e existem disparidades de acesso por raça e classe social no entanto faltam nuances na literatura acadêmica sobre a compreensão dos alunos sobre como eles financiam sua educação universitária examinamos como as diferenças baseadas em classe influenciam a forma como os alunos financiam a educação universitária baseamonos em conceitos da sociologia econômica e da criação de sentido para examinar como os antecedentes de classe moldam a construção de significado dos alunos sobre finança s e o financiamento de sua educação universitária por meio de entrevistas com 56 alunos de faculdades comunitárias examinamos o que o dinheiro significa para os alunos e como isso varia entre as classes com implicações nas decisões e resultados de transferência nós revelamos implicações importantes para o comportamento e as decisões dos alunos na faculdade palavraschave faculdade comunitária auxílio financeiro estudantil classe social sociologia econômica ensino superior transferência de faculdade comunitária and could rely on their families for financial help uppermiddleclass students expected their parents to fully finance their undergraduate education and living expenses but bore the costs of any postgraduate degrees this study addresses the longitudinal intersections between students social class their understandings of the social meanings of money and the impact of these factors on their educational trajectories literature review expectations and outcomes in higher education vary by social class students from middle uppermiddle and upperclass backgrounds might assume that college attendance is expected but that is not the case for students from other class backgrounds and these are patterns that are reinforced in public schools social class and stratified public schools can thus limit students imagined future in higher education causing students to restrict the types of institutions they consider applying to or attending students social class can shape everything from their choice of institution to how they navigate college once they have been accepted and have matriculated once they are taking courses their social class influences their patterns of engagement with the institution such as how they spend their time in class at work or in participating in campus activities all students bring resourcesor capitalfrom their social cultural and familiar backgrounds to their educational environment but these resources are not always easily converted for use in the higher education environment students from lower socioeconomic backgrounds might have difficulty acclimating to the climate and interacting with their peers though they are certainly capable of mustering their resources to integrate into the campus climate as prior research has shown beyond social interaction acclimation to higher education can lead to the transmission of peer social and cultural capital that can offset the difference in information students from lower socioeconomic statusesparticularly firstgeneration college studentsreceive from their parents most of the literature examining the role social class plays in student experiences and conceptions of money focuses on 4year institutions what these processes look like for community college students who tend to face greater resource constraints in college financing and therefore greater uncertainty is a needed addition to the literature social class student perspectives and the financing of education at community college when it comes to paying for higher education the highcost highdiscount modelin which students rarely pay the full cost of education out of pocket thanks to grants loans and scholarship discountsof american higher education financing means that students from lower socioeconomic statuses cannot afford higher education without assistance the high price of tuitionthe sticker shockmight deter some parents from encouraging their children to participate in any college preparation efforts since college would be viewed as economically unachievable relatedly the perceived cost of financing college is often misrepresented among firstgeneration and lowsocioeconomicstatus students networks lowincome students beliefs about their access to college and financial aid information keep them from even considering college as a possibility the sticker shock arising from seeing undiscounted tuition prices can scare students away from 4year institutions and lead them to the comparatively lowercost community college and it can encourage students to seek financial aid to subsidize college attendance community colleges are often marketed as a quick flexible and costeffective way to obtain the newest credentialan appealing enticement for students wanting to be competitive in the workforce but lacking the financial means to pay financial aid can be difficult to accessespecially for firstgeneration college students because of the complexity of the filing process the significant amount of personal financial information students are required to provide and the many steps students may face to keep aid after enrolling the practices and structures of community colleges may create further challenges some older literature has argued quite forcefully for the reproductive function that community colleges play in keeping students within their original social class rather than enabling social mobility for instance karabel described community colleges as facilitating the american myth of equal educational opportunity by offering open access to higher education but failing to help students transfer and complete their degrees because of their complex structures lack of sufficient resources and socalled cooling out function of encouraging students to lower their educational aspirations institutional agents such as faculty and staff members can help students with their educational goals however there is danger in relying solely on these institutional agents to disrupt the institutional practice of community college because sometimes the agents class background might reinforce students stratification by social class as the economic burden of financing higher education has fallen more squarely on students and their families students have turned to loans and alternative financial services such as payday loans to pay for both college and related expenses such as housing and transportation a primary source of financial support for lowincome students at community colleges is financial aid especially in the form of student loans it is challenging for students to find clear information on financial aid availability and how to apply for it but higherincome students do not face similar informational burdens because they are comparatively less resourcedconstrained higher education expenditures and willingness to accrue loan debt vary among different groups with research indicating that in general black students are more willing to take on educational debt especially compared to latinao students who are more averse to accruing any sort of debt indeed one qualitative study that examined black college students experiences with aid showed that they had substantial knowledge of their families financial situations and a nuanced understanding of aid however little qualitative research examines how family class and other elements of students experiences shape students varied encounters with financial aid financial aid professionals policymakers and researchers might treat grants loans scholarships and service aid as all falling under the umbrella of financial aid at the student level however the nuances of financial aid experience and the kinds of aid students receive matter for their trajectories within higher education students might use terminology such as fafsa to refer to everything from the financial aid office to their financial aid packages including how much and what kind of aid they receive loans represent a necessary evil for students enrolled in higher education previous scholarship found mixed results about the accuracy of students knowledge about their own financial aid amounts and types parents play a role in this formation of financial knowledge students mimicking their parents knowledgeeven when it is inaccuratecan negatively affect students degree attainment whether students pursue higher education financing depends on the students social and familial context conceptual framework the social meaning of financial aid in our research we draw on concepts from sensemaking theory and economic sociology to understand students conceptions of how they finance their college education these theoretical perspectives emphasize the links between cognition class culture and decisionmaking moving beyond the more dominant economic or rational actor decisionmaking models sensemaking theory highlights how actors engage with policies including financial aid policy and how their understandings of the policies are shaped by their prior knowledge and beliefs as well as by their social contexts and communities in the context of financing postsecondary education we use zelizers concept of the social meaning of money to explore how different funding sources are imbued with different cultural meanings with implications for how students make financial decisions about higher education types of money are not equivalent currency rather the money itself its source and the type of money hold different social meanings which in turn influences the use of the money for example a 20 holiday gift from a grandparent given in the form of a check might feel different to an individual and therefore be used in a different manner than for example a 20 bill found on the street or a 20 coffee shop gift card given as a holiday bonus by an employer these are all equivalent in terms of their monetary value but are likely to be used in different ways previous researchers have applied zelizers paradigm outside of undergraduate education finding that the source of money and the way additional funding was delivered caused recipients to treat cash differently than they would their ordinary paychecks other research applied the theory to the role of money in the socialization of graduate students and faculty in the literature on financial aid policy some researchers have drawn on zelizers work to indicate that loans are treated differently than other forms of financial aid especially grants loans are seen as less real or tangible than grantsthey are viewed more like credit cards than cashand financial aid is more than a monetary exchange as students can interpret it as a message of value or esteem communicated by the institution this helps explain why students can have strong reactions to any yeartoyear changes in their financial aid packages other literature also notes the different valences that different forms of aid hold for students in a study of community college students receiving loans mckinney et al found that students viewed financial aid as a type of lottery they hoped to win free money to pay for college and viewed loans as a last resort in our research we drew these threads together to explicitly investigate the social meaning of money in college financing for community college students and its impact on their trajectories additionally these conceptual frameworks informed our analysis of the interview data as we explain in the methods section we asked 1 how do students class backgrounds shape their understandings of money personal finances and financial aid 2 how do these beliefs and understandings affect their transfer decisions and outcomes data and methods we conducted a qualitative case study drawing on longitudinal interview data and a demographic questionnaire administered to 65 community college students these data came from a larger study in which we interviewed students from two large urban community college systems in texas which we call community college a and b respectively study participants and data collection in the first year of our study we recruited 103 students who selfidentified as planning to transfer to a 4year school within the next 12 months2 each fall after the first year of the study we interviewed between 55 and 65 students in years 4 and 5 of the study we added additional interview questions specifically concerning financial aid and social class therefore the 56 students with whom we spoke specifically about these topics are the focus of this paper we supplemented interview data from those years with any additional content on those topics students shared in previous interviews participants were at various stages of the process at the time of this study interviews were conducted primarily in person though some were done by phone they lasted between 30 and 60 minutes and were audio recorded and transcribed in the interviews we asked questions such as how were you planning on financing your education how do you feel about how much you have spent on college to date how do you feel about the costs of college generally we also asked several questions about students socioeconomic background including asking about their educational and family background and their experience growing up we also asked what did your parents do for a living when you were growing up did they go to college did other people in your family go to college and do you think your parents occupationeducation influenced your own career and educational goals if so how we probed specifically for degree and certificate information about their familial educational level additionally students completed surveys in which they indicated their current jobs current personal and household income social class identification parents occupations and approximate amount of student loan debt if any by asking students openended questions about their social class and how they feel about financing their postsecondary education we were able to hear in their own words how they made sense of their socioeconomic background and how they created links between their background and educational goals as well as their feelings about college costsan approach aligned with sensemaking theory their responses which often drew boundaries between the types of funding sources they had to draw on aligned to zelizers conception of the social meaning of money which we incorporated into our analytic process data analysis to analyze our data we divided participants into groups using four social class categoriesworking class lowermiddle class middle class and uppermiddle class3 and asked questions about their relationships with money and higher education to identify students social class we compared their selfidentified social class with their descriptions of their family background to draw conclusions about their class status working class students parental occupations consisted of bluecollar work without a managerial role such as cleaning or construction the 14 lowermiddleclass students came from families with parents who had higherpaying and higherstatus jobs than those of the working class their parents jobs largely did not require a college degree the parents of the 15 middleclass students mostly worked in jobs requiring a college education the three uppermiddleclass students parents were generally highly educated and in highincome professions to further clarify our construction of social class categories we wrote short memos on each social class group shared them with the whole team and then thought collectively about themes and findings the memos contained rich quotes from participants narratives we recognize that selfidentification of class in a context like the united states is complex therefore we relied on both student and researcher defined categories we wrestled intellectually and ethically with categories of social classwhich were derived from selfreports as well as from the information shared in interviews regarding students family backgroundsand with the important intersections of race gender and immigration status for race is the modality in which class is lived our findings reflect an intersectional analysis of participants experiences and give indepth descriptions of particular cases we compared what students selfreported as their social class with the information from the interviews to place them in a class category that more closely matched the sociological literature we changed 19 students class categorizations additionally we checked each others placement of the participants class and met to resolve disagreements we expand on our definitions of each class in the relevant findings section below and in table 2 after establishing interrater reliability among members of the team we inductively coded the data in dedoosewith a focus on how students navigated the transfer processand wrote detailed case memos for each student we then created data matrices where each row represented a student and included rich data on students class backgrounds and sociocultural context how the students thought about the costs of higher education how they financed their education and the transfer status or outcome we moved iteratively between our matrix and detailed individual memos that we had been building over the years of analysis for each study participant in this analysis we reviewed the data matrices and the memos using the lens of social meaning of money as applied to college financing the conceptual framework informed our writing as we continued to move iteratively from the matrices and memos to writing the profiles used in this article when writing the analysis we referenced both the matrices and the memos to provide quotes and nuances that illustrated the complex views students bring to financing college education always careful to check that we captured the understandings of college financing unique to their social class environment the conceptual framework shaped data analysis and data reporting including our selection of specific students to be used in case profiles for example when we discussed emirs experience we asked not only how he financed education but what higher education meant for him limitations our work has limitations first participants left over the 5 years of studyonly 60 of the initial 103 students were interviewed in year 4 and 65 in year 5 we focus here on the 56 students who were asked explicitly about finances during their interview not all students were asked these questions due to time limitations students who did not follow up with the study might have been more likely to be struggling with the demands of balancing higher education and their other responsibilities potentially biasing our data toward students with more social and material resources or who had made progress toward transferring second our work focused conceptually on social class and although we examined intersections with race and gender where they emerged our instruments did not systematically capture students racialized or gendered experiences findings social class and the meaning of money among community college entrants below we discuss the perceptions of money by social class we share broad patterns of how students funded their education how money affected their trajectories and how students made sense of money including its social meaning see table 2 for patterns of transfer status by social class additionally we provide individuallevel profiles of students in each group to capture the richness of their experiences these profiles offer unique and important insights about the broader group we deepen the conversation in places by sharing other group members perspectives and circumstances briefly workingclass students believed higher education was an investment in their future economic success for those reasons workingclass students views of how to pay for college were wrapped up in the purpose of higher education and whether they ought to pay for college in the first place lowermiddleclass students found higher education to be unaffordable middleclass students could use their family income to finance higher education and wanted to keep their class privilege uppermiddleclass students viewed financing higher education as essentially their parents responsibility higher education pays for social mobility for workingclass students working class students those whose parents occupations consisted of bluecollar work such as cleaning or construction used multiple funding streams to fund their higher education journey including family savings work income loans and other types of financial aid unfortunately these complex funding streams often did not cover all the expenses of higher education even students who were initially loanadverse had to take out loans during their studies and some left college with huge loan debt but no degree for the workingclass students in our study degree attainment represented a goal for the whole family not just for the individual workingclass students were wary of the steep price of higher education however they viewed higher education as an investment that represented not only the possibility as one participant said of a more settled life for themselves and their families but also of an opportunity for selfdiscovery and growth the three student profiles below address shared themes found within this group that higher education is an individual good that education belongs to their community and that higher education has potential to lead to selfdiscovery we address each theme by using one students story as a representative example of a shared theme within this group higher education represented social mobility for those reasons they shared an understanding that there was no price too high to pay for education individual good and a necessary evil the case of walter walter4 a firstgeneration college student and a white man started his higher education journey with a full ride to a 4year institution but lost that funding because of his academic performance when he returned to college walter qualified for a pell grantthe federal grant available for the most economically needy students and used that to support his enrollment at community college a in addition to funding his living costs and tuition payments with outofpocket payments from work and the occasional loan from his grandparents walter took out the maximum allowable loan amount at community college a the most of any student in the workingclass group that amount however did not fully cover the cost of his associate degree between financial and other difficulties in completing the requirements for transferhe had been pursuing credits toward an associate of applied science rather than a transferfriendly associate of science degreewalter ultimately stopped out of higher education as of the final year of the study he had received exclusively an associate of applied science degree and no longer wished to transfer walter conceptualized the cost of college as a necessary evil in his words walter thought college was affordable if people made serious sacrifices he was not interested in free college policies arguing that because he sacrificed to get his degree other people ought to do the same walter positioned himself as a savvy navigator of the financial arena he was confident that he had used his economic capital to manipulate the higher education system to his own ends in the first year of our study he saw the cost of debt as a part of the navigation process as far as finances are concerned i plan on making a ton of money youve got to spend money to make money and thats not really a key factor although it will be a significant factor because of financial aid but im not worried about that element so much im already 20000 in debt for student loans so whats another 100 000 class and how it interacts with his college funding experience had a negative impact on walters trajectory he assumed he had to invest that large of amount of money to obtain his degree and he expressed that there was no limit to what he would invest in himself however he ultimately stopped out without transferring his only interest in higher education seemed to be the personal financial benefits and chance for upward mobility fifteen students in this group shared walters views of higher educations leading to financial security in contrast emir found higher education to be a familial enterprise community property the case of emir emir is a firstgeneration college latino and white man who has received a bachelors degree in theater he took out some loansbetween 6000 and 10000 worthbut worked fulltime while he was in college to reduce the loan burden he also completed the fafsa and received forms of financial aid including the pell grant the time he spent working caused him to miss out on opportunities that would have given him experience in his career some of his classmates of different social classes were able to take unpaid internships but emir was unable to afford that opportunity he highlighted this difference in class in his undergraduate major there are people who are here 100 percent funded dont have a job dont have to worry about anything and thats because of the economic values of the family that they grew up in the place that they came from the socioeconomic class that they are in it allows them to be like oh i dont need to worry about all that other stuff i can just be here and i can 100 percent get all the experience i need and then immediately get a job right after whereas the cost of a loan was the necessary sacrifice for walter the cost for emir was rejecting an experiencean unpaid internshipthat could have led to future success in his career for emir the attainment of a college degree was wrapped up in a sense of obligation toward his mother who had sacrificed her own education to raise him workingclass students many of whom were the first generation in college and students of color felt a sense of familial responsibility regarding their degree the degree would provide access to more resources for the entire family not just for the student students expressed both a sense of indebtedness to the family and the need to be a role model for others in the family this additional expectation however does not often translate to more financial support from the family emirs lived experience of higher education and his familys perception of higher education are at odds his familys view of a degree was straightforward with a degree comes increased money opportunity and resources because of his experience with his artsbased degree however emirs understanding of a higher education was more nuanced he knew that a degree alone was not enough to reach a higher socioeconomic status he could not risk taking an unpaid internship that might increase his chances for a betterpaying job and access to networks because he needed a paying job this example illustrates that even when someone has access to educational opportunities financial limitations can decrease the economic value of the experience for the families of workingclass students higher education represents social mobility because the success of one of the family members can lead to more mobility throughout the family he completed his degree and at the time of this study worked as a grocery store manager selfdiscovery the case of barbara barbara is a firstgeneration latina who had transferred to a 4year school and has begun graduate education her path began with community college because that was cheaper than a 4year school she reported in year 1 when i had tried to apply for financial aid straight out of high school i had no idea what to do because my mom doesnt have a social security number and i didnt talk to my father at the time because her mother is workingclass and undocumented she has no social security number to put on the fafsa barbaras father paid for community college but when she transferred she sought financial aid given that the 4year school would be more expensive than her community college because barbaras father was paying for school she felt in year 1 that she had the freedom to study what interested her rather than having to choose a vocationallyoriented major barbara viewed educational expenses more as a gift she could pick a major she liked rather than one that would get her a job her experience along with that of emir highlights how lack of funding influences students choices and their experience of their studies workingclass students had to be strategic with their major and class choices to make sure their education was costeffective through the course of her schooling barbara ran into multiple funding issues she had to justify the number of classes she was taking and share her situation in detail to receive financial aid in other words she had to prove her financial need to the financial aid office barbara frames education overall as something that helps her to fulfill her eternal quest for knowledge and learn more about her cultural background her desire to attain higher education is a personal drive rather than a financial one barbaras motivation to seek higher education resembles that of five other students in this group finances however still shaped her educational journey in that she had to keep proving financial need barbara was pursuing graduate education in the social sciences during year 5 of this study summary the workingclass students in this study expressed a range of experience with funding higher education and the social meaning of money walter had an individualistic orientation toward higher education it would benefit his economic future he was willing to invest as much money as he could in himself but ultimately received no degree and accrued substantial loan debtthe most out of any member of the workingclass group emirs orientation toward higher education was familial at the expense of his own career aims he completed higher education because his family wanted him to but he chose his major for himself the privilege his classmates had to focus exclusively on their degree rather than earning an income was not there for emir causing him to opt out of a career in the arts barbara also prioritized selfdiscovery rather than an economic orientation toward higher education and despite facing significant financial constraints used higher education to learn more about herself and her culture lowermiddleclass students lowermiddleclass students came from families with parents who had higherpaying and higherstatus jobs than those of the working class but their jobs largely did not require a college degree the 14 lowermiddleclass students in the study had debt ranging from 0 to 34999 four students had over 20000 in loan debt and two students had no debt at all nine were firstgeneration college students and five were continuing generation only one student was still planning to transfer as of the fifth year of the study the rest had transferred and four had graduated with a bachelors degree the other nine were working toward their bachelors degrees with one having temporarily stopped out of college because of financial constraints and eight still enrolled in higher education in fullor parttime status students were largely debtaverse and took on loans only as a last resort students divided their conceptions of money usage into two categories educational costs and living expenses in terms of income students conceptualized money as coming from financial aidor what they called fafsa by which they meant grants or scholarshipsstudent loans their own income from work andor workstudy or family financial help the students in the lowermiddleclass group largely selected a community college as their starting institution because it was affordable students who were admitted to 4year institutionsespecially private schoolsafter graduating from high school could not afford the educational expenses and opted for the cheaper community college given the expense of the 4year relative to the community college students wanted to wait until they were attending a 4year institution to take out any educational loans reasoning that they wanted to save that expenditure for a more expensive institution this was particularly relevant for students who thought they might pursue graduate education one student said i went to community college because i didnt have the money i didnt want to start getting loans out because she planned to pursue a professional degree after her bachelors the students in this group were disgruntled by the high costs of college compared to the financial aid available to them experienced extremely complex procedures to finance their higher education and struggled to balance their educational opportunities with their economic constraints perceptions of college affordability the case of tatiana higher education was seen at least initially as financially out of reach by students in the lowermiddleclass group tatiana a firstgeneration latina and indigenous student who transferred to a 4year institution felt betrayed by the costs of college in high school messaging from her teachers and others was as follows pick your dream schools your top three dream schools and apply for them regardless regardless of if you can afford it she landed at a community college because i got accepted to two out of three that were my dream colleges right i still couldnt afford them fortunately she realized later that she could receive military benefits to finance her education because of her fathers service tatiana said because previous to me realizing that i could use gi benefits that we even had that option i was under the guise and impression that i had to i was a regular person who had to pay for college out of pocket and had to get either a loan or a scholarship this unexpected windfall enabled tatiana to transfer to a 4year institution and opened new possibilities though tatiana was able to successfully transfer because of the military benefits coverage of educational expenses she still needed to work to fund her living expenses a process that delayed her 4year graduation we share tatianas case because of the illustrative contrast between her initial method of college funding and her later methods four other students in this group were especially upset about the unaffordability of higher education relative to their and their familys income other students like ilana shared stories of the complex processes required to fund their educational journeys the effort required for financial aid the case of ilana ilana was a firstgeneration latina student who had successfully transferred to a 4year institution ilana was loanaverse at the beginning of her educational journey because she wanted to go to professional school and knew the high loan burden that would entail like tatiana ilana had been admitted to a 4year institution upon high school graduation but could not afford to attend it ilanas top choice was out of state but having received no scholarships and insufficient grant aid she said 40 thousand dollars is something i couldnt agree to she then attended community colleges because of the low cost and the good scholarships she received a choice she later regretted because she had to retake courses later at her 4year institution and she believed she had been insufficiently prepared at the community college ilana explained i could go back and tell my high school self oh you have a full ride here its not the best school but go there because youre going to prepare better and you get used to the university feel when she did transfer managing financial aid was a substantial burden on her time ilana received only loans in aid from the 4year institution at the beginning of her time there trying to minimize loan amounts she worked at her apartment complex located far from campus to save money between commuting and those time demands she had difficulty keeping her grades high meaning she lost eligibility for the minimum grade requirements of aid therefore ilana had to work closely with student emergency services on campus and repeatedly take out a series of shortterm tuition and other loans to have enough money to eat she summarized if i owe money it just builds and if i dont have it it makes it worse before graduation she suddenly became pelleligible which reduced the time she spent applying for aid but at that point her gpa was low enough that her dreams of attending professional school were dashed five other students in the lowermiddleclass group shared her complex patchwork of college financing methods to enter higher education including cassandra finances and the swirling student the case of cassandra perceptions and actual experience with college financing harmed cassandras ability to persist in higher education and eventually attend a postgraduate program cassandra was a continuinggeneration black student who had successfully transferred but had attended three different 4year institutions by the time our study concluded with a bachelors degree at least a year away her desire to support and set a good example for her son kept cassandra motivated to continue working toward higher education whatever the costs cassandra wanted more than a basic job and thought the diploma represented an opportunity to get more respect and that you took the time out to get the proper schooling to do something that youre interested in because of cassandras financial situation however paying for the diploma was a complicated process at cassandras first transfer institution in year 3 she was on academic probation which had spiraling effects on her college funding and trajectory i didnt get approved for financial aid this semester even after trying to appeal … so i took a semester off because i cant pay for it out of pocket not even on a payment plan because there you have to pay a certain amount up front and it was way too much even for one class right now im just taking on two jobs so that way i can make up for that income since i am on break from school and prayerfully i can go back next semester classes were offered only at times that conflicted with her work and she needed a second job to afford a car cassandra had insufficient time to both work and go to school leading to a drop in grades and ineligibility for financial aid this led to her stopping out of school and switching institutions attaining a bachelors degree was her goalshe wanted to work in psychological counselingbut her perceptions of college financing put that out of reach four other lowermiddleclass students had similar experiences with entering and leaving higher education as finances allowed summary the students in this group show the difficult economic and educational decisions they had to make in receiving some financial aid but not enough to live on while still paying for school cassandra and ilanas time in higher education was strongly affected by all the work they had to do to finance school their experience further shows how lack of money can have cascading effects on financial aid their need to work long hours outside of school caused their grades to suffer leading to problems in receiving needbased financial aid tatiana had a similar route to higher education financing until her familys military benefits provided enough money for her education causing her to have very different experiences with funding college in the course of her higher education journey they all were committed to receiving a degree to meet their professional goals as was promised in narratives about higher education middleclass students middleclass students families were largely collegeeducated and held jobs requiring that degree level middleclass students wanted degrees to keep their class privilege eight of the 15 students identified as female nine as white three as latinx two as black one as asianlatinx six students in this social class group were firstgeneration students eleven of the students had transferred with five of those having graduated three students in this group were using military benefits while in higher education generally the 15 students who identified as middle class thought that college was expensive but that the cost was worth it to retain the social class in which they were raised almost ubiquitously they chose to start higher education in community college because doing so was cost effective they framed taking on debt as stressful but thought that the loans they accrued were reasonable as one student said within this group some students recognized their privilege and others did not regardless of this selfawareness only one of the students challenged what he saw as an inequitable and reproductive system in the next section we spend significant time with two participants in the middleclass group and briefly visit with other students when comparisons or connections enrich the story keeping it middle class dawsons case after dawson graduated from high school her parents paid for her to attend a private christian university in texas but she failed out after one year dawson who is a continuinggeneration white student moved to dallas where she got in trouble and ended up with probation terms that required that she be either in school or working full time her parents agreed to pay for her housing and her education so she enrolled in a local community college system though credits transferred for only two of her courses from the university after marrying and having a child dawson moved back to her hometown and transferred to another community college system around the time she finished her applied associate of science degree dawsons parents decided they would not pay for her to complete her bachelors degree though they continued to support her emotionally in her pursuit of education and materially in terms of childcare help although financial resources were tight dawson selected a highercost online program at a private school because if she had attended school inperson she would have lost time with family that was invaluable she took out between 10000 and 14999 in loans to cover the costs dawson had decided she wanted to be a teacher but was advised that the most expedient path to graduation would be to major in general studies with a concentration in math she graduated with her bachelor of arts degree and was working as a math teacher in a local high school the last time we spoke with her dawsons decision to pursue college and eventually become a teacher was informed by her own life experiences she relished her middleclass upbringing and wanted to provide the same for her children dawson said my mom was a teacher and i loved having her home in the summers and on weekends and my dad was a police officer but he was a police officer for the school district so both of my parents had summers off you cant beat the schedule dawsons initial start in a private 4year school did distinguish her from most of the other middleclass students who framed starting in community college as a lot less pressure with more course availability a cheap cost and no testing requirement as different participants said dawson did not possess substantial knowledge of how to finance higher education but her experience with what she calls fafsa highlights the ways that even moderate financial privilege can buffer middleclass students from financial stress after taking on the costs of tuition dawson got some loans but her mom paid for one semester as a christmas gift and covered her last semester as a graduation gift and dawson was not overly bothered by the loans or the cost of higher education like many of the other middleclass students who took out loans speaking specifically about the cost of the private online school that conferred her bachelors dawson said it was an exorbitant amount but i dont feel like i overpaid i definitely got my moneys worth dawson understood higher education as an attainable investment dawsons middleclass family insulated her from a heavy debt burden and her familys continued financial support allowed her to complete her degree and move into a career that offers the opportunity for a middleclass life although dawsons case is unique in its clarity regarding exactly how much her parents lifestyle could facilitate her educational trajectory nine other students were also able to rely largely on sources other than loans to finance their educations structural critiques of higher education darens case daren was one of those students he was a married veteran of the marines and a firstgeneration college student the oldest of four children from a latinx family during most of his childhood in central texas his mom stayed home to take care of him and his siblings while his father worked in manufacturing daren enrolled in a trade school after high school but it didnt work out and he joined the marines after 10 years in the service he returned to texas and used his gi bill benefits to pursue a government job daren also gained knowledge about how to navigate the broader higher education system from his relationships at veterans centers and the veterans affairs offices for example one veteran center recommended that he begin his studies at a community college since he had been out of school for so long with this support daren was one of few students across our entire sample who found the transfer process seamless daren had the benefits of the post911 gi bill and of texass hazlewood act to finance his education he paid out of pocket only for travel to a study abroad program in central america although he completed the fafsa and briefly considered a 12000 loan he declined to due the interest burden daren was proud of completing his degree in 4 years which he knew a lot of people did not accomplish though proud of his degree daren was the lone student in the middleclass group who spoke adamantly against the economics of higher education for students reflecting on this in year 5 daren said im glad i went to college because the gi bill paid for it its not like it came out of my pocket thats a plus but thinking about college for those without veterans benefits daren said that it is morally wrong that higher education institutions rob students from money they dont have and leave them burdened with this huge debt he observed the bad thing about the us is that college is more of a commodity than a right compared to the situation in other countries that vastly subsidize the cost of education darens knowledge of foreign higher education systems came from his time overseas in the militarytime that is now covering the cost of his own education even though darens first stint in higher education at the trade school was not successful his evaluation of the schools service to the community resonated with all the students in the middleclass group he commented they do a good service with regards to cost as far as cost like tuition you pay a lower cost than you would at 4year college i think community college is the best route for any student thats struggling as far as getting money for school … once you get your 30 hours you can transfer to any 4year college and not worry about that daren also criticized 4year schools for not delivering enough in return for their high costs i believe 4year colleges should do more to bring in students from lower socioeconomic classes he said and also do more to facilitate the experiences of students who are disabled darens pride in his degree and his belief that education was necessary to increase his odds at landing a good job reflected the feelings of middleclass students in our study but daren noted he never would have attended college if he had not had the post911 gi bill to draw on and he was stated clearly that the opportunity to get a degree without debt should not be limited to veterans students in the middleclass group were aware of the benefits their class privilege could give them for financing their education though two other students were skeptical of the value of the degree relative to their expenditures summary the middleclass students expected that their higher education would be expensive but like dawson were willing to take on that burden in the form of loans to maintain their class privilege many of these students also had the benefit of relying on their parents for any financial or emotional support through the higher education journey some of the middleclass students were convinced of the economic benefit of higher education others were less certain daren in particular employed a structural critique of the educational system using a perspective gained through the economic privileges he received from the military financing the uppermiddleclass students were completely willing to participate in undergraduate higher education because of their familial socialization uppermiddleclass students uppermiddleclass students families were both highly educated and high income uppermiddleclass students had a different orientation toward the value of their degrees given the expectations that their parents would cover those undergraduate expenses three uppermiddleclass students participated in the study ellery micah and maria ellery an american indianalaska native student had no student loan debt micah a white student had between 6000 and 9999 in debt and maria a white and asian student had over 40000 in debt primarily from a masters degree maria and ellery had graduated with bachelors degrees and micah was enrolled in a bachelors program these students all began their education in a community college they chose to do so because of insufficient parental funds to go to their firstchoice outofstate institution responsibility for paying for college on their own despite high parental income and not getting accepted to their firstchoice institution ellery and maria both had older siblings successfully transfer from community college a to a 4year institution and valued their guidance on that path micah saw achieving a bachelors degree as his responsibility to set a good example for his younger siblings because of the small size of this group we address shared themes and differences among its members as a whole the parents of uppermiddleclass students and their role in financing college the expectation of the three students in this category and from financial aid sources was that their parents would pay for their educational expenses through their undergraduate years this group had all received private education in k12 that was designed to prepare them for a college education all were expected to go to college and believed that their parents would enable that as ellery said it was just assumed that i was going to go to college after high school ellery and marias parents funded their undergraduate education when maria wanted to continue on to a masters degree however she needed to take out loans for that goal she was at peace with that decision because of her parents contribution to her undergraduate education maria said my undergrad was really cheap but my current program was like 44000 i think … so thats kind of expensive but i mean also that i chose to do it so this is like my undergrad to me it was more of a requirement than a choice because you need or you should really have a degree today but my masters i chose it higher education was worthwhile for maria because it contributed to her goal of independence this group conceptualized a college education as expensive but achievable micahs parents would not give him money directly toward his college expenses micah found college expensive since he was paying for it out of pocket without the benefit of being an independent student for financial aid purposes when reflecting on higher education however micah said it was within reach if people tried hard whether college is overly expensive or not i think theres always a way to accomplish a goal if you really really want it ellery whose parents entirely financed her education and living costs knew how expensive college was because of her parents unwillingness or inability to fund her outofstate choice she said she went to the community college with the intent of transferring because my parents didnt want to pay the outofstate tuition because i didnt get scholarships that i wanted in retrospect she wanted to repay her parents for their investment in her education and its subsequent use for her earning potential education with the potential of being fully funded by others was an attainable achievable goal in the participants psychosocial and educational development discussion in this longitudinal study we examined how students understand college financing how they navigate financing higher education and how that varies across social classes across social class categories and aligning with previous research we find that students chose to attend community college because of its comparative affordability compared to 4year institutions our study shows that students are comfortable using financial aid for their survival expenses not just for costs specifically related to school in many ways any funding received from financial aid was treated as replacement or supplemental income for the money they could have been earning in the workforce loans were a last resort and the least preferred source of replacement income but students were willing to take them on when necessary the different meaning of varied monetary sources is reflected in the terminology students use for particular elements of the college financing process families and family money played a significant role for all students but how much money the family had mediated the way that students from different groups thought about higher education and its financing notably the findings indicate that higher education is not an individual endeavor for students from the working and lowermiddleclass environments it is a family enterprise paid for with family money because funding higher education is a collaborative enterprise undertaken for the good of the whole family participants are not free economic agents making rational choices in their best interests in the free market for those reasons higher education choices are restricted to what is in the familys best interest higher education is a potentially risky familial investment that could affect the entire familys wellbeing to minimize risk students are incentivized to pursue majors and degrees that lead to stable wellpaying jobs such as nursing or accounting rather than liberal arts or other degrees where the transition from major to known career is less certain such as linguistics loan aversion can be read as an attempt to minimize the risk of college as an investment particularly for firstgeneration college students emirs arts degree was a notable exception some participants from the workingclass and lowermiddleclass groups had substantial difficultly with the mechanics of financing college education ilana spent hours trying to prove her financial need to her 4year institution cassandra had to drop in and out of school based on her fluctuating financial situation walter accrued substantial loan debt but no 4year degree we suspect that participants class background social and cultural capital and familiarity with college systems contributed to their experiences on college campuses simply put if they had more money they would not need to work so hard to find it middleclass students did not share a similar concern with the familial orientation of college they hoped their parents would pay as much as they could to finance their college education but that was not a certainty middleclass students expected to accrue at least some loan debt but they were pleased whenever they could avoid it uppermiddleclass students expected that their parents would fully fund their undergraduate college education they felt that their parents owed that to them particularly because the family income level and wealth meant that students would receive only loanbased financial aid students understood that costs of the pursuit of any further degrees would fall on them alone our study adds to the limited literature addressing how these groups conceptualize and finance higher education and offers insights into how students use financial aid terminology the importance of military benefits in financing higher education for both tatiana and daren could represent a future area of study for militaryaffiliated students further we add to the literature about social class and financing higher education by taking a longitudinal approach to the social meaning of money and its role in higher education for students who spent time being educated in a community college setting this addition to the literature provides an important perspective by centering how community college students from the four different social classes addressed make sense of college financing and moneys role in their transfer trajectories the results indicate that although social mobility or maintenance of class privilege is their goal not all students are certain that higher education provided that opportunity for their economic flourishing these findings reflect prior results but dig deeper to understand how the social meaning of money and students experiences in college further shape their orientation toward higher education conclusion and implications for practice our work illuminates how financing higher education plays out differently for students from different class backgrounds as well as how social networks such as family and peers shape students understandings and uses of money for their higher educational goals the lack of clarity and the inconstancy of funding creates additional stress that can contribute to different trajectories in attaining higher education degrees our study has several implications for students our work suggests that students should apply for financial aid as early as possible in their college journeys such as in their senior year of high school and to complete the fafsa even if they believe that they will not qualify for institutional aid we are curious about how the recent implementation of mandatory fafsa completion for high school students in texas for instance might affect this facet of college experience students and their families when they can afford it may wish to apply to multiple institutions and compare financial aid offers perhaps college tours could involve visits to the financial aid office in institutional support contexts our findings suggest that financial aid practitioners and policymakers should be mindful of the language they use to refer to college financing and how that differs from students use this conscientiousness is particularly salient for financial aid versus loans students treat received loanswhether federal subsidized or unsubsidized whether state or privateas a distinct category from what students call financial aid or fafsa which for them refers to grantsmoney they do not have to pay back letters communicating aid to students could be explicit in distinguishing between aid that needs to be repaid and aid that does not assuming students meet the requirements to keep their financial aid given the common perception that loans are a necessary evil in the words of walter and prior literature more college financing could be apportioned in grant or merit aid though we realize this is less feasible broadly we suggest that conversations about money and financing become normalized in higher education outside of the financial aid office classbased differencesamong other factors like firstgeneration status shape students experiences in both higher education and college financing beyond holding financial literacy seminars institutions can find ways to address class experiences creatively and tactfully such as by including students families in their programming communicating messages of belonging to students from all class backgrounds and continuing to promote programming for firstgeneration college students some aspects of students identities like class that can shape their college experience are less apparent to practitioners encouraging a onesizefitsall model of student support that might not meet individual students needs based on their class background navigating college while navigating financial aid systems requires substantial student skill and time as cassandras and illanas experiences illustrate higher education staff and faculty can help develop those skills to establish a more inclusive environment faculty can also be informed about the basics of financial aid to become good informational resources for students the pandemics pause on student loan collection and disbursement of funds through higher education through the cares act temporarily eased financial burdens on students we wonder which elements can be preserved to create a more affordable educational experience examine how marketbased ideas in pk12 and higher education shape inequality opportunity and democracy in the us lauren schudde the university of texas at austin lauren schudde is an associate professor of educational leadership and policy she studies how to ameliorate social inequities in the united states through higher education policy about the editorial team please send errata notes to audrey amreinbeardsley at join epaas facebook community at and twitter feed epaaaape education policy analysis archives

higher education is increasingly expensive and access disparities by race and social class exist yet we lack nuance in the scholarly literature about students understandings of how 1 we would like to thank the greater texas foundation for their support of this researchaccess to higher education depends on its relative affordability for students and their families students who have different access to economic capital because of their socioeconomic statuses possess different collegegoing options attending college often involves risk and high stakes given the uncertainty of returns on the investment manski 1993serido et al 2020 for community college students seeking to transfer the risks are even greater students enroll in community colleges knowing that later in their postsecondary trajectories they are not guaranteed admission to the 4year college of their choice hilmer 1997 researchers have examined how students social class can affect their likelihood to transfer

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healthcare professionals perspectives on elder abuse a recent national study found one in ten of 5777 respondents persons 60 years and older reported emotional physical or sexual mistreatment or potential neglect in the past year it is difficult for persons who are older to report mistreatment victims have many reasons for not reporting elder mistreatment including fear of retaliation being afraid of institutionalization being ashamed lack of information on who to contact for reporting and thinking no one can help in the critical care setting patients are treated for brief but severe episodes of illness and the intensity of the situation may not allow for exploration or thoughts of elder abuse barriers for healthcare providers in the critical care setting for reporting elder abuse are varied and include the patient as potential victim patients familysignificant others and the healthcare provider high patient acuity and lack of consciousness are important factors that hinder reporting of abuse by the patient and when alert and responsive the typical barriers exist ie fear of retaliation fear of being placed in a nursing home powerlessness and wanting to protect their family family members may know or actually be the perpetrators and they deny the abuse for the healthcare provider reporting barriers may be lack of knowledge about the law not wanting to be involved in court cases and not routinely screening for abuse in some states healthcare professionals are not obligated to report elder abuse to adult protective services but in 44 states and the district of columbia they are required by law to report elder abuse guidelines from the american medical association note that a physician may be the only person outside the family whom an elder sees regularly and is therefore in a key position to report elder abuse healthcare professionals attest to viewing cases of suspected elder abuse but fail to report those cases in a retrospective medical record review of 28 thermally injured patients 60 years and older findings indicated that the patients were poorly screened for elder abuse and 7 persons were victims of abuse neglect or selfneglect but only 2 cases had intervention by adult protective services in another study physicians were found to report only 2 of all suspected cases in the same study a substantially larger number of cases were reported by social workers and nurses from 2010 to 2050 the us population is expected to grow from 310 million to 439 million and by 2030 one in five persons will be 65 years and older healthcare professionals in all settings will need to become increasingly aware of elder abuse and reporting mechanisms from 2010 to 2030 the dependency ratio will increase from 22 to 35 persons the higher the dependency ratio the greater the potential burden on health care reasons for lack of reporting are understudied while laws require reporting regardless of mitigating circumstances most healthcare professionals consider the broader context of the patient before reporting including patient autonomy and rights patientphysician confidentiality quality of life and future patienthealthcare professional relationships rodriguez and colleagues interviewed a convenience sample of 20 family and general internal medicine physicians to identify their perspectives on mandated reporting of elder abuse they reported that physicians worry about future physicianpatient rapport and trust patient quality of life and physician control when deciding to make an elder abuse report schmeidel and colleagues expanded that study and interviewed nurses and physicians in primary care settings with a main conclusion that pragmatic elder abuse education is necessary and the reporting system may need reorganization this study continues the authors earlier work and examines the perspectives of other healthcare professionals critical care nurses it has been noted that there is sparse research regarding critical care nurses and their perceptions of elder abuse the purpose of this study was to explore through interviews of critical nurses their perspectives on elder abuse to achieve a better understanding of the problems of reporting and to generate ideas for improving the process this qualitative approach using indepth interviews is appropriate for exploring a complex domain that is not fully understoodin this case perspectives on and barriers to mandatory reporting of elder abuseand is meant to be hypothesisgenerating rather than hypothesis testing methods the methods for this project were approved by the institutional review board of the university of iowa methods are described for subject recruitment instrument interviews and qualitative analyses subject recruitment a list of critical care nurses was obtained from the iowa board of nursing all nurses employed in critical care settings were selected from three counties in iowa a cover letter with the list of interview questions was sent to all 396 nurses also included in the envelope was a form to complete and return in a postagepaid envelope indicating the respondent would participate in the study contact information was provided on the form after receipt of agreement to participate a researcher contacted the respondent and set up a time and place for interview thirtyeight envelopes from nurses were returned as undeliverable no further attempts were made to engage nonresponders after the initial invitation letter instrument and interviews an interview guide developed by rodriguez and colleagues was used for this study the guide had 13 openended interview questions and was developed from literature review and expert input the questions were developed for physicians and were modified for the critical care nurses no demographic information was collected because of the sensitivity of the topic anonymity was protected because a respondent could indicate they were aware of an elder abuse incident and had not reported it which would be in violation of iowa laws one interviewer was trained in ethnographic techniques and she has conducted similar research the interviews were conducted in the respondents or interviewers office at the beginning of the interview respondents were reminded not to indicate who they were or the names of any of the abuse victims interviews lasted from 20 to 50 minutes were all taperecorded and transcribed verbatim qualitative analysis a multistep process of thematic analysis was used to identify the core themes that represent the perceptions of nurses and physicians about elder abuse all transcriptions were entered in nvivo a qualitative software program that allows for coding and systematic searching of interview data after development of a preliminary codebook initial coding was conducted by the interviewer to identify general themes in the responses of all persons interviewed a second coding step entailed members of the research team representing each profession interactively reading through interview transcripts all members of the research team concurred on themes identified during the transcript review results twelve nurses who worked in intensive care units agreed to participate in the interviews during the project 10 nurses were interviewed for an overall interview rate of 83 and 27 of those initially contacted to participate the nurses all worked in hospitalbased critical care units in three iowa counties interview responses are provided within the concepts of types of elder abuse suspicions of elder abuse reporting of elder abuse barriers to reporting elder abuse legislation and improvement in practice types of elder abuse nurses reported the kinds of abuse they may encounter as emotional abuse financial exploitation neglect and physical abuse none of the nurses reported sexual abuse and one nurse stated im trying to think…i dont think weve ever seen sexual…not to my knowledge another nurse stated ive worked in the surgical intensive care unit for over 20 years and i havent seen any signs of any physical abuse partly because as a nurse in the icu youre usually so busy you dont have time to scratch your nose neglect issues were frequently mentioned and described as the patient having many sores on the body bruises needing hygiene care and looking malnourished one nurse reported they will be very filthy theyll have sores its obvious they havent been bathed or shampooed for a long time so we see a lot of that type of thing an example of financial exploitation was provided the patient was on a ventilator controlled life support and the family wanted us to wake him up to sign his social security check and that was kind of like a red flag right there and the patient was in for 3 months and the only time we saw the family was the first of the month when the check came in a report of actual abuse occurring in the intensive care unit was depicted by a nurse i had one case where the wife would come in every day and sat for 3 hours next to her husbands bed and shortly after she left the ventilator alarm would always go off and we could never figure out why and we always ended up changing the tubing well we sat and watched her one day and she sat there with her sewing needles and was poking all these holes in the ventilator tubing and shed called in later asking oh is he still alive so that was something we did report suspicions of elder abuse nurses report being suspicious of elder abuse if the patient 1 depicts being malnourished and unkempt 2 has bruising or other marks on the body with no reasonable explanation 3 has burn marks in places where the patient cant reach 4 cant provide a clear explanation reluctance to answer questions or 5 if a family member hovers or appears uncomfortable with health care professionals present many reported suspicions because of evidence such as sores on their body and the patient being hungry two nurses reported their admission questionnaire asks about their care at home and if they are safe one reported the joint commission standards have mandated that we ask people you know have you been sexually abused have you ever been physically abused and that sort of thing so my particular situation its rare…we ask those questions to an awake and oriented person well most of our people come to us completely anesthetized from the operating room and by the time they do wake up theyre pretty disoriented a nurse described one situation as an elderly gentleman came in with cigarette burns on his back and he did not smoke and a stepson who was a primary care giver did we just kind of figured that had to be the son there was no logical explanation for it other than that and it wasnt a single burn it was multiple burns on his back an example of establishing rapport to confirm suspicions was provided ultimately my goal is to be able to have time alone with that patient if we have a good rapport going on the family will leave if we force them to leave a lot of times that really frightens the patient and that puts up more defenses because then they really think they are going to get in trouble thus suspicions of elder abuse lead to the reporting of an allegation of abuse reporting of elder abuse similar themes were found from all the nurses where reporting of abuse is conducted in the hospital setting according to hospital policy in most instances the nurses reported suspected abuse to the patients physician or the units social worker and in a va hospital one nurse reported i know in the hospital i work in right now that we arent supposed to report it directly to the department of human services we are supposed to go to the federal before we go to state as this is a federal hospital we have to report it to the manager and then the social worker and then she takes it further one nurse said i would report because theres not a penalty to reporting unless you are doing it to be malicious theres no penalty and theres no harm to the patient by me saying something doesnt seem right here stressing the importance of physical injuries one nurse would find the physician probably first so that the physical conditions can be dealt with and then we have our nurse managers and the nurse managers then are required to notify appropriate people nurses generally seemed to let someone else do the actual reporting to the states adult protective services agency no ive never reported the abuse ive told them what ive noticed and then the social worker does the report and another similar response weve got the chain of command our charge nurses or supervisor and so on its always worked we have an excellent social worker another similar theme to reporting was that the nurses didnt know what happens after the allegation is reported to the social worker a nurse described im not sure how the system works as far as reporting up past the social worker…where its supposed to go but id always go to the social worker similarly nurses did not know the end result of the case if it was founded or not a nurse conveyed i dont really know whatever happens afterwards it goes to the manager it goes to the social worker and then it goes to…i dont know like a safety officer or something and then it goes…i dont know where it goes it goes to some federal officer and then state gets notified so its like where does it go its like out there in virtual space or something another nurse said we never find out a result in emergency situations a nurse reported if it was severe enough you would have to call the authorities absolutely call the police and make sure whoever the perpetrator was had no access to the patient and because of the shift changes and staffing another nurse conveyed …because we do 12hour shifts but there are a lot of nurses that take care of these patients so you always want to make sure to give your thoughts and your feedback to give it to the next nurse to be sure it doesnt fall through the cracks because youre not going to come back a week later and be like well you know i thought there could potentially be… you dont want that barriers to reporting elder abuse reasons provided by the nurses why patients are reluctant to report being abused include being scared feeling they deserve the abuse it may get worse when they get home fear of being relocated to a nursing home or different institution fear of abandonment or they dont want to get their children in trouble one nurse stated you have an inverse ratio of power in that relationship whether its with a spouse or a neighbor or a child or whoever the perpetrator is these people are older they are dependent on who ever or at least their perception is that they are dependent on that person for whatever shelter food clothing care money or whatever i think they are afraid to disrupt it another nurse reiterated the same thought people that are codependent on other people tend to need that other person and tend to justify the abuse a similar thread across interviews was that the perpetrator was a relative and they didnt want to get them in trouble the nurse felt the patient thinks oh i brought this child up this is how i brought them up to be they get real touchy when its their kid legislation nurses provided mixed responses about the states legislation including the following we dont need a law the law should be better enforced and healthcare professionals education should be more frequent and content expanded a nurse responded about iowa legislation that i dont really think we even need the law because we do it anyway and another nurse provided a different opinion oh i think it definitely needs to be there because you know without that some people when they notice it well thats too bad but its not me healthcare professionals in iowa are required to report allegations of elder abuse a nurses perception about this reporting was i think that if people feel like its mandatory they have to they are more likely to do it than if they think oh i dont really have to do it i know its wrong but i dont really want to get involved whereas another said the nurses that i know anyway take that seriously and realize that they have made an oath so that if they feel that something is going on with someone that it is their moral and ethical duty to step up and say this isnt right and im not going to let it continue completion of a dependent adult abuse curriculum is required for healthcare professionals beginning when they enter a healthcare profession and every five years thereafter additional content to this curriculum was suggested as more education about it reporting abuse what we can and cannot do and our legal liability are we putting ourselves up for a lawsuit another complaint about the law was the law doesnt lay out the signs and symptoms of abuse doesnt tell you when you see it it doesnt give you that way of noticing the abuse it just gives you a way of contacting the law enforcement it doesnt give you a way of recognizing the abuse or…how to recognize the symptoms i think its adequate but like i said id like to have something on elderly abuse and just abuse in general annually because i dont think every three years is enough in response to the law needing to be better enforced one nurse stated we dont have investigators out there indicating that the law should provide for additional investigators for conducting investigations of alleged abuse another final thought on the law was in the best of all worlds we wouldnt have abuse and then wouldnt need the law improvement in practice various ideas were suggested for improving nursing practice for elder abuse in critical care suggestions included the following conduct health history in private ask safety questions on admission assessment readdress the issue of elder abuse at discharge from the unit establish the reporting of elder abuse as a priority for the unit and offer elder abuse education in addition to that required by law one nurse reports on admissions we ask questions like are you in a relationship where you feel unsafe are you in a relationship where you are being harmed by someone do you want to harm yourself those kinds of things we ask those questions and that gives them an opportunity to say yes emphasizing the need for admission assessment another nurse responded you know i think probably… you have to identify that there is truly a problem and for example a problem there epidemiology comes up documents transmission of one bacteria from one patient to another that can be stopped by washing your hands and they show that there is a problem and if there is problem that it can be changed by doing this so i think that if you could document that there is some type of abuse going on then i think there is more motivation and maybe thats how to change additional education was suggested by providing information about the seriousness of elder abuse a nurse suggested i think it should almost be like an annual thing that they cover in the hospital because i dont know i think with the way the economic situation is out therei just think things are going to get worse instead of better and i think we need to be more aware of that another nurse stated just keeping the education going in conclusion to the interviews one nurse stated i just really think were on top of it not to toot our own horn but i really do i really think that were on top of it… any admission i mean were really looking at those things whether you realize it or not discussion the purpose of this study was to explore the perspectives of critical care nurses on elder abuse to achieve a better understanding of the problems of reporting and generate ideas for improving the process a variety of responses emerged some responses similar for a particular concept and dissimilar for other concepts intensive care nurses are aware of the different types of elder abuse they described different scenarios regarding emotional abuse financial exploitation neglect and physical abuse and noted that none were aware of sexual abuse being aware of abuse is the first step in caring for persons who are atrisk or are victims of abuse burgess and colleagues emphasize the importance for critical care nurses of having protocols in place to detect and manage elder sexual abuse protocols would allow nurses to detect abusive instances but also identify risk factors that may contribute to abuse and establish a mechanism for reporting the suspicion or allegation of abuse these nurses want to do the right thing that is to ensure that victims of elder abuse are identified and properly cared for during their icu stay and after discharge icu policies and procedures must be an integral part of the standards of care hoyt provides a compliance checklist for forensic issues in the icu that includes the following 1 staff orientation for use of abuse and neglect screening tools with appropriate documentation 2 forensic case management criteria 3 management of sentinel events 4 equipment and supplies for evidentiary specimens available in a dedicated locked storage area 5 references and resources available to all staff members and 6 procedures that include collection of specimens photo documentation chainofcustody and reporting referral 16 these nurses did have the intuition for being suspicious of abuse winfrey and smith describe a phenomenon called the suspiciousness factor which is an intuitive sense of heightened alertness based on knowledge and experience that compels a nurse to take action in response to a given circumstance or series of events nurses described reasons for being suspicious and in one instance the suspicion became real when the nurse realized the ventilator tubing was being damaged nurses need to continually be aware to act on their suspicious feelings and to obtain additional information from the patients or respective family memberssignificant others who can provide needed information this extra intense probing must continue until their curiosity is satisfied as noted by one of the interviewees the opportunity for obtaining information is sometimes shortlived in the intensive care setting the nurses indicated the process for reporting elder abuse in the critical care setting is vague and unknown they collect some of the information or enough information to raise concern and pass that information on to the patients physician or the units social worker the actual mechanism of calling adult protective services has not been done by this group of nurses as they are following hospital protocol as a result they never know the results of the report no feedback is provided to them about further investigation by the states adult protective services unit this lack of feedback may be a reason why one nurse thought there were not enough investigators in the state hospital social services could implement a protocol that provides feedback to reporters when they are notified of the decision by adult protective services to accept the report and provide an outcome of the investigation having such a mechanism in place would raise awareness of elder abuse and provide the reporter with more confidence that the extra work of investigating was worth the effort no new information was gleaned from the nurses perceptions regarding the older persons rationale for not reporting elder abuse the nurses described the law for dependent elder abuse on a continuum from not being necessary to the need for it to be in place as healthcare professionals in iowa nurses are required by law to be mandatory reporters a suggestion from nurses in critical care units is that they be notified when the abuse they have reported to hospital employees is actually reported to adult protective services hospital employees who report the allegation of abuse receive the results of adult protective services investigations and should report those results to the healthcare professionals involved in the collection of relevant information while iowa is currently the only state with mandatory training on dependent adult abuse confusion still persists as to the actual law surrounding both abuse and mandatory reporting especially by nurses differing institutional requirements and chains of command may contribute to this confusion however when asked what changes or improvements could be made many people from all groups suggested more frequent and more practical education while currently mandated for every five years in iowa participants requested refreshers to be given as often as yearly they also desired content to focus on specific cases how to identify elder abuse as well as how to best respond some novel and useful suggestions were offered for improving critical care practice in relation to elder abuse assessment for abuse or risk factors of abuse is acknowledged on admission to a unit however one nurse thought this assessment should also occur at discharge from the unit persons admitted to critical care are in critical condition and usually not of sound mind to answer questions or provide relevant information but at discharge their health has improved and useful information may be obtained even though iowa law requires dependent adult abuse education the numbers of elder abuse investigations and substantiations have not changed since 1988 when this law was implemented these nurses believe education is valuable and indicated they want more education than that which is required every five years while this sample size was small it was appropriate in order to fulfill our study purpose which was to identify the range and complexity of issues and barriers perceived by critical care nurses in relation to elder abuse and within the sample size range for similar exploratory qualitative studies our sample was limited to three counties in iowa which report to the iowa department of human services whose elder abuse legislation is different from other states nurses who agreed to participate may have particular interest in elder abuse from prior experience and responses may be different from those who did not participate conclusion critical care nurses are aware of elder abuse and somewhat systematically evaluate for abuse at admission to their unit they recognize signs and symptoms of abuse and are suspicious when it is warranted they are aware of why an older person does not want to report abuse and take this into consideration when soliciting information facts values and experience impact personal approaches to defining abuse suspicion and dependence for each individual healthcare professional promoting the inclusion of elder abuse reporting and investigations in unit protocol andor policies and procedures is warranted for providing quality of care what is known about this topic • elder abuse presents in any health care setting including critical care • in iowa health care providers are required to report suspicions of elder abuse what this paper adds • protocols for reporting elder abuse are needed in critical care settings • barriers for older patients in critical care not reporting abuse are similar to other settings including fear of retaliation perpetrator is a relative and physical injury openended interview questions instructions remember during the interview i will be taping our conversation please provide no information that would identify yourself or any of your patients we are interested in understanding nurses thoughts on addressing elder abuse in the outpatient clinical setting 1 please tell me about the kinds of elder abuse that an icuccu nurse might encounter in the inpatient setting 2 please tell me about any patient situations in which for whatever reason made you think that there may be risk of or probable elder abuse 12 what changes can be made to the clinic setting or environment that will help improve the effectiveness of nurse efforts to address elder abuse 13 is there anything else that we havent talked about that you would like to say about improving nurse effectiveness in addressing elder abuse

aimsto explore through interviews of critical care nurses their perspectives on elder abuse to achieve a better understanding of the problems of reporting and generate ideas for improving the process backgroundin 44 states and the district of columbia healthcare providers are required by law to report elder abuse but the patient patients family and healthcare providers all have barriers to reporting allegations of elder abusemethodthrough a mailed survey critical care nurses were invited to participate in a taped indepth qualitative interview resultsten nurses were interviewed a thematic analysis was used to describe the following core themes types of elder abuse suspicions of elder abuse reporting of elder abuse barriers to reporting elder abuse legislation and improvement in practice conclusionscritical care nurses are aware of elder abuse and somewhat systematically evaluate for abuse at admission to their unit they recognize signs and symptoms of abuse and are suspicious when it is warranted they are aware of why an older person does not want to report abuse and take this into consideration when soliciting information facts values and experience influence personally defining abuse suspicion and dependence for each individual healthcare professional relevance to clinical practicecritical care unit protocols andor policies and procedure for reporting elder abuse are needed in critical care settings and are warranted for providing quality of care

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century following the sharing economy trend and benefiting from advances in communication technologies mobility as a service became a promising avenue for more sustainable inclusive and efficient mobility however despite interest from academia and other urban stakeholders the practical benefits of maas concerning environmental and social challenges remain largely unknown current transport theory and practice give a central role to accessibility both as one of the main aims of mobility planning and as a nonmaterial primary good to be taken into consideration from the point of view of justice the ability to easily reach a desired destination has tangible direct and indirect benefits for peoples quality of life and theories of justice indicate that a just system should aim for the morally proper distribution of benefits and burdens over members of society together with the landuse system access to transportation is crucial to guarantee social inclusion as it offers equal access to opportunities such as employment essential services and recreational facilities however access to opportunities is unfairly distributed within many territories and societies indicating that transportation systems are a source of unfairness in this context we hypothesize that although maas was intended to be an efficient sustainable and convenient solution its practice suggests that it could generate socioterritorial inequalities if not adequately integrated the first wellknown definition of maas is given in hietanen who describes it as a mobility distribution model in which a customers major transportation needs are met over one interface and are offered by a service provider it is a recent concept still evolving which lacks a solid understanding many authors have sought to address this gap by evaluating the state of the art several reviews have explored maas from different points of view these include technological advancements business models theoretical conceptualizations travel behavior impacts the implications of local policy and governance and endusers perceptions other reviews have examined the impacts of maas on environmental sustainability and social conditions it is interesting to note that all these authors recognize that maas may be a solution to current mobility problems but while some recognize it as a potential source of inequality none evaluate the relationship between maas and stis or justice this paper addresses this gap by examining accessibility for different social groups and territories the present article reviews the literature on realworld maas applications and evaluates their effects on stis our findings are structured into three main axes first we define the functional structure of maas along with its promises and expected results second we identify several components that can be used to evaluate transportation inequality benefits and burdens the affected members of society and the underlying distributive principles third we investigate how the maas concept and current implementations perform in terms of equity and justice with respect to access to the system itself its impact on access to opportunities its practical effects on societal behavior and perceptions and its impacts on citizens wellbeing our results clarify the scientific and technical gaps regarding maas and geographical and social inequalities this review is structured into five sections including this introduction section 2 presents the concept along with its expected benefits and burdens and section 22 discusses inequality from a transportation point of view section 3 presents the methodology section 4 presents the main findings and in section 5 we discuss maas schemes and their association with stis in depth conceptual background although its practical benefits and future consequences are still largely unknown mobility as a service has been growing worldwide since its first official appearance in 2014 in finland it promised a onesizefitsall solution that could revolutionize the future of urban transport according to heikkilä maas is a system in which a comprehensive range of mobility services are provided to customers by mobility operators in other words it is a service that through a shared digital channel enables users to plan book and pay for multiple types of mobility an alternative definition is given by durand et al where it is envisaged as a concept that integrates existing and new mobility services into one single digital platform providing customized doortodoor transport and offering personalized trip planning and payment options the latter definition stresses the requirement to satisfy the users needs and the integration of multiple modes within a single interface normally requiring the use of a portable device connected to the internet as the term suggests the main objective of maas is to allow individuals to access relevant opportunities without the need to own a means of transport thereby transforming mobility into a service that can be used whenever needed several elements repeatedly appear in discussions about maas these include multimodality the integration of transport modes multiplayer cooperation usercentric services tailormade solutions packaged or payasyougo payment options account registration demandoriented services technology integration and a single digital platform ariasmolinares and garcíapalomares identified the following maas goals to integrate smart mobility systems with public transport or traditional transportation modes while incorporating a useroriented approach centered on a single mobile phone application that concentrates realtime information a multimodal journey planner and payment integration for multiple modes of transport in the form of mobility packages maas structure and levels of integration maas systems rely on the integration and cooperation of at least five key players transport users ie customers who hire the mobility service to access a particular destination transport operators who supply the mobility service by providing their vehicle mobility brokers who sell the mobility service to users by providing a platform that connects and organizes interactions between them data and technology providers who operate telecommunications systems and supply technological solutions and policymakers ie public authorities who are responsible for enforcing regulations and protecting societal goals conceptually customers interact with suppliers via a mediator this interaction relies on existing channels while all players are subject to governmental agencies in practice the level of participation of these key players is not always balanced the relationship between government and nongovernmental players may vary depending on the political environment the level of regulation and how public contracts are awarded how maas schemes allow these players to interact illustrates how interconnected and integrated the solution is if we take a multilayered scheme as a practical example the first interaction layer emerges as transport users access information through a technological solution a second layer comprises the mobility broker who acts as an intermediary between transport users and the timetables and itineraries provided by operators a third layer consists of physical interactions between transport users and vehicles provided by operators these layers are not necessarily chronologically or spatially orderedillustrated by the overall interaction between users operators brokers regulatory agencies or other law enforcement bodies how these parts and actors interact is a key element in discussions about maas integration maas integration several authors have defined schema to characterize transportation systems in terms of the level of maas integration for example sochor et al and ho et al identify four incremental levels the integration of information booking and payments bundled services and societal values the latter authors note that the main limitation in current maas systems relates to the highest levelthe integration of societal goals alternatively lyons et al interpret integration from the perspective of the cognitive effort of users they identify five levels no integration the integration of operational and multimodal information the integration of limited modes the integration of all modes in certain circumstances and the integration of all modes in all circumstances finally bandeira et al state that current analyses of maas integration levels neglect important dimensions such as geographic coverage and sustainability they propose six categories environmental policy social cohesion personalization it integration multimodality and geographic area rating them from 0 to 5 to provide a final score based on the sum of each category full integration operational informational and transactional integration for all journeys 4 societal goals integration policies incentives etc societal goals integration policies incentives etc full integration under certain conditions not all modal combinations offer a fully integrated experience 3 service integration contracts bundles subscription etc service integration contracts bundles subscriptions etc partial integration some journeys offer a fully integrated experience 2 bookingpayment integration tripfind book and pay booking integration public or deep linking or via an api limited integration information integration across some modes with operation integration payment integration single payment to all providers payment for monthly trips 1 information integration multimodal travel and price planner information integration multimodal travel and price planner basic integration information integration across modes 0 no integration separate individual services no integration separate individual services no integration no operational information or crossmode transactions the above approaches exemplify attempts to characterize maas integration but are not free of limitations for example it is not immediately obvious what being a level 4 maas system means beyond the number furthermore characterizations are assumed to be incremental for instance a system that is classified as level 4 is assumed to encompass the benefits of all the lower levels however this may not be true as a system may meet level 2 requirements but not those of level 1 this point is illustrated by ridehailing companies that allow singletrip planning and payment but do not offer multimodal integration although the approach presented by bandeira et al introduces more dimensions it gives the same weight to all categories which can be misleading if we want to assess the system from a sustainability or equity perspective moreover the final scores lack meaning and only allow a numerical comparison of levels these observations highlight that the literature lacks a descriptive system that makes it possible to rank and compare different maas systems using societal impact as a cornerstone such a methodology would allow practitioners and researchers to characterize identify and properly assess different maas systems benefits and burdens maas is expected to bring benefits to a wide range of stakeholders users are expected to have a better experience increased access to opportunities lower transportation costs shorter journey times reduced car dependency and better wellbeing the public sector is expected to benefit from better transport information better resource allocation fewer traffic accidents and a more reliable system operators are expected to benefit from access to a new profitable market enhanced traditional transport options and the expansion of business opportunities for data providers however there is little empirical evidence of the benefits of maas reported outcomes include a reduction in per capita vehicle kilometers traveled increased trip awareness and planning a potential shift from private cars to active modes reduced private vehicle ownership and parking demand improved social equity and a reduction in the impact of home and work locations on transport costs maas is also reported to potentially improve service quality supply better data and mobility information and increase price competition it has in a few limited cases been shown to make it easier for citizens to access and utilize complementary mobility services on the other hand the new maas paradigm could be a barrier in certain cases in addition to the challenges faced by operators and the public sector which encompass supplyside issues along with governance and business models these obstacles may also affect end users examples include economic barriers associated with bundled maas prices technological barriers for lessproficient individuals and geographic barriers stemming from the spatial and temporal coverage of systems the negative effects of maas usage should also be considered in particular various attributes may prevent the system from being developed to its full potential or even prevent users from accessing it for instance maas may compete with active transport modes or traditional pt systems this can happen when maas schemes do not incorporate incentives to meet societal goals which is one of the most complex elements of maas integration such aspects are not discussed in the literature due to the lack of fullyfledged maas schemes transport inequality maas may have a negative impact on social and territorial equity it is wellknown that transport is a source of inequity associated with social and territorial exclusion transport inequality is understood as differential transport conditions for distinct groups while exclusion is a state where an individual or group is unable to participate in activities that are considered normal in a specific civil society while there is a clear association between transport inequality and poverty it is repeatedly associated with many other social issues a clear example of transport inequality relates to the conditions that users of private and pt systems are subject to simply put lowerincome households have less access to both private vehicles and central locations as prohibitive costs force them to reside in the most poorly served suburbs this creates a precarious situation for families that must rely on slower modes and endure longer commuting times in less comfortable conditions other authors explore transportation inequality from different perspectives following church et al lucas discusses the social exclusion aspect of transport understood as difficulty in physically accessing opportunities that depend on transport systems it could be said that transport exclusion reflects a disconnection between residents and many key activities banister sees transport inequality as the disparate conditions that exist for distinct socioeconomic groups when accessing transport infrastructure similarly lucas et al discuss the idea of transport poverty which encompasses an inability to pay for transportation a lack of transport and the difficulty of reaching key destinations gössling conceptualizes urban transport justice as resulting from unequal risk exposure the distribution of space and the value placed on the transport time overall these ideas bring the concept of transport inequality closer to that of accessibility pereira et al develop the concept of distributive justice and argue that a deep understanding of justice in transport demand depends on a better understanding of accessibility and human capacity martens et al define equity and justice as the morally proper distribution of benefits and burdens over members of society and list three key components of transport equity distributive principles that determine if a distribution is morally proper or not benefits and burdens and the social groups affected by this distribution the first component distributive principles relates to several theories of justice that discuss the fair allocation of benefits and burdens in society all plausible theories of distributive justice share the general idea of equality however this does not mean that they all agree on what benefits should be equally distributed while one defends the right to equal income and wealth another defends the equal right over ones labor and property nevertheless equality is a fundamental concept that is used to support how individuals in a social organization should be treated therefore the debate about justice theories and distributive principles is not founded on the question of the acceptability of equality as a fundamental value but rather on how to interpret it or what benefit should be equally distributed the second key component of transport equity refers to the benefits and burdens that are used in its assessment the choice of what to measure is important because decisions about how to supply or manage transport systems may create disparities among the social groups that compose society in this context martens et al organized benefits and burdens into the following four focal variables based on the social justice literature resources relate to individual or household attributes for example owning a car the availability of bicycle infrastructure the availability of an unpolluted environment opportunities and risks relate to the implications of holding certain resources as it is possible to hold a resource but lack opportunities while other conditions may pose a risk outcomes are objectively measurable benefits or burdens wellbeing refers to peoples subjective perception of their situation which results from the interplay of resources risks and opportunities outcomes and context the third key component is the classification and identification of social groups that are affected by unfair conditions this involves evaluating groups that are most likely to experience disadvantageous transport conditions several papers classify social groups based on for example income gender age ethnicity or disability maas like any other transport supply system can affect equity conditions especially in terms of accessibility linking maas integration levels with transport equity assessment tools seen through the lens of accessibility seems a plausible way to evaluate inequalities created by maas schemes systematic review methodology this study presents the outcomes of a systematic literature review of maas studies based on scientificallysound papers a key incentive driving the deployment of maas systems is that they offer a competitive alternative to private cars mainly due to solutions based on intermodality therefore in this review we understand maas as a system that integrates several modes although as stated in section 21 integration levels are not incremental our study focused on realworld applications of maas scopus and sciencedirect metasearch engines were used to identify peerreviewed articles or conference papers while book chapters and the gray literature were not considered the method is presented in figure 2 the keywords used were maas or mobility as a service or shared mobility and case study experiment pilot trial program impact and application in the domains of social sciences engineering environmental sciences computer sciences decision sciences econometrics and finance merging results from both search engines resulted in 2009 distinct papers next we filtered the dataset to identify papers that assessed transport inequality in this step we used the rayyan software package to enter 10 relevant keywords equity equality justice exclusion socially disadvantaged this resulted in 146 distinct papers that had at least one of these keywords in the title abstract or as a keyword next we used these preliminary results to expand the scope of the review specifically we fished from within the pool of 146 preselected papers another 11 inequalityrelated keywords vulnerable publicprivate preconditions discounts equitable barriers elderly users needs inclusiveness disabilities and poverty which helped us identify an additional 164 papers bringing our total 310 these were later filtered to exclude unrelated topics such as autonomous vehicles or carbon emissions this resulted in a final total of 166 distinct papers we then read the abstract of all these papers and excluded those that were not rwaoriented which limited our selection to 20 articles these steps highlight that despite the high number of recent articles on the topic of maas assessments of the societal factor based on rwa or empirical data are scarce the findings reported in the selected papers were then evaluated in terms of how they reflected inequalities associated with a maas scheme we adopted the resources opportunities outcomes and wellbeing approach given that it provides an analytical framework to conduct a systematic equity analysis furthermore it is one of the first approaches designed exclusively to measure equity in the transportation area this approach focuses on the individualuser and not on other stakeholders which could be a limitation however as we aim to identify stis it fulfills our requirements equity measurement in transport is still in the early stages of development and hence there are no defined indicators to address it as there are in other fields such as housing or health our analysis indicated that resources reflects access to maas schemes in other words how easy it is for a potential user to use the system opportunities refers to accessibility provided by maas in other words how maas schemes enhance opportunities to reach desired destinations based on peoples resources outcomes refers to objective measurements of travel patterns and activities finally wellbeing refers to the travelers subjective assessment of their travel choices the reported rwa case studies illustrated the four roow classes for each maas scheme we searched for textual evidence associated with the core elements of each class beginning with r we searched for argumentative evidence of conditions that might affect access to the maas system and classified them into six broad categories budget location readiness savviness vehicle and infrastructure for instance resources were associated with a budget if the system had a minimum entry price they were associated with savviness if they required an understanding of complex technology and they were linked with infrastructure if access was hindered we applied the same logic to the other three categories turning to op we classified opportunities into three categories based on costs time or equity for instance systems could have an observable effect on total transport expenditure the amount of time spent in transit or differential access to opportunities regarding ot benefits were identified if a paper reported changes in travel patterns resulting from maas usage these changes were grouped into four categories and reported either numerically or descriptively finally for w we searched for reports of travelers opinions perceptions or any descriptions of satisfaction levels an initial examination of each trials characteristics revealed some noteworthy first impressions only three studies were run in lowincome nations raising concerns about maas affordability equity and the potential for transport gentrification in terms of geography most studies were undertaken in europe and asia neglecting places such as south america and africa it should be noted that some studies do not present the case as a maas system however they were included because they addressed multimodality and transport integration regarding the impact of maas on active travel and sustainable modes while there was no direct mention of escooters 16 of the 20 studies addressed bikesharing in association with pt in general the assessed studies explored a variety of modes and payment options and remarkably some took place in rural or lowdensity areas with the aim of evaluating the potential of maas to overcome transportation challenges in these locations the analysis revealed significant differences between trials concerning the context and the development stage due to the complexity of deploying a multimodal digital transport pilot most cases were based on small samples which jeopardized generalizing their results as acknowledged by several authors highlighting the importance of conducting bigger pilots some used significantly bigger samples and treated participants as active system users finally a few trials focused on the operators point of view rather than users assessment of maas benefitsburdens based on the roow approach in this section we evaluate the impacts identified in maas trials with respect to the four classes of benefitsburdens reported results were classified as a function of resources relevancy for adoption opportunities outcomes and whether there was a positive or negative effect on wellbeing it should be noted that some papers reported no results regarding one or more of these items table 4 presents the results of our evaluation and lists the main conclusions for each of the four classes it is interesting to note that even though some papers assessed the same trial the results of the roow analysis offer different perspectives results summary according to the roow approach a summary for each focal variable is presented as follows resources the reviewed articles suggest that access to maas systems is affected by six major factors they are i budget the impact of the service on the end users budget which determines whether an individual or family will be able to afford the provided service ii savviness how easy or difficult it is for potential users to understand interact with and benefit from the technological solutions that support service usage iii coverage spatial availability related to the distance between the origin destination and the systems entry point iv infrastructure the physical characteristics of the system provided to users v vehicle limitations imposed by vehiclebased conditions either from the users or the operators point of view vi readiness system and users temporal availability or synchronicity only a few papers discuss inequality in terms of resources both abdelwahab et al and jiao and wang extensively discuss locational inequality while the latter also explores the unequal spatial distribution of benefits with respect to general costs for those who adopt integrated modes other papers only briefly mention possible equity benefits and do not debate the topic in detail opportunities some of the reviewed papers recognize that maasoriented systems might objectively affect users access to opportunities although we found evidence of accessibility measurements in 13 of the 20 reviewed papers the issue was not explored in detail instead the discussion was limited to three types of generic comments presented below i time gains in terms of commuting time parking time and shorter distances ii cost in most cases costs were discussed in generic terms only one paper presented a detailed cost comparison iii inclusion understood as better accessibility for mobilitychallenged groups due to maas usage was mentioned in several papers furthermore we noted that most papers that directly addressed societal impacts were focused on multimodal systems and not specifically maas while this could be due to the novelty of maas systems researchers and practitioners should consider this point in the design and operation of services outcomes reported outcomes could be classified into the following four categories i modal change relates to decisions taken by maassystem users to replace one mode by another our analysis indicates increased usage of several modes competition between maas systems and pt shifts from cars to other modes and cases where car users resisted change ii total trips refers to a change in the number of trips undertaken by participants such changes were either observed as a simple increment in the total number of trips or as improved mobility other papers observed changes in the total number of trips made by private car iii distance refers to the observed change in trip distance due to maas adoption results indicate that ondemand service rides are shorter than trips made by car or transit that there is a reduction in km driven per month and that more short trips are made iv preference refers to behavioral change this outcome encompasses the direct effects of maas adoption on participants behaviors excluding modal distance or frequency changes it indicates difficulties in retaining maas users after the trial period or its effects on users values and habits only a few papers reported no outcomes moreover it is noteworthy that papers that were focused on operators reported limited observable outcomes and mostly relied on historical data wellbeing wellbeing required an analysis that went beyond observations of system usage only studies that incorporated questionnaires and interviews reported wellbeing data seven papers did not report how participants subjectively perceived the implementation of maasoriented systems the other thirteen interpreted perceptions as positive or negative i positive feedback in general this was reported in terms of general satisfaction savings promoted by the system a less positive attitude towards cars or a more positive attitude to alternative modes ii negative feedback users were unhappy with limited coverage technical shortcomings such as a lack of planning apps or ebikes with flat batteries and waiting times at least three papers are particularly notable strömberg et al specifically focused on capturing users perceptions and classified them into behavioral subgroups sochor et al carried out an indepth evaluation of satisfied users motivations and eckhardt et al used a satisfaction assessment to compare cases however none of the reviewed papers carried out a subjective wellbeing assessment with respect to inequalities or justice inequality and justice the reviewed papers either directly or indirectly analyzed possible sources of inequality notably costs proximity to certain infrastructure differences in age and gender and technological literacy these factors indicate some potential positive and negative impacts of maas when maas adoption is limited by high prices unfair competition with private vehicles or technological barriers any existing unequal transport conditions are carried into the new solution and deserve attention beyond the problem of being able to access maas as a transport solution inequalities arise from the ability to physically access the system the reviewed studies lack clarity regarding the accessibility potential associated with maas qualitative results say too little about improved conditions for users seeking to reach their destination and quantitative results do not specify a time or any other formal indicators of accessibility gains on the other hand reduced costs are noted for both end users and the public sector which can be seen as an accessibility gain the evaluation of accessibility loss and gains remains a gap in the literature that maasoriented trials have not addressed this observation applies to both objective and subjective measures that should be applied to potential inequality criteria among the social groups discussed one of the reasons for the lack of sti assessments could be that four of the 20 trials were analyzed from the operators perspective where the main goal is to design a profitable service however it is precisely in these cases that public organizations should intervene and guarantee that maas implementation is aligned with societal goals and reduced stis finally while the goal of our review was not to assess accessibility per se the reported trials could be a potential data source for a comprehensive accessibility analysis and estimate of impacts on stis the results of such a study could become a tool for researchers and practitioners worldwide who must make decisions about maas design implementation and governance discussion and conclusions this paper sought to explore three aspects of maas the first is their structure although the theory is presented in hundreds of papers the concept only becomes tangible when maas schemes are implemented in practice rwa applications show the actual appearance of maas reshaping the abstract concept to align with practical constraints the second relates to transport inequality which although widely discussed in the literature is rarely linked to maas this review presented a way to evaluate maas schemes with respect to four components of inequality through the roow approach the third aspect refers to how existing maas schemes address stis which are rarely discussed in the literature this review found that from a rwa point of view little is known about the impact of maas on stis after filtering out theoretical and conceptual works only 20 rwabased papers remained and of these only two directly considered the implications for equity or accessibility after applying the roow analytical framework we conclude that maas might have both desirable and undesirable impacts on stis on the positive side maas schemes provide access to new modes that would otherwise be hidden from users and may serve as a solution for both rurallowdensity areas and healthsocial carerelated trips by providing ondemand services on the negative side maas is perceived as expensive hence it is a barrier for lowincome people the latter together with the need to be digitally literate could generate social exclusion furthermore there are equity issues such as limited internet access limited geographical coverage or prohibitive entry prices finally the legal framework may hinder privatepublic collaboration in this context institutional design is crucial to mitigate any negative effects of maas on sti in particular spatial injustice could emerge if transport authorities only serve areas where there is strong civic support our analysis found that the reviewed papers did not measure the social benefits that maas could provide none of the case studies presented a clear policy to incentivize the adoption of transport modes that are aligned with collective values such as environmental sustainability or equity some schemes included pt as one of a range of options which in other circumstances might have been rejected by more caroriented users however this alone is not enough to classify a scheme as aligned with broad social values leaving the final decision of whether to use a more sustainable option to an end user who is under market pressure cannot be seen as a societalvalueoriented approach the main advantage of the private car over public transport is its flexibility versus the rigidity of the latter regarding routes coverage and schedules maas has the potential to provide flexibility to public transportation travel as the integration of several transport modes that maas encompasses allows to overcome wellknown issues such as limited coverage delays uncertainty and even scheduling associated with public transport for instance maas offers the possibility of demand responsive transport for transit deserted or lowdemand zones as well as a white label api marketing app development and technical support a concrete example of this is the case of the shotl service in the scottish highlands which allowed smart city technology to a rural area improving the level of service and even reducing operational costs we argue that maas should not be seen solely as a solution to reduce private car trips but rather as a means to improve accessibility of noncar users and as a tool for public authorities to enhance and gain control of urban mobility by exploiting its potential more studies on this end are needed to assess how these innovations would impact equity considering not only the horizontal but the vertical cost of its implementation turning to opportunities to improve maas there is a need for wellfunded public awareness campaigns as their absence directly impacts accessibility the potential use of maas to move goods and for companies to provide maas subscriptions to their employees should also be assessed from the operators perspective trust is essential for data sharing between stakeholders and maas solutions should be contextspecific rather than onesizefitsall however given that most maas systems are run by forprofit companies it is unrealistic to expect the private sector to ensure public services and provide equitable mobility services to all populations only time will tell if the maas models offered by private companies are aligned with governmental objectives such as limiting car usage and providing an improved pt infrastructure with fewer subsidies the literature on the broader implications of sti for maas governance remains underdeveloped and this gap has been repeatedly highlighted in recent publications maas implementations will challenge governance and policy frameworks in new ways our review highlights that at the present time most maas schemes are focused on questions of viability whether people are willing to pay for the service and whether demand will increase hence the intervention of public authorities is mandatory to guarantee transport justice the roow approach gives us some hints on how to move forward from a roow perspective maas schemes contain at least three factors that may drive exclusion each reflecting a distinct tier of inequality people may be excluded from entering the system due to a lack of basic resources not being covered by the systems supply infrastructure or simply not benefiting from its intended positive results each of these factors may be unequally distributed across societal and economic groups or geographical areas another potential dimension which is not discussed in the reviewed papers concerns disparities between generations reflecting a timebased inequality that is closer to the concept of sustainability given the early stages of maas development the cases analyzed were mostly pilots or smallscale interventions limiting our findings to the current state of the art which could be steered in the future considering the rapid evolution of the maas concept and systems if the users accessibility is not prioritized stis will most likely increase because of maas implementation future work should clarify how public authorities could intervene and what role they should play in maas implementation operation and governance for instance transport authorities need a transformation to be able to handle the management of mobility databases and platforms so they can enforce an opendata policy for operators and serve as a trusted third party while holding control of the users information also they need to be able to assess whether new mobility services or technologies contribute to the citys transportation policy objectives before providing support it would also be interesting to investigate stakeholders awareness of stis and their ability to guarantee mobility services in deprived or lowdemand areas with the correct approach maas could be used to both successfully fill transit deserts and reduce inequality four basic questions should be raised who will or is planning the system operating it financing it and which and how will inhabitants benefit from it finally the literature lacks a comprehensive method to assess maas systems current integrationlevel approaches preclude comparisons or rankings given their incremental perspective this could be achieved by considering the different interaction opportunities between players interactions between players may occur via several elements for a robust solution maas schemes should encompass these elements in their solutions the more interactions they facilitate the higher the integration level should be

in the twentieth century mobility solutions were focused on private motor vehicles not only did these solutions alter the urban form

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i introduction the environmental movement has emerged as one of the forces of civil society facing the power of capital and the state public space as a network of citizens who voice public interests plays an important role in public policy making in the case of the indonesia berkebun movement for example the strength of the netizen social movement lies in its capacity to use social media and develop discourse in the digital media public sphere the implementation of environmental communication strategies has been considered as one of the keys to success in environmental campaigns in many countries environmental communication is communication about environmental affairs it includes all the diverse forms of interpersonal group public organizational and mediated communication that shape social debates about environmental issues and problems and our relationship with the rest of nature the goal of an environmental campaign is essentially to spread core messages to unlock public awareness and participation this goal can be achieved if organizations are able to design key messages through storytelling that draws inspiration from local knowledge or environmental wisdom the experience of dealing with disaster situations or environmental crises contributes to citizens involvement in environmental campaign movements such involvement is a consequence of their communicative actions the consequences of this communicative action can clearly be seen from the emergence of an environmental campaign movement led by a number of young disaster survivors in toaya village in sindue district donggala regency central sulawesi their village was severely affected by a series of earthquakes tsunamis and liquefaction in august 2018 based on bptp data in 2019 toaya village was among the 7 villages that suffered heavy damage to their agricultural land damage to the irrigation system has triggered fears of a food crisis after the disaster a number of young disaster survivors initiated a communitybased reconstruction program in toaya village this action program involves several youth communities to contribute to ecoaction since 2019 they established institute tana sanggamu as an organization of young disaster survivors through the organization they work to build community knowledge by creating agricultural classes and communal organic gardens the tana sanggamu institute also conducted important research namely collecting social data and geospatial data which was then written into a book entitled ngapa nu rangaranga history and dynamics of toaya village community in facing disaster the ecoaction environmental campaign was able to increase the visibility of the issue in toaya village however as media coverage of the impact of the disaster in toaya and other areas of central sulawesi declined so did public attention to environmental issues related to the impact of the disaster this situation is feared to lead to apathy and helplessness towards environmental issues to overcome these problems an appropriate communication strategy is needed its success will depend on how the survivor community is able to carry out environmental communication tasks in its campaigns more than ever there is a need to communicate environmental information that reaches and attracts segments of the population that are usually reluctant to engage in environmental discourse this research will answer the question below how the eco action digital campaign practices carried out by young disaster survivors in toaya village how is the environmental communication model in the digital ecoaction campaign in toaya village ii research method this research uses a qualitative approach method according to creswell qualitative research is a method that investigates a social phenomenon and human problems researchers create a complex picture examine words detailed reports from respondents views and conduct studies in natural situations sugiyono stated that the qualitative method is also referred to as a constructive method because with this methods scattered data can be found then constructed in a theme that is more meaningful and easy to understand qualitative research methods are often called naturalistic research methods because the research is conducted in natural conditions the research location is located in toaya village sindue district donggala regency central sulawesi the subjects of this research were determined through purposive sampling technique where the informants were selected based on predetermined criteria head of tana sanggamu foundation volunteers who have been involved in environmental advocacy programs in toaya village communities who have indepth knowledge of environmental advocacy activities carried out in toaya village the analysis technique in this research refers to qualitative analysis techniques by collecting data directly in the field the results of the data obtained in the field are then narrated and then grouped and sorted data that are considered to be used as a reference in the data analysis process data analysis techniques according to creswell begin with preparing and organizing data for analysis then reducing the data into themes through the process of coding and summarizing codes and finally presenting the data in the form of charts tables or discussions iii study literature there are some literatures that are used to analyse this research topic a environmental communication the application of environmental communication has been considered as one of the keys to success in environmental campaigns in many countries for this reason a number of experts have even developed the concept of environmental communication as a separate scientific study professor hafied cangara and his colleague from the philippines alexander g flor for example separate this concept from development communication which tends to ignore cultural aspects in its study and application both argue that environmental communication programs must always contain cultural dimensions this is because forms of environmental communication can always be seen in traditional environmental wisdom in the form of myths and folklore passed down from generation to generation from this perspective storytelling and appropriate media selection become key components in the concept of environmental communication in the united states robert cox et al developed environmental communication from the concept of mass communication specifically environmental journalism according to cox environmental communication is a pragmatic and constitutive means of providing people with an understanding of the environment as well as our relationship with the universe from coxs perspective environmental advocacy must first be directed at developing discourse in the media public sphere in line with the concepts of robert cox pezzullo and flor cangara the goal of environmental campaigns and advocacy is basically to spread core messages to open public awareness and participation this goal can be achieved if the organization is able to design key messages through narrative and has the capacity to produce and use mass communication media to spread the narrative environmental appeals when done effectively can be framed in a way that does not conflict with a persons values or their personal interests environmental communication aims to improve peoples ability to respond to any appropriate signs from the environment according to human civilization and natural biological systems environmental communication according to robert is a pragmatic and constructive medium to provide understanding to the public about the environment through the main communicators in environmental communication are government and nongovernmental organizations that have a commitment to environmental management fatonah argues that environmental communication is one part of sustainable development communication namely all efforts and ways and techniques for conveying ideas and skills from those who initiate development aimed at the wider community so that people can understand accept and participate rico servaes classify environmental communication as one of the thematic subdisciplines in the field of development communication and social change that addresses all interactions between humans and the environment recommended font sizes are shown in table 1 b environmental advocate conceptually an environmental advocacy campaign is a strategic action involving communication undertaken to achieve a specific goal within a specific timeframe and target audience as such environmental campaigns are broader than simply questioning or criticizing government policies or environmental impact activities in their classic study of campaigns everett rogers and douglas storey identified four features of most campaigns 1 campaigns have a purpose that is specific results are intended to result from the campaigns communication efforts 2 campaigns are aimed at large audiences 3 campaigns often have a specific time limit 4 campaigns involve a series of organized communication activities inspired by rogers and storey robert cox pezzullo identified three key points in environmental campaign design namely the goal audience and campaign strategy every campaign initiator should ask three key questions what exactly is the campaign trying to achieve which decision makers have the ability to respond and what can persuade those decision makers to act in accordance with the campaign objectives social media has become one of the most effective tools in reaching many people including marginalized groups social media is also effectively used in natural disaster risk communication in various environmental issues social media has been proven to provide appropriate solutions the ability to manage social media is relevant in efforts to foster disaster awareness promote sustainability and market environmentally friendly products c storytelling for environmental campaigns the american national storytelling network defines storytelling as an ancient art form and a valuable form of human expression storytelling is an interactive art of using words and actions to reveal the elements and images of a story while encouraging the imagination of the listener storytelling has several characteristics that are indispensable in environmental communication storytelling is interactive as it involves twoway interaction between the storyteller and the listener to build closeness and impact of the message storytelling uses spoken language that tends to be simple and easily understood by language users environmental advocacy organizations often communicate climate change issues by sharing apocalyptic narratives to convey the need for immediate action according to the same repetitive narrative pattern not only creates boredom among supporters but also means missed opportunities to engage potential new alliances this is exacerbated by peoples tendency to consume stories that affirm their social identity and disengage when stories challenge their assumptions and beliefs the study by kahan et al found that the people most likely to deny climate change were actually the most science literate their research suggests that apathy towards climate change is not due to a lack of information but from threats to participants social identity and position in their social group if the environmental advocacy community doesnt deliberately organize how they share their stories they can end up only speaking to people who see the world as they see it thus further entrenching divisions to counter this dynamic they need to break the traditional fairytale script by changing the plot structure and emotions elevating the cast of new characters and creating experiences that audiences want to participate in d convergence communication model the convergence model of communication was developed by lawrence kincaid and his colleague wilbur schramm compared to other communication models that form the basis for environmental communication campaigns the convergence model is considered more holistic as it breaks down the whole into parts and isolates these parts from each other therefore it will be more sensitive to the cultural context of the communication action this holistic feeling is based on the eastern concept of appreciating the totality and dynamism of experience in the context of environmental campaigns communication should not be considered only as an enabler of environmental management but as an integral part of it without this essential component the entire environmental endeavor is jeopardized iv result based on the history toaya village is one of the villages in sindue subdistrict sindue district central sulawesi province as the capital of the subdistrict the village is quite densely populated from the current data there are 884 households with a total of 3340 people toaya village has five hamlets with the following populations located in the lowlands of the central sulawesi sea coast toaya village is at an altitude of between 15 50 meters above sea level with contour lines in settlements that are tenuous forming many expanses that at some points reach a depth of 5 10 meters if a straight line is drawn from the lowest point located on the shoreline and in the settlement area to the highest point the topographic slice of toaya village and the top view will appear as shown in figure 1 a disaster prone locations in the book ngapa nu rangaranga it is explained that there are two major natural disasters that toaya villagers are concerned about namely earthquakes and tsunamis considering that toayas settlement is directly adjacent to the makassar strait coupled with the height of the villagers settlements which can be said to be almost flat with the sea in addition toaya village is still close to the palu koro fault which is the second longest fault in indonesia after the sumatra fault the palu koro fault is 500 km long bisecting sulawesi island extending from the north in palu bay to bone bay in the south the palukoro fault poses the biggest threat to central sulawesi especially palu and its surrounding areas every year it shifts about 45cm historical records show that the strongest earthquake on this fault as happened in 2018 also occurred in 1909 which was estimated to be of magnitude 7 according to the meteorology climatology and geophysics agency the paramaeter of the tectonic earthquake that occurred in donggala regency central sulawesi on friday september 28 2018 at 170244 wib with m 77 located 018 ls and 119 85 east with a distance of 26 km from the north of donggala central sulawesi with a depth of 10 kmthe cause of the earthquake by considering the location of the epicenter and the depth of the hypocenter the earthquake that occurred was a type of shallow earthquake due to the activity of the palukoro fault the results of the source mechanism show that this earthquake was generated by deformation with the movement mechanism of the horizontal fault structure e tanasanggamu community tana sanggamu foundation was originally a group of young people from toaya village who volunteered during the emergency response period after the earthquake disaster in central sulawesi in october 2018 at that time they jointly opened a post for raising and distributing aid to disaster victims after the emergency response period they then agreed to do something to restore their village including the traumatized community after the earthquake in cooperation with the mosintuwu foundation which at that time offered several postearthquake recovery programs they then created further work programs that could help their village in advancing the economy while preserving their area then the mosintuwu community was formed which in 2020 was incorporated and turned into the tana sanggamu foundation from the results of an interview with ade nuriadin institutionally the vision of the tana sanggamu foundation is to build an independent village based on the principles of local wisdom tana sanggamu has its own philosophy which is based on the meaning of the word tana means land sanggamu means a handful so based on the communitys belief that from a handful of land that will be life in this world for the tana sanggamu foundation this can be interpreted as guarded land this is the vision of every work program of the tana sanggamu foundation which seeks to improve the welfare of the community while preserving nature using local wisdom f environmental communication in the practice of digital ecoaction campaign for youth disaster survivors in toaya central sulawesi environmental communication is a popular topic these days the rise of environmental degradation which then results in more frequent natural disasters has become a concern for various groups various community groups have emerged to try to take an active role in preserving the environment the role of environmental communication as a pragmatic and constitutive tool in providing an understanding of the environment to the community needs to be increasingly promoted oravec and klurce explain that environmental communication is a study of the human perspective in seeing knowing and building socioculturally towards the surrounding nature using language and certain symbols as a material in acting and guiding human behavior towards their environment meanwhile according to flor environmental communication is the use of communication approaches principles strategies and techniques for environmental management and protection briefly defined as the deliberate exchange of information both in the form of knowledge and in the form of policies about the environment based on these definitions it can be understood that communicating about the environment requires the involvement of various existing resources campaigning for environmental conservation requires the right strategy to reach as many people as possible the strategy can be done by getting to know more about the local location this is what the tana sangganu foundation did in seeking environmental advocacy in toaya village sindue district donggala regency tana sanggamu foundation is one of the community groups that focuses on voicing environmental issues so that they can be of concern to the wider community in some of its programs the tana sanggamu foundation seeks to improve the welfare of the community by utilizing the vast idle land while preserving nature they realize that damage due to natural disasters can be minimized if the community can unite in protecting the environment in environmental campaign activities as stated by ade nuryadin the tana sanggamu foundation always does it through a cultural approach this is in line with the concept of environmental communication conveyed by which argues that environmental communication programs must always contain a cultural dimension this is because forms of environmental communication can always be seen in traditional environmental wisdom in the form of myths and folklore passed down from generation to generation some programs related to ecoaction digital campaign practices that have been carried out by tana sanggamu foundation include 1 tutur project according to ade nuryadin the theme was chosen based on the principle that in an effort to preserve culture every element in the village must be able to also be outside the village and can cooperate with each other we call it a form of multiparty collaboration in caring for and preserving traditional arts and culture the vision and mission of cultural preservation in the village must be internalized into the family and every individual in the village members of the tana sanggamu foundation believe that to be able to maintain care for and contribute to the development of knowledge and identity of the indonesian nation traditional culture can be processed in the form of audiovisual media the media was chosen as an effort so that traditional oral literature can be well archived and in accordance with the needs of modern society today and to strengthen the identity of the indonesian nation in connection with the digital ecoaction practice tana sanggamu believes that the customs and culture featured in the storytelling project contain strong values in maintaining harmonious relationships between humans and nature harmonization between humans and nature is what we try to show in traditional music and documentary films the poems in traditional music tell stories about history culture and the situation faced by society today likewise the documentary senandung bunga dari bulukadia tells the story of the role of two oral tradition maestros bungacina and hajaidin who have been instrumental in maintaining harmonious relations between humans and nature and other creatures through the traditional ritual ceremonies they perform 2 ino ana project inoana is a movement to raise awareness of village communities in protecting and preserving the environment and biodiversity through the application of sustainable agriculture systems the use of hazardous chemicals in agriculture greatly impacts the sustainability of the environment and affects the quality of soil water air and agricultural products the use of hazardous chemicals such as fertilizers pesticides and herbicides every year continues to increase in number in every garden period so that farmers can get maximum yields however the fact is that crop yields are not in line with what is expected the increase affects the costs that must be incurred by farmers it is not uncommon for farmers to incur losses the inoana movement tries to explore local knowledge in agriculture owned by the village community this knowledge is used to restore environmentally friendly farming methods the knowledge is also combined with the knowledge of organic farming systems that already exist and are used by farmers in other regions so that it becomes a stronger knowledge and can be applied effectively by the villagers putra one of the volunteers who is active in the inoana program believes that the farming methods used by tanasanggamu foundation can realize the vision of building a village based on culture and the environment this can be seen with the organic farming activities that are still ongoing until now in addition the inoana movement is also a movement to restore the gotongroyong culture of the village community this movement started with a collaboration between the ino group and the ana group this movement seeks to prepare an independent village by producing superior products in agriculture that can improve the welfare of the community and preserve the environment and biodiversity in a sustainable manner this program is packaged with a sustainable agriculture model from the data collected by the tanasanggamu foundation when a disaster occurs farmers or farm laborers in toaya village are the most affected community groups based on the data 6070 of toaya villagers work as farmers and farm laborers when a disaster occurs their livelihoods disappear due to the destruction of agricultural facilities and infrastructure based on this we designed sustainable agriculture activities by making 8 organic farming classes and developing organic peanut commodities compilation of the village book the preparation of this village book is the result of collaboration with the mosintuwu foundation which is located in tentena poso district this book contains 7 chapters including history of toaya village geospatial toaya history of disaster toaya and the covid19 pandemic young people and village dynamics village dream map and stories of tana sanggamu young people this book which is about the communitybased reconstruction process in toaya village raises the importance of the community knowing the environment in which they live as well as how the toaya community has an understanding of dealing with disasters by learning from natural conditions no plastic program this activity is based on the problems faced by the toaya village community contained in the village book fights between young people early marriage due to the lack of knowledge of young people related to sex education the decline of cultural values and so on we try to convey through making posters that contain good messages from figures in the village the figures we involve are figures who have influence on both parents and youth groups on the issue of plastic waste reduction we made a joint movement to clean the beach every sunday involving crossvillage youth groups 5 village dialogue green movement in agriculture a forum established to spread good knowledge to the village community this program was conducted 6 times in toaya village by attracting archaeologists lecturers and social workers topics that were delivered in the village dialogue were this activity provides a lot of important knowledge that can be used to care for nature as well as a disaster mitigation program 6 photography learning class notesa this learning program which invites photography practitioner edward charles aims to encourage youth awareness and involvement in positive activities young people can improve their photography skills and use photography as a medium to campaign for issues facing rural communities although the class did not run well due to internal organizational problems at least some of the youth have learned 7 filming of senandung bunga dari bulukadia this movie tells the story of bungacina and hajaidin two oral tradition practitioners in kumbasa village who try to maintain customs and culture through the songs they sing the song tells the story of the origin of life in an old village bulu kadia just as the title suggests almost the entire movie is accompanied by the humming of poems and the beating of gimba which is believed and passed down from generation to generation as a reminder as well as a medium to maintain the relationship between humans and ancestors through a traditional procession also known as the balianobalia ceremony all activity programs carried out by the tanasanggamu foundation in the context of environmental campaigns are very capable of gaining public sympathy this can be seen from the participation of the community in each program implemented this was conveyed by riski one of the volunteers who is often involved in several activities carried out by the tanasanggamu foundation according to riski the activities carried out are very useful and can have a direct effect on the community so the community wants to be directly involved riski gave an example of the inoana project which teaches young people to farm using the old peoples way without using chemicals as fertilizers which will be harmful to nature and health of course with this program the community in this case mothers and children are directly involved in gardening and selling the harvest from their plantations in socializing their activities the tanaanggamu foundation always publishes through various official social media of the tana sanggamu foundation such as facebook instagram and youtube the activities and movements carried out by several environmental activism movements through social media are one of the important factors in determining the achievement of campaign targets namely the dissemination of information on environmental programs to the public social media offers various advantages through attractive features that allow the delivery of information more effectively to the public this makes it easier for communities especially proenvironmental movements to disseminate environmental messages g environmental communication model of ecoaction campaign in toaya village from the previous explanation it can be seen that the environmental communication model carried out by youth in toaya village sindue district central sulawesi can be described as follows figure 2 model of environmental communication of ecoaction campaign in toaya village in the figure above it can be seen that the environmental communication model starts with a discussion between the community and the local community from the results of these talks the community then conducts research in the field by studying the environment including the topography and demographics of the village after that the community compiles geospatial data as a basis for developing environmentalbased programs in the implementation of the activity program the community participated and contributed their thoughts and energy this is also able to provide a deeper understanding to the community especially to raise awareness of the importance of environmental conservation and the benefits obtained every program implemented is always documented and published through online media especially official social media owned by tanasanggamu foundation v conclusions in campaigning for environmental preservation the youth community of disaster survivors in toaya village uses environmental communication strategies to reach and involves people as many as possible the strategy starts with getting to know more about the characteristics of the local location this is done so that the program can provide appropriate solutions to the environmental problems faced some of ecoactions campaign programs include tutur project inoana village book compilation no plastic program village dialogue photography learning class film making based on the research results the environmental communication model designed begins with a discussion between the community and the local community from the results of these conversations the community then carried out research in the field by studying environmental characteristics including local wisdom topography and village demography after that the community compiled geospatial data as a basis for developing environmentalbased programs in implementing the activity program the community participates and contributes their thoughts and energy this is also able to provide a deeper understanding to the community especially to increase awareness of the importance of environmental conservation and the benefits obtained every program implemented is always documented and published using storytelling techniques through online media especially the official social media belonging to the tanasanggamu foundation

this research aims to find the most important function of communication and local knowledge in the ecoaction campaign strategy of the earthquake and tsunami disaster survivors community in toaya village the theory used is communication convergence theory the research method used qualitative with a case study approach the technique of taking informants uses purposive data collection techniques are indepth interviews and direct observation for analysis techniques using data reduction data presentation and conclusion drawing based on the results of the research in campaigning for environmental conservation youth in toaya village try to get to know more about the local location this is done so that the program can provide the right solution to the environmental problems faced some of the ecoaction campaign programs include tutur project inoana village book compilation no plasctic program village dialogue photography learning class filmmaking the environmental communication model that has been designed starts with a discussion between the community and the local community from the results of these talks the community then conducted research in the field by studying the environment including the topography and demographics of the village after that the community compiled geospatial data as a basis for developing environmentalbased programs in the implementation of the activity program the community participated and contributed their thoughts and energy this is also able to provide a deeper understanding to the community especially to raise awareness of the importance of environmental conservation and the benefits obtained every program implemented is always documented and published through online media especially official social media owned by tanasanggamu foundation

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introduction the stigma associated with tuberculosis is a social phenomenon present in several cultures and communities 1 historically the moral change after the identification of its pathogen by robert koch as well as the confirmation of its transmissivity contributed to evidence certain social categories as the only ones to be affected by the disease 2 this is due to the fact that the spread of tb was more prevalent among the poor due to their precarious life conditions in large industrial cities in the late nineteenth and early twentieth centuries conditions which contributed to infection and development of the disease according to the author 3 this fact led to changes in the speeches of spokespersons regarding the social image of tb and as a result the stigma of contagion was developed in the current epidemiological reality of tb in brazil and worldwide reports on the impact of stigma both in the search for a diagnosis and adherence to treatment was seen in asian and african countries 45 the americas 67 and europe 8 extended substantial investigations on this phenomenon are very important according to goffman 9 the process of stigmatization occurs because of the contradictory relation between the attributes and stereotypes that the normal population creates for a given set of people such a relation generates inferior identities and may vary according to the evidence and exposure of the characteristics of the individual in turn the psychosocial aspect emphasizes the contextual and dynamic nature of stigma and its immediate effects in the perspective of stigmatizer stigmatized and the interaction between them 10 therefore beyond the biologicist perspective the experience with the stigma of tb presents different results according to historical cultural and social aspects in general the reasons for such stigmatizing attitudes are divided into three categories lack of knowledge andor myths about the disease association of tb with other health conditions such as aids poverty and marginalizing behaviors 11 in different geographical regions authors have been trying to understand the prevalence and extent of the stigma in the community through the use of standardized assessment tools 12 13 14 however cultural adaptation and validation between the different versions of these instruments are required so that the tb stigma assessment actions and the analysis of determining factors provided by scales developed in other countries with their sociocultural differences are relevant in the brazilian environment no specific scale that has been adapted for use in the country was identified in the national literature to assess stigma in tb patients thus the present work aims at culturally adapting the tuberculosisrelated stigma scale for use in brazil method this study is a methodological investigation consisting of the process of translation and semantic validation of the items of the tuberculosisrelated stigma scale developed and validated in southern thailand the scale consists of 23 items and the total score ranges from 0 to 279 higher score indicates higher level of stigma two subscales enable the assessment of stigma associated with tb in specific domains the perspectives of the community in relation to tb the perspectives of patients in relation to tb 14 contact with the project coordinator in southern thailand was initially established and an authorization to translate and culturally adapt the process to the brazilian context was requested the items were subsequently translated and semantically validated through the procedures indicated by beaton et al 15 and the group disabkids® 16 respectively the scale was translated independently by two translators one fluent in the source language and the other a native speaker of the target language the first one was familiar with the assessed construct while the other was not aware of the objectives of the translation with these two translated versions synthesis was initiated by discussion with both the research group and the researchers responsible for the original scale the backtranslation to the original language was then performed by two native speakers of the target language who were not aware of the theme the consensus version in english was subsequently compared with the original version of the scale and approved by the project coordinator in southern thailand semantic validation of the scale was performed with patients undergoing tb treatment in the city of ribeirão preto located in the northeastern region of the state of são paulo 313 kilometers from the state capital and 706 kilometers from brasília ribeirão preto has an estimated population of 658059 inhabitants in a territory of 65092 km² 18 according to the human development index of 080 literacy rate of 30 and the são paulo social vulnerability index the city is in the group of those presenting good social and economic indicators 1819 in the city the care for tb patients is centralized in the reference clinics with tb control programs distributed in five health districts these services work with specialized teams consisting of a minimum of one physician two nursing assistants and one nurse performing activities related to diagnosis clinical management of cases and their contacts medical visits and coverage of the directly observed treatment in relation to the epidemiological situation of tb in 2013 the incidence was of 2817 cases per 100000 inhabitants and 18 of tbhiv coinfection re the population of the study consisted of tb patients aged over 18 years living in the city of ribeirão preto and undergoing treatment in the reference clinics for a minimum period of two weeks patients that did not present the minimum skills to understand the questions of the scale and those who did not feel comfortable to talk about the objectives of the investigation in the presence of the researchers were excluded convenience sampling with patients undergoing tb treatment in the reference clinics of the western and northern regions of the city between september and december 2014 was performed for the semantic validation the choice of these health services is justified as they are located in two areas that have a concentration of new cases of tb and coincide with the areas of concentration of poverty and intermediate living conditions 21 the number of participants in this stage was established according to the method disabkids validated in six european countries and brazil 1622 two groups were formed considering the selected reference clinics with the 23 items that make up the scale three subgroups were formed consisting of items 1 to 7 of the first dimension consisting of items 8 to 11 of the first dimension and 1 to 4 of the second dimension consisting of items 5 to 12 of the second dimension three patients were considered for each subgroup selection of participants was performed through an initial contact with the teams in the reference clinics of western and northern districts introduction of the research objectives and nonparticipant observation of the care provided in the service and followup of dot at home from this local recognition the individuals eligible for the study were identified verbal and written information on the research was provided and the invitation to participate was made in the event of adherence by patients the free and informed consent form was read and signed in two copies by them then the patients were requested to complete the tuberculosisrelated stigma scale and the general impressions form subsequently the participants of each subgroup answered the questions of the specific form in addition to the quantitative data the researcher also registered in her field notes the qualitative impressions of the individuals of the study on their understanding of the items of the scale and the experience of the stigma associated with tb clinical information on the condition of patients were obtained from medical records and charts available in the clinics data were analyzed in the software statistica version 120 descriptive analyses were conducted in all variables measures of dispersion central tendency were calculated for continuous variables measures of absolute and relative frequencies were calculated for categorical variables the study was approved by the ethics committee of the school of nursing of ribeirão preto of the university of são paulo results of the total of 26 patients undergoing treatment in the two reference clinics 17 participated in the study there was no refusal and one patient died according to the reference clinics for tb diagnosis and treatment the distribution of sociodemographic and clinical variables suggests a prevalence of male patients affected by the disease in economically productive groups with years of education ranging between six and nine and presenting average family income below two minimum wages per month in relation to the clinical variables it was observed that two individuals were seropositive for hiv and that there are respectively in the western and northern districts clinics 5 and 6 individuals with the pulmonary clinical form most of these consisting in new cases with no previous treatment the general impressions of the scale are presented in table 2 it is possible to observe that in general the scale was well accepted and easily understood by most participants it was also verified that 12 interviewees considered it as good while 16 considered the items as very important for the assessment of the stigma associated with tb and was easy to understand in the specific analysis form of the tuberculosisrelated stigma scale the items were fully understood except for item 1 some people prefer not to have someone with tb living in their community item 3 some people think people with tb are disgusting item 5 some people with tb lose friends when they share the information that they have the disease and item 8 some people with tb will choose carefully those to share the information about the disease which were not understood by 167 of the individuals however no changes in items were suggested item 2 some people keep distance from tb patients was not found relevant for 334 of the individuals in relation to the reformulation of items five individuals suggested changes to colloquial terms after some discussion the researchers agreed with the suggestions of the participants resulting in the version adapted for brazil in the analysis of registered qualitative impressions the stigma associated with tb was represented in the following reports discussion this paper aimed at introducing the stages of the process of cultural adaptation of the tuberculosisrelated stigma scale for tb patients in brazil to this end the guidelines suggested in national and international literature were followed 152324 according to authors 24 some instruments are developed considering only a given culture while others are developed to be culturally adapted questions of the general impression form in item 1 some people prefer not to have individuals with tb living in their community 2 some people keep distance from tb patients 3 some people think people with tb are disgusting 4 some people feel uncomfortable when they are close to a person with tb 5 some people do not want people with tb playing with their children 6 some people do not want to talk with those who have tb 7 if a person has tb some members of the community will behave differently in relation to that person for the rest of their lives 8 some people may not want to eat or drink with friends that have tb 9 some people avoid touching people with tb 10 some people may not want to eat or drink with family members that have tb 11 some people fear those who have tb the translation of the scale from the source language to the target language required a series of careful steps in order to minimize the linguistic cultural theoretical and practical biases in the brazilian context in this process the formal expressions were replaced by others that can be easily understood such as the term insulted by hurt another criterion discussed by researchers and translators refers to replacing the verb to have by to be considering the transient nature of the disease through the proper treatment and achievement of cure as well as the connotation used in the brazilian culture pedroso et al 25 suggest that the most significant problem caused by the use of an inappropriate method of translation and cultural adaptation consists in a misrepresented measurement of what is intended to be calculated therefore submitting the reconciled backtranslation of the scale to the project coordinator in southern thailand and her approval for the final version in brazilian portuguese contributed to the semantic equivalence of the versions however due to the possibility of failures and limitations the translation of the scale alone is not a procedure that ensures its applicability the methodological strictness of the cultural adaptation does not exclude the need to verify the understanding of the items by the targetaudience through the scale face semantic and conceptual validation if an item remains incomprehensible or behaves in a different way than expected by the researchers it must be reviewed and adapted 24 item 1 some people with tb feel guilty because their family carries the burden of taking care of them 2 some people with tb keep distance from other people in order to avoid the transmission of tb germs 3 some people that have tb feel lonely 4 some people with tb feel hurt with the way other people react when they learn that they have tb 5 some people with tb lose friends when they share the information that they have the disease 6 some people with tb are worried about the possibility of having aids too 7 some people with tb fear telling people out their families that they have the disease 8 some people with tb will carefully choose those who they will inform about their condition 9 some people with tb fear going to tb clinics because other people may see them there 10 some people with tb fear telling their families that they have the disease 11 some people with tb fear telling other people about their condition because other people may think they have aids too 12 some people feel guilty as they may have been affected by tb due to the habit of smoking drinking alcohol and not taking care of themselves descriptive analyses of the semantic validation evidenced the understanding and acceptance of the items resulting from the translation process a total of 941 of the interviewed patients considered the items as very important in the assessment of stigma associated with tb they were easy to understand with appropriate categories of answers that were easily answerable during the interviews the expressions of stigmatizing behaviors and attitudes described in the items included the elements of the construct with varied levels of difficulty the replacement of colloquial terms suggested by individuals with low educational level is pointed out by pasquali 26 as a strength because if these group of individuals understands the item it is expected that the group with higher levels of education will also understand it it was observed that some individuals presented a certain level of difficulty in understanding four of the items of the scale requiring more time to answer the questionnaires the difficulty in understanding such items may be associated with the levels of stigma and its impact on the social relations and selfesteem of these individuals according to authors 2728 the process may occur more subtly for some people because being labeled as belonging to a given stigmatized condition leads to expectations of discrimination and devaluation therefore besides facing the negative experiences resulting from the symptoms of their own health condition tb patients often have to deal with negative attitudes and behaviors by society according to corrigan and watson 10 this subjective process occurs when members of a stigmatized group accept the prejudice associated with their condition and apply these negative attitudes and beliefs to themselves affecting their quality of life the individual tends to anticipate the rejection devaluation and discrimination from other people and begins to develop strategies to prevent these experiences avoiding social interactions and hiding their health condition and treatment history 29 informal reports on low levels of satisfaction in relation to important spheres of life including work family and relationships with friends were presented during the interviews with patients that were undergoing tb treatment for less than a month equivalence between experiences of stigma reported by patients undergoing tb treatment in southern thailand 4 and patients in brazil was observed although the use of scales represents a challenge in the assessment of the social stigma of tb it is possible to explain why this factor represents a predictor of delay of diagnosis and nonadherence to treatment in certain contexts and not in others these scales consist of tools for the assessment and channeling of resources to strengthen social support networks that include intersectoral actions of tb treatment in the health services 11 there is evidence that a good social support may represent a protective factor and that a poor social network may contribute to the vulnerability and internalization of stigmatizing attitudes 30 it is observed that the intersectoral action in health services involves the creation of spaces for communication and overcoming of conflicts leading to accumulation of strengths creation of individuality and the discovery of the possible course of actions 31 in the course of providing intersectoral health services it is necessary to establish the paradigm for the social production of health and provide tools to deal with the impact of the stigma in the health of tb patients regarding the limitations of the study it is important to take into account that brazil is a large country with cultural historical and social differences that may affect the processes of cultural adaptation and validation of scales of subjective assessment like the tuberculosisrelated stigma scale the need of application of the scale by interviewers may have impacted the choices of the respondents however this is the most appropriate method of data collection when the subjects present difficulties such as the ability to write reliably illiteracy or people with low educational levels and low income this limitation was also pointed out by researchers in the process of validation of the stigma tool in nicaragua 12 the interaction of tb patients with people reveal discriminatory behavior and their devaluation in family society and health services the investigation of this interaction and its implications in the control of the disease requires new approaches producing theoretical and methodological challenges for researchers preliminary results of the scale indicate adequacy of the equivalence between the original and the brazilian versions considering the assessed linguistic and cultural variations however the scale validation process is in progress and the analyses of future psychometric properties will test the reliability and validity of the scale in the brazilian context in order to complement the presented cultural adaptation according to disclosed publications about the impact of stigma associated with tb and the practical experience in the process of cultural adaptation of the scale a scarcity of assessments of stigma related to tb in comparison with other health conditions was verified adapted validated scales may contribute in the study of populations affected by the stigma of tb and support interventions of actions on this disease that will reflect the experience of living with people affected by this disease making the tuberculosisrelated stigma scale available in brazil may enable the comparison of the results of research between two countries and foster discussions on strategies to reduce stigma in different social realities collaborators ja crispim worked in the conception of the study analysis and interpretation of data and writing of the article mm touso and m yamamura in the analysis and interpretation of data and writing of the article mp popolin and mcc garcia in the critical review of the article cb santos pf palha and ra arcêncio in the conception of the study interpretation of data critical review of the article and approval of the version to be published

the process of stigmatization associated with tb has been undervalued in national research as this social aspect is important in the control of the disease especially in marginalized populations this paper introduces the stages of the process of cultural adaptation in brazil of the tuberculosisrelated stigma scale for tb patients it is a methodological study in which the items of the scale were translated and backtranslated with semantic validation with 15 individuals of the target population after translation the reconciled backtranslated version was compared with the original version by the project coordinator in southern thailand who approved the final version in brazilian portuguese the results of the semantic validation conducted with tb patients enable the identification that in general the scale was well accepted and easily understood by the participants

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introduction studies of social mobility have increasingly emphasised the importance of social networks as an important tenet of social capital most approaches within the social sciences treat social capital either as a form of productive asset or as a form of social relations exhibiting a degree of the liminality of social and economic processes in social mobility in this article we explore the effects of social networks on consumption behaviour in households and we define networks that relate to participation in collectives that are formal in nature here social networks as a form of social capital are dynamic defined as both the flow and stock of social relations based on norms and networks which enhance resource flow to households allowing for changes in the consumption behaviour the second section of this article identifies aspects of relationships between social capital networks and household consumption expenditure the third section discusses the findings from an empirical enquiry into the influence of networks on household consumption expenditure based on the national household panel survey in india the final sections present the discussion of results and conclusions social networks and consumption expenditure conceptual framework it is widely acknowledged that social capital is seen as a vital resource unequally distributed in society with varying outcomes for different groups in society evidence of social capital at the macro level shows how trust and civic engagement relate to higher levels of growth while at the micro level individual factors such as incentives to invest in social capital such as education or networks such as family or group membership are significant this article acknowledges the miscellany of approaches and identifies the need for a more nuanced understanding of the mediating role of social capital in mobility studies given the exhaustive discussion on social capital in the literature we only refer to the literature on social networks as a form of social capital drawing from portes networks are important in economic life because they are the sources for the acquisition of scarce means such as capital and information and because they simultaneously impose effective constraints on the unrestricted pursuit of personal gain as illustrated by fedderke et al forms of social capital display functions of transparency and rationalisation allowing for outcomes such as the flow of information and reduced transaction costs for bourdieu and wacquant social capital can be defined as the sum of the resources actual or virtual that accrue to an individual or group by virtue of possessing a durable network of more or less institutionalised relationships of mutual acquaintance and recognition social networks could be distinguished from other forms of capital through the element of externality generated by the social element involving interaction which may have economic effects for example putnam shows that gaining trust through joining social clubs such as amateur choirs generates externalities and reduces transaction costs this article draws on social networks as a form of social capital that households belong to based on a wider conception of assets that people both possess and use in their daily lives this allows us to situate social networks as an asset and to analyse the nature and pattern of relationships of members of households with key actors such as the state market and community this pattern of connections reflects a multitude of factors some operating at the level of the individual others more at a macro level associated with cultural economic or political dimensions of society this article is more concerned with the microlevel relationship of households within the wider sphere of community and civil society it is important to parse out elements of density and closure in social networks that are akin to social capital by embedding social relations within and between social groups the distinction between types density and strength of networks is relevant here we refer to two types of capital that is bonding networks relate to social networks between homogeneous groups operating with common interests for example womens groups and bridging networks that include socially heterogeneous groups allowing for wider networking and exchange of resources among diverse interest groups thus as fukuyama states there is a variation of radius of trust between these two groups further strong ties may exist between homogeneous groups but may reinforce exclusive identities and be inward looking while bridging social capital may be based on weak ties yet more outward looking comprising people of different social cleavages particularly the much discussed subtypes of bonding and bridging thus benefits to members of such groups can vary with different types of social networking reverberating the classic distinction between weak and strong ties noted by granovetter further the type of network and strength of ties have an important bearing on information generated and exchanged while the types and number of networks play an important role in defining the nature of social capital that is generated further the homogeneity of groups may also limit the nature of information and resource flow as all members have access to the same networks this article adopts a connectionist view of social capital that integrates both the bridging and bonding elements of social capital the rationale being that while it is bonding social capital that assists and supports a household its benefits are limited due to the similar levels of information and resources throughout the network it is only when bridging capital enters that more resourcesinformation are brought into the network and distributed leading to greater outcomes in achieving wellbeing this allows for concerted focus on resource flow through social ties and to see if these two types of network vary in their outcomes for household consumption in the south american context godinot et al and perlman show how social networks serving as social and political assets engendering both agency and improving capabilities enable social mobility yet the explorations of the link between social networks and consumption of particular significance to our study are limited to a few studies that focus on individual consumption and leisure practices and taste there is some reference by marques to how networks affect access to goods and services in são paulo where networks may enhance or mitigate the effects of poverty through segregation other studies show that the membership of selfhelp groups has shaped individual consumption practices this article specifically examines how social relationships embedded through social networks influence the consumption expenditure of households through improving access to resources information and opportunities it is relevant here to draw on the concept of social exchange based on the work of blau who emphasises the importance of the structure of social position on social life and the formation of different networks evidence points to the effects of social isolation through resource monopoly by the rich or reduced access to information and cultural repertoires by those with lower socioeconomic status accentuated by different social groupings as in the case of immigrants in italy in india social policies play a critical role in the creation of social networks enabled through the coinfluences of state market and family in india the human development index shows an increase of 21 per cent between 19992000 and 200708 in education and health showing increasing levels of welfare and social mobility across india further the average monthly per capita consumption expenditure in india rose consistently in both rural and urban regions between 200405 and 200910 reflected in a reduction in the incidence of poverty as shanker and gaiha found political and social networks are critical for raising awareness of development programmes such as the national rural employment guarantee scheme in india that increases information trust reciprocity and resource flow for example narayan and pritchett show how trust as a form of social capital is important within communities this article considers whether membership of networks in formal organisations produces benefits among different social groups on social gendered and spatial inequalities this is important as often structural power relations lead to biased working of patronage networks in resource redistribution this is also an unintended consequence of negative social capital in the sense that poor households are often disadvantaged in accessing and deciding key issues that affect them locally they lack favourable allies in the social hierarchy of power structures and it can be questioned whether social networks as an asset may complement or substitute for other productive assets in particular the role of power structures in mediating with an asset base among different social groups is relevant in the indian context for example marginalised groups either constitutionally recognised as scheduled tribes scheduled castes or minorities such as muslims do possess a weaker asset base which is the source of their higher levels of poverty vanneman et al show the importance of status groups on social networks where brahmins have the most contacts while sts are less connected and muslims have the fewest contacts in india the states of chhattisgarh orissa bihar madhya pradesh jharkhand uttar pradesh rajasthan and assam comprising the economically poor states belonging to the bimaru group record an hdi below the national average the composition of social groupings within such regions is also important in the context of india as the eight poorest states contain nearly 48 per cent of all scs 52 per cent of sts and 44 per cent of all muslims in the country thus social grouping also influences the levels of economic and social inequality across regions and observations on social interactions between and within such groups are important for this article in a similar vein women may have access to an increased resource base through networks such as selfhelp groups and this has further implications for household welfare with a direct bearing on womens empowerment and bargaining power against this background this study examines the effect of social networks on consumption expenditure per se specifically in relation to density intensity and payoff however the potential complexity in measuring the impact of social networks weights the value given to different social networks the weight of varying degrees of connections between and within groups and the effect of a number of social networks within a community participating in a social network and variations in cost and demands of social networks we distinguish between types of network with varying opportunities for generating formal versus informal networks we ask whether the levels and types of social network are significant in improving consumption expenditure and whether this produces similar effects on gender regions and other social divisions this is because the degree of the knowledge gap depends on whether the number of social networks matters for welfare and whether participation in any kind of formal network provides a stimulus for policies on social welfare and mobility therefore the main objective is to investigate the effect of the number and type of social networks on household welfare in india methodology and data the 200405 indian human development survey is a nationally representative multitopic survey of 41554 households in 1503 villages and 971 urban neighbourhoods across india covering topics concerning health education employment economic status marriage fertility gender relations and social capital it is structured into individual household and villagelevel datasets although the household is the unit of analysis for the current study and we rely on a sample of 41237 households for the analysis this sample constitutes 99 per cent of the sample in the original data set although we use the household data some individual and villagelevel variables were extracted from the respective datasets we estimate the usual determinants of poverty model but with concentration on the effect of whether a household member belongs to a social network number of social networks affiliated to a household and type of social network the 2005 ihds villagelevel survey gathers information on the presence of 13 social networks in a village including womens groups such as mahila mandal 1 youth club sports group trade unionprofessional group selfhelp groups credit or savings group religious or social group caste association development group or ngo agricultural or milk cooperative and political network 2 in this article we choose mahila mandal as the reference group on the basis that it is the only one that is restricted to women ordinary least squares estimation is used however results based on a logit model is provided in appendix table 1 for crossreference four variants of ols regression and an instrumental variable model were estimated first we examine the effect of whether being involved in a social network affects poverty using a dummy response of whether any household member belonged to a social network as the main explanatory variable second we capture a social network as a count variable based on the number of social networks that are affiliated to a household that is we count the number of social networks affiliated to a household based on social network membership of individuals in the household third we investigate the quadratic of a number of social networks to explore nonlinearities between monthly consumption expenditure per capita and number of social networks finally we examine the effect of different types of social network on monthly consumption expenditure per capita other explanatory variables are ruralurban settlement household structure and composition whether the household belongs to a scheduled tribe or caste the number of household members with at least higher secondary education household ownership of land and geographical location dummies for the sake of comparability we use the same set of other explanatory variables in each of the four models also for ease of interpretation and data smoothing we take the logarithm of monthly consumption expenditure per capita in estimating all the models the results were verified based on mundane postestimation techniquesapproaches such as reporting robust coefficients to correct for heteroskedasticity checking for omitted variables using ramseys specification test dealing with nonnormality of residuals and inspecting the presence and effect of multicollinearity for the sake of brevity these tests are not reported in the article however the current study considers the issue of endogeneity as both theory and empirical work suggest that social network capital and poverty are bicausally related as is the case with all other microeconometric empirical work that uses instrumental variable to address endogeneity finding an appropriate instrument is always daunting although narayan and pritchett deal with endogeneity in their estimation we are sceptical about the strength of the instrument used in their article our scepticism is informed by the following first the relevance of the instrument in this context there is the need to examine the strength of an instrument based on the two definitions of weak instruments provided by stock and yogo their viewpoint suggests that weak instrument examination should be based on first bias of the iv estimator relative to the bias of ols and second the value of the alpha level of the wald test the latter implies that by engaging in iv the entire model should be examined the results from narayan and pritchett show that although the standard error for clusterlevel social capital reduces in the case of the iv estimation compared to ols some of the other variables in their model show varying signs and higher standard errors among the possible reasons for this variation between iv and ols could be the relevance of the instrument used second since conceptualisation of social capital is primarily dependent on both social network and trust we remain sceptical of the intuition underlying the use of trust as an instrument for social network that is since either social network or trust can be used as a proxy measure for social capital and the source of endogeneity is a bicausal relationship between social capital and poverty then the use of trust as an instrument is difficult to justify in this article we use the number of social networks and other recreational facilities in a village as an instrument for the number of social networks affiliated to a household the justification is that the number of social networks that are affiliated to a household will be dependent on the number of social networks in the village and the latter can only be related to household poverty through household members who join social networks from a statistical viewpoint we test the two conditions of validity based on the anderson canonical correlation lm statistic and craggdonald wald fstatistic the latter tests the null hypothesis that the equation is underidentified the craggdonald wald fstatistic provides several thresholds to facilitate a decision on the extent of the weakness of the instrument used stock and yogo computed critical values suggesting that in the case of one instrument then the decision rule should be based on the value 10 the null hypothesis underlying the weak identification test is that the equation is weakly identified in addition to the above test we perform the durbinwuhausman test of endogeneity findings and discussion the discussion of results is preceded by a crosstabulation of the relationship between household affiliation to social networks and some selected correlates of social networks and descriptive statistics the last row of table 1 shows that in india two in every five households have at least one member belonging to a social network the crosstabulations in table 1 represent the chisquare test statistic which tests the hypothesis of independence between household social network affiliation and its correlates with the exception of the crosstabulation between scheduled castetribe and social network all other associations are statistically significant the second row of table 1 shows that of the households that are affiliated to a social network 80 per cent are above the poverty line the classification of geographical areas is informed by both geographical location and poverty as mentioned above as the states constituting bimaru are relatively poorer than the other classifications and the category others has the least proportion of households below the poverty line based on the 2005 ihds data in our analysis we find that regional differences are also marked as states in the southern regions of the country constitute more than half of the proportion of households with at least one member affiliated to a social network this is an interesting observation as other studies show such regional differences in the coverage of shgs throughout the country with a stronger presence in southern states such as andhra pradesh in total there are about 796000 shgs with an estimated membership of 97 million thus the inequalities in the number of social networks across regions may also point to inequalities in levels of economic indicators further we find that ruralurban residence is also important as less than a quarter of the households with social network affiliation are resident in urban areas showing a lower penetration of networks in rural areas where social divisions could be higher table 2 presents the four variants of least squares estimations column 2 shows that a household with at least one member affiliated to a social network leads to an increase in monthly consumption per capita of approximately 11 per cent also observed in column 3 is an increase of approximately 5 per cent in monthly consumption per capita for an additional household affiliation with a social network we further explore potential nonlinearities between the number of social networks and monthly consumption per capita in column 4 the negative sign of the square of the number of social networks indicates that the observed increases reach only a certain point before decreasing the calculated turning point after which the response to increases in the number of social networks leads to a fall in consumption is approximately nine networks however we are less optimistic about this finding as the number of respondents beyond this point is only 006 per cent of the entire sample column 4 in table 2 examines the effect of different types of social network on consumption we observe that except for selfhelp group membership household affiliation with all the other networks compared to womenbased shgs leads to higher consumption per capita significant variations are observed with the coefficients of the different types of social network compared to mahila mandal households with at least one member affiliated with a development agency or an ngo are likely to increase their consumption by 20 per cent while households with caste social network associations are able to increase consumption by only 4 per cent in line with our hypotheses we find that factors such as geographical residence educational status size of household and the number of infants impacted on consumption 017 017 017 017 973 per capita with important implications for joining networks for example household residents in urban areas have a higher consumption per capita than their rural counterparts and households with a greater number of relatively more educated members are able to increase their consumption per capita by about 20 per cent finally larger household sizes and the number of infants are observed to reduce the consumption per capita by approximately 9 and 6 per cent respectively appendix table 3 shows similar results for the case of logit estimation the results of the iv estimation alongside the reduced form model are presented in table 3 as already mentioned the instrument used to address potential bicausality between a household number of social networks capital and poverty is the number of social networks and other recreational facilities in a village the firststage regression confirms that one of the conditions in identifying an instrument as the coefficient of a number of social networks and other recreational facilities in a village in the household number of social networks equation is statistically significant the iv estimation shows that the number of social networks has a positive effect on consumption per capita by a higher magnitude of approximately 21 per cent compared to ols comparing the effect of all the other explanatory variables in the iv estimation with the ols the signs and magnitudes do not vary across these two estimations to verify the strength of the instruments we present results for both underand weak identification in both cases the respective null hypothesis of the instrument being underidentified and the model being weakly identified are rejected furthermore the test of endogeneity confirms the theoretical position that social networks and poverty are bicausally related finally the durbinwuhausman test rejects the hypothesis that the ols yields consistent estimates on this note we assert that an additional increase in the number of social networks that a household is affiliated to causes consumption per capita to increase by approximately 21 per cent in general our findings show that changes in consumption are also determined by the type and number of networks as the number of social networks is observed to be positively associated with monthly per capita consumption expenditure of course not all networks provide equal benefits as households with at least one member affiliated with a development agency or an ngo is likely to increase its consumption by 20 per cent those with political networks increase by 5 per cent and those with affiliation in a casterelated network are able to increase consumption expenditure by only 4 per cent more surprisingly the impact of womenbased shg membership on household consumption is negative this could suggest that networks through bonding capital for example among homogenous or closed groups may provide the same level of information among members which may have no impact on their household consumption rather bridging networks across social groups may improve social relations based on norms and networks that spill over to the household community and wider society and enhance resource flow to households for improved consumption behaviour the negative impact of femalebased shg membership on household consumption is initially puzzling but less surprising given the emergent buzz around microcredit and womens empowerment in the indian state of andhra pradesh deininger shows how approaches that combine microcredit with efforts to address specific needs of the poor to enhance their economic potential show benefits in empowerment and nutritional intake with some consumption smoothing and income diversification but not asset formation evidence on the benefits of such shg membership of women themselves is questionable as garikipati argues that womens loans through shgs are often used to benefit their men by enhancing male ownership of the households productive assets showing little control on loancreated assets while balasubramanian argues that women within households are worse off with microcredit furthermore the additional increase in the number of social networks that a household is affiliated to also causes consumption per capita to rise that is the number of social networks per se has a positive effect on consumption per capita thus the type of network and strength of ties has an important bearing on the information generated and exchanged particularly as gender plays a key role creating both weak and strong ties through homogenous selfhelp groups with women from similar backgrounds but also other kinds of network where trust and reciprocity are important for developing such communitybased solidarity participation in such networks has improved levels of wellbeing through awareness information source resource sharing and resilience against vulnerability conclusions this article sets out to explore the effect of social networks as a vital component of the household asset base on consumption levels among households in india using ihds data the findings indicate that households with participation in social networks improved their consumption levels showing the possibilities of social mobility leading to overall wellbeing and improved welfare we were also informed by a range of determinants for social networks that impacted on consumption per capita such as region social grouping urbanrural residence and educational status our findings show that penetration of households into the different types of network is quite high across regions in india with two out of every five households having at least one member belonging to a social network however not all networks lead to the same conclusion this is an interesting observation whereby membership of different networks yields varying outcomes of consumption this is perhaps because groups formed on the basis of social identity such as caste may focus on social rights or justice rather than on improving economic gains however bridging networks across social groups may improve social relations based on norms and networks that spill over to the household community and wider society the negative impact of a womenbased shg membership on household consumption needs further probing given the emergent buzz around microcredit and womens empowerment further our findings show that states in the southern area constitute more than half of the households with at least one member affiliated with a social network less than a quarter of households with social network affiliation are residing in urban areas which may pinpoint ruralurban disparities in the distribution of social networks as well as higher participation of households further those with higher human capital levels such as education also seemed to improve their consumption patterns through such social affiliations there is some encouraging evidence that the human development index and its component indices have shown convergence across states as the poorer states with a high concentration of various marginalised groups are catching up with the national average this strongly suggests that these groups are starting to share the benefits of the process of human development particularly through good governance and massive social mobilisation one of the major findings that 80 per cent of households affiliated to a social network are above the poverty line corroborates the evidence that networking is often more extensive among upwardly mobile groups christakis and fowler suggest that levels of personal wellbeing directly relate to position in social network chains this could also be suggestive of the causal relationship between membership of networks and impact on welfare or vice versa as vanneman et al suggest that networking is extensive among advantaged groups suggestive of resource monopoly by the welloff this is supported by our finding that those with political networks also see an increase in consumption showing their gainful position within such networks the study finds that participating in the number and nature of social networks is critical in enhancing an environment through which specific social groups can strengthen life choices through improved consumption levels wellbeing and social mobility shoba arun is senior lecturer in the department of sociology manchester metropolitan university as an economic sociologist her research interests relate to comparative and global issues of socioeconomic inequalities including gender and social divisions in relation to the household and labour market samuel annim is associate professor of economics at the university of cape coast ghana and a research associate at the lancashire business school university of central lancashire uk his areas of research are microfinance and households health and finance decisionmaking issues in addition to publicationoriented research he has undertaken consultancy services for international organizations such as ifad and the world bank on issues related to poverty and microfinance notes 1 mahila mandalas are voluntary organisations in india aimed at womens progress in society through providing basic needs such as health nutrition education and family welfare as well improving economic benefits through savings groups and economic activities 2 political network is based on whether somebody in the household or close to the household is an official of the village panchayatnagarpalikaward committee

the article sheds light on the mediating role of social networks on consumption behaviour a significant facet of social mobility and wellbeing based on the indian human development survey the article explores to what extent households across india participating in social networks have increased their consumption levels while participation in formal social networks does result in improved household consumption levels the type and number of networks are pivotal to this change nevertheless not all networks lead to similar effects although the number of social networks per se has a positive effect on consumption furthermore the networks based on homogeneous groups such as womens selfhelp groups have a negative or lesser effect on smoothing consumption while those affiliated with heterogeneous networks have a positive effect on increasing consumption

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introduction since its first appearance in wuhan around middecember 2019 the coronavirus pandemic has started to spread across the world the steady increase in daily deaths and confirmed cases since the beginning of 2020 has prompted the governments of affected countries to adopt protection strategies relying mainly on social distancing and other containment actions to combat the epidemic a socalled lockdown was put in place in france from 17 march to 11 may 2020 most workplaces and public places including schools shops bars and restaurants were closed or made accessible in a limited way the daily lives of millions of french people have suddenly been transformed leading to a significant change in lifestyles family relationships and work routines with significant consequences on their quality of life and psychological wellbeing in the short medium and long term 1 in these extraordinary times the coronavirus crisis was been enormously covered and discussed in both the media and academia from early on this content also focused on the implications of the virus for sport exercise and physical activity 2 however less is known about the consequences on the practice of pa and as concerns the changes in lifestyle in the short medium and long term in this paper we analyze the impact of social distancing on the practice of pa of a sample of french adults who answered an online questionnaire loneliness and social isolation are usually associated with poor mental and physical health and pose an important risk factor as regards the probability of experiencing the most common mental disorders 3 for example sociability 4 and also nonsedentary lifestyles are usually associated with reduced overall mortality an increase in life expectancy and a greater likelihood of living an old age in good conditions 5 unhealthy lifestyles and problematic behaviors are risk factors for physical 6 and mental health 7 strong evidence associates physical inactivity and sedentary behaviour with an increased risk of chronic diseases which are the leading causes of death worldwide 8 scientific evidence leaves no doubt about the need to lead an active physical life to develop and protect ones overall health at all ages 9 according to the who 10 today physical inactivity and a sedentary lifestyle are the fourth leading cause of death worldwide and are a major public health problem furthermore sedentary lifestyles lead to physiological disorders which in turn generate significant costs in terms of health expenditure 11 pa promotion to prevent the pandemic spread of diseases linked to physical inactivity and sedentary lifestyles and to improve populations health has been for decades a core objective of health strategies and policies globally 12 the coronavirus crisis radically changed this assumption the mandated restrictions on pa which widely affected those related to work commuting sport and exercise disrupted the pa routine of millions of people and generated a contradictory situation on the one hand most kinds of pas were perceived as risky behaviours being a way to spread covid19 on the other hand while taking precautions pa remains an important tool to maintain the population healthy despite the lockdown 13 14 15 previous pandemic crises as for example that caused by the severe acute respiratory syndrome caused serious public health consequences not only linked to the viral infection per se indirect impacts on communities health havent been assessed systematically although early studies on the effects of quarantine and lockdown as protective measures show its negative psychological effects on the population 16 previous studies related to the sars pandemic show that the community in hong kong responded by adopting healthier behaviours 17 however some authors hypothesize that this health crisis has the potential to further impact and accelerate the physical inactivity and sedentary behaviour pandemic we have been confronted with and failing to address for a number of years 18 and all the risks that follow from it 1920 despite the scientific consensus and the deployment of incentive policies to promote pa and engage people in more active lifestyles the phenomena of sedentary condition and inactivity are increasing especially in highincome countries 21 many scholars engaged in public healths analyzes of the present pandemic situation stress that both modifiable lifestyle factors like diet and pa 22 and mental health issues 23 should not be marginalized from policy makers considerations studies from china the center of the first wave of the epidemic showed how nearly 60 of chinese adults had inadequate physical activity which was more than twice the global prevalence during the early days of the novel epidemic 24 starting from this background in this paper we focus on the changes in lifestyles of a sample of french adults during the first lockdown in the months between march and may 2020 with an emphasis on pa in particular we test the following hypotheses the pandemic had an impact on the frequency of physical activity sociodemographic characteristics and health conditions influence the likelihood of physical activity or not during the breakdown materials and methods design the results presented here are part of pandemic emergency in social perspective evidence from a large websurvey research an international exploratory research that studied the social and psychological impact of the physical distancing measures imposed by the covid19 pandemic in six european countries the online survey included a total of 31 questions that covered the following areas demographic information covid19 experience covid19 and media source information covid19 risk perception lifestyle behaviours perceived stress the 8item version of personal health questionnaire depression scale scored basing on kroenke et al 25 health condition the survey was administered using the qualtrics web survey platform data collection occurred between march and june 2020 the respondents were recruited through a snowball nonprobabilistic sampling strategy through the facebook platform in particular we shared the link to our web survey in facebook groups which were dedicated to the covid19 pandemic the inclusion criterion was the age of majority the study was approved by the ethics committee of the policlinico gemelli catholic university of the sacred heart of rome statistical analysis a descriptive analysis of participants was performed using relative frequencies chisquared tests were performed to compare the responses in the selected variables based on gender and pa practice during the period of social distancing in order to calculate the odds ratio and its 95 confidence interval of the variables in which there were statistical significance based on pa practice during the period of social distancing a multinomial logistic regression model was done using all these variables additionally two other multinomial logistic regression models were done using the same variables in order to calculate the or for the changes from no sport practice before social distancing to practice during this period and from sport practice before social distance to no practice during this period as dependent variables both of them dichotomous variables all data were analyzed using spss software and statistical significance was considered as p 005 results we received 2410 answers in france after excluding people who did not answer all questions data of a total of 2099 participants 816 of which were females were considered for the analysis the age of participants ranged from 18 to 88 with a mean age of 411 ±127 table 1 shows the sociodemographic characteristics of participants as well as responses to health and pas practice questions by sex most participants were in a relationship cohabitant or married with a university degree workers and lived in a city with less than 100000 inhabitants as for people living in the same household during the social distancing period only 155 lived alone and 374 lived without children all or some of the time regarding the health related questions only 52 reported bad or very bad health 306 suffered chronic diseases 105 reported serious limitations in their daily activities and 276 scored as moderate moderate severe or severe depression in the personal health questionnaire depression scale 26 concerning pas practice 541 reported they regularly practiced sports before confinement and 573 said they practiced a pa during the period of social distancing analyzing changes in pa practice during the period of social distancing 343 of people who did not practice any pa before this period started to and 222 of those who practiced pa before this period stopped focusing on pas practice during the period of social distancing we can find the answers on table 2 these answers are based on the sociodemographic and healthrelated characteristics of participants we found statistically significant differences based on all variables except for marital status and number of people who live together table 3 shows the results of the multivariate regression for the pas practice during the social distancing period using as reference category not practiced ap during the social distancing period and table 4 shows the results of the multivariate regression for the pas practice changes during the social distancing period among people who practiced pas before the social distancing period the probability to keep practicing pas is higher among those with a lower level of education among housewives and retirees and among those who live in cities of 1000019999 inhabitants concerning those who did not practice pas before the period of social distancing the probability of starting to practice is greater in those with a lower level of education as well as for those who suffer from a chronic disease discussion as with many other recent research that analyzed lifestyle changes during the social distancing period our findings are complex and somewhat ambiguous some of our results were partially unexpected first some aspects that we thought might have an effect on pa dont seem so significant this is the case of the age category which does not seem to have a significant effect on its variation during the first lockdown consistently with other research relating to the effect of age on the quantity and quality of physical activity 28 we would have expected a less ambiguous correlation during the social distancing period too and a more important age effect another unexpected result was related to those who did not practice pas before the first lockdown those who suffered from a chronic disease had 151 times more probability of starting to practice this is a population at risk of a sedentary lifestyle which overall is not always easy to involve in pa in particular a recent study on lifestyle adherence in stayathome patients with chronic coronary syndromes found that almost half of participants reported a reduction in physical activity during first french lockdown 29 other aspects that we took for granted have been confirmed by data analysis for example concerning the psychological aspects that we have considered using the phq8 questionnaire as other studies point out too 30 the fact of being in an healthy or normal mental health condition allows to give continuity over time to the practice of physical activity and we can also assume that it helps to maintain a healthy lifestyle conversely many crosssectional studies have reported that depressed patients are more sedentary 31 however this association may be bidirectional problematic mental health may lead to decreased levels of exercise due to low motivation and energy and decreased exercise may be a risk factor for depression 30 if we focus on healthier conducts our data show that having a lower educational level and living in a small town are positive factors of influence with respect to the fact of continuing practicing pas during the first lockdown or starting practicing a pa if they never did an hypothesis to explain why people who leave in a small town practice more pa could be that they went out even if there was a ban on going out our analysis show a strong correlation between the fact of living in one of these towns and the tendency to practice pa and thus confirms this hypothesis our data does not allow us to point out the difference between those who have enough space to practice in their living environment and those who do not we can assume that the lockdown experience changed something in the perception and future design of living spaces a survey carried out on a sample of 1056 people by opinion way for artémis courtage in june 2020 highlights the new appeal of housing with outdoor space 10 of participants declared they wanted to move in a rural area 29 of twentyfivetothirtyfours wanted a garden and 23 a terrace 33 as for the educational level and the place of residence we note that there is also a strong correlation with regard to whether or not to practice sport before the first lockdown again there is a more important number of people not practicing sport among those with a lower secondary school or a diplomaupper secondary school educational level living in small towns furthermore those having a lower secondary school educational level are the ones having a positive balance between those who practiced less and those who started but looking more deeply those who have a low level of education are also those who have shown a greater variability in the practice of physical activity between before and during the first lockdown finally a last interesting aspect related to healthy practices we note an interesting continuity in the practice of pa among retirees who practiced even before the first lockdown this is certainly an interesting indicator of a healthy lifestyle that tries to remain so even in situations of crisis furthermore recent studies have clearly demonstrated the mental health benefits of physical activity in adults 34 and older adults 35 during lockdown in particular in a recently published study faulkner et al 34 show that participants who reported a negative change in exercise behaviour during the initial covid19 restrictions demonstrated poorer mental health and wellbeing compared to those demonstrating either a positiveor no change in their exercise behaviour our data in fact show overall a positive increase in the amount of pa practice in our sample which is an indicator of improvement lifestyles during the first lockdown this result is in contrast to a spanish research in which a decrease in pa was found 36 conclusions certainly our results place the emphasis once again and in accordance with what emerged in the literature on the complexity and multifactoriality of the changes that emerged during the first lockdown in relation to the various profiles of respondents in this complexity the education factor emerges as a significant determinant of pa that certainly has to be explored further in order to understand these results it will be necessary to integrate other variables such as the motivation and to explore the subjective dimension of the experience of social distancing in relation to the practice of pas from the data in our possession there does not seem to be a main influencing factor of pa during the first lockdown this leads us to open new avenues for reflection from a perspective of prevention accompaniment of change andor intervention it is important to identify the main factors of influence of pa these are some factors that we have chosen not to analyze given the descriptive and exploratory nature of our work but which emerge between the lines of our results when analyzing the impact of the lockdown we can observe the differences between some categories and the role of the educational level emerges ambiguously the analysis of these factors could bring out the social inequalities at the basis of the changes that we have observed and could therefore provide the tools to be able to build adapted health and pa policies if some new lockdowns occur limits of the study the respondents were recruited through a snowball nonprobabilistic sampling strategy through the facebook platform this means that the people who responded to our questionnaire were also the most active on social media especially on facebook although nonprobabilistic sampling strategies do not allow to obtain representative samples of the entire population in accordance with brickman bhutta 37 the administration of an online survey through the use of social networks offers new opportunities for scholars to collect data faster at lower cost and with less need for assistance for responding compared to what could be possible through traditional data collection methods for these reasons facebook may be a useful tool for exploratory work and for rapid pretesting of surveys destined for dissemination via traditional method additionally the crosssectional design limits the ability to draw on causal associations key points • among those who practiced pa before the social distancing period the probability of keeping practicing pa was higher among those with a lower level of education housewives retirees and those who lived in small cities • as for those who did not practice pa before the social distancing the probability of starting to practice is greater in those with a lower level of education and for those who suffered from a chronic disease • our results place the emphasis on the complexity of the changes that emerged during the first lockdown • in this complexity the education factor emerges as a significant determinant of pa that certainly should be explored further author contributions ap conceptualization investigation resources writingoriginal draft visualization pro methodology and formal analysis validation writingoriginal draft review and editing pm validation writingreview and editing tp validation writingreview and editing ll supervision data curation project administration resources validation writingreview and editing all authors have read and agreed to the published version of the manuscript funding this research received no external funding institutional review board statement the study was conducted according to the guidelines of the declaration of helsinki and approved by the ethics committee of policlinico gemelli università cattolica del sacro cuore rome italy informed consent statement informed consent was obtained from all subjects involved in the study data availability statement data available on demand acknowledgments no acknowledgements

the objective of this crosssectional study is to analyze the changes in physical activity pa practice of a sample of 2099 french adults mostly females who answered an online questionnaire during the first covid19 lockdown marchmay 2020 a descriptive analysis of participants was performed using relative frequencies chisquared tests were performed to compare the responses of selected variables multinomial logistic regressions were performed to compare the variations of pa with all the variables identified the age of participants ranged from 18 to 88 among people who practiced pas before the first lockdown the probability to keep practicing pas is higher among those with a lower level of education among housewives and retirees and among those who lived in cities of 1000019999 inhabitants for those who did not practice pas before the social distancing the probability of starting to practice is greater in those with a lower level of education and for those who suffered from a chronic disease our results place the emphasis on the complexity and multifactoriality of the changes that emerged during the first lockdown the education factor emerges as a significant determinant of pa that should certainly be explored further

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introduction hivaids is both a social welfare and healthcare problem that is integral to social work research and practice as of 2015 over 36 million people were living with hivaids globally but less than half had access to medical treatment as many scholars and experts have claimed the state and civil society have not done enough to solve hivaids and its related problems while the business sector has little interest in this problem these studies highlight the sectoral inefficienciesstate civil society and businessin addressing hivaids and its related problems in recent years social entrepreneurship has gained much attention in sw practice and theory despite a lack of consensus on the definition of se se is generally understood as a process of pursuing business and innovation opportunities to enact social change in sw research se is viewed as the business of sw sw scholars conceptualized se as the hybrid of social work macro practice principles and business innovation activities ses have emerged as a wellbeing providers around the world offering alternative and effective ways to solve health care and sw problems through communitybased actions in a sustainable approach sw and se share a conceptual overlap rooted in social value creation morality social justice and client interest sw embraces ses social welfare logic although sw has not conventionally focused on the commercial and innovation logics recent years however have seen a growing interest in the promise of social innovation and entrepreneurship to advance sw research amid criticism of the macromicro divide in sw which has marginalized macro practices other reasons for the surging interest in se in sw field include the growing complexity of todays social problems and the declining funding for social services across the globe the business and innovation practices in se partly to address the funding gaps and partly to offer more effective solutions to social problems could affect how service providers interact with clients and how a client is defined despite the growing interest on se as an innovative entrepreneurial and sustainable approach to sw practice there is little empirical research on how ses address sws domain of healthcare challenges pertaining to hivaids the few papers on se in the sw literature have been primarily conceptual and provide little intellectual exchanges between se and sw hivaids and related problems are complex and difficult to solve hence there is merit in finding answers from new perspectives such as se todate we do not know what interventions the activities processes procedures and actions that social entrepreneurs employ to solve hivaids problems an understanding of how social entrepreneurs make such interventions will make important contributions to the theory and practice at the intersection of sw and se in this study we ask the following question how do social entrepreneurs solve hivaids problems solving hivaids problems from social work to social entrepreneurship hiv was discovered to be a retrovirus in 1983 and was viewed as a deadly cancer that killed more than 80 of patients within two years of diagnosis while hivaids treatment changed radically since 1986 with the introduction of the first antiretroviral drug azt which dramatically reduced hivaids mortality from the early 1980s to 1996 the primary role of social workers was to assist aids patients in finding meaning in life while facing the dying process today sws primary intervention aims to reduce highrisk behaviors and enroll people with hivaidss in primary medical care and new treatment protocols and their secondary role is in hivaids prevention as well as to support medication adherence and palliative care although hivaids is now considered a treatable longterm chronic illness as current medications do not offer a medical cure scholars have found that stigma and discrimination against those with the virus and patients related fears around disclosure are the key barriers to effective care treatment and prevention scholars have also found evidence that social inequality due to poverty lack of public education about hivaids and its spread homophobia and housing and gender inequities underlie health inequalities including death other scholars demonstrate that social support and emotional and informational support as well as formal and informal supports is important for people with hivaidss other scholars using a macro perspective argue that collaborations among all parties solving hivaids problems are critical in recent years employment has been seen as a social determinant of health for people with hivaidss globally because employment can regulate sleep and healthy behaviors and increase neurocognitive functioning and medication adherence employment is a common intervention used in se particularly among workintegration ses as a means of empowering disadvantaged clients economically psychologically and sociopolitically several studies show that sesw projects that integrated vocational and clinical services for homeless youths were more effective in improving the wellbeing of clients than traditional social services programs other studies also provide evidence that sesw projects have effectively enhanced independence health status social networks and employability of vulnerable population through employment however se offers more than just employment for example ses have made health workers more accessible to clients by providing mobile services an area at the periphery of sw se could also optimize the delivery of comprehensive health interventions help make such services less reliant on external funding and more responsive to the needs of communities the innovation and financial sustainability aspects distinguish se intervention model from the traditional sw model essentially se emphasizes on creative innovative and enterprising ways of solving problems through borrowing tweaking modifying and hybridizing new and existing ideas and solutions among others to pursue more effective and or efficient solutions to social problems including borrowing techniques traditionally used in sw the literature shows that social workers who work with hivaids issues have largely focused on the micro interventions such as providing medical care prevention and support to clients and their families and linking them with relevant service providers like health social support and education in contrast se can be thought of as an integration of micro and macro level interventions as it not only focuses on caring and treating the clients but also employing multisectoral strategies to create favorable conditions and institutions to deliver innovative and sustainable solutions to people living with hivaids for example mauricio ramos a social entrepreneur from mexico introduced a homebased care and medication model partners with health worker volunteers creates training programs and engages in healthcare policy advocacywhich bridged the micro and macro level work in this example se combines different roles of social workers educators health providers and involves efforts to create systematic changes in the social system and power relations the roots of most social and health problems because se combines innovation business practices and various aspects of empowerment programs in a reallife context se can be seen as a logical extension of sw practice and research and a source of new insights for sw research and practice se and sw have theoretical overlap in that like the se the field of sw acknowledges the value of partnership with service users and emphasizes the issues of empowerment of service users however to date we know little about what ses do and how ses are solving the hivaids issues and how their work might inform sw research in this study we define se interventions as a range of activities processes procedures and actions adopted by social entrepreneurs to solve social problems theorizing se interventions will contribute to both sw and se literature by providing a better understanding of interventions employed by ses in supporting vulnerable population such as plwhas and provide practical insights to practitioners and policymakers this requires an indepth examination of what ses actually do today we are witnessing a growing number of global se platforms that find and support outstanding with pattern setting ideas for social change from ashoka and echoing green schwab to avpn this presents new opportunities and a natural laboratory to study how se operates to effect change for individuals groups and the larger sociopolitical system and to study what interventions that ses employ to enact change methodology we employed the grounded theory approach and used gioias method of open axial and selective coding to code the profiles of ashoka social entrepreneurs to answer our research question more details about the gioias method are provided in the online appendix i we adopted the grounded theory approach because there is little prior work in this domain and we know very little how se might extend sw practices in the hivaids sector we operationalize se interventions as the strategies adopted by the fellows to tackle social problems the profiles of ashoka fellows in the hivaids sector contain a section on strategies to solve hivaids problems which formed the core of the data analyzed in this article these profiles were written and maintained by ashoka based on multiple rounds of interviews with social entrepreneurs by multiple interviewers and presented in a uniform format in ashokas website a sample fellow profile can be found in online appendix ii sampling ashoka was chosen as a sampling site because it is one of the worlds largest and most successful se support organizations and plays a major role in shaping our understanding of how se operates to effect change for individuals groups and the larger sociopolitical system ashoka had more than 3000 fellows as of november 2016 and categorized its fellows into six fields of workcivic engagement economic development environment healthcare human rights and learningeducation our focal interest was the fellows in the hivaids category situated within the field of healthcare as the first step to sampling we found that out of over 3000 fellows there were 388 of them working in the healthcare field secondly we looked into these 388 fellows and identified that there were 58 fellows working on hivaidsrelated issues which is 149 of the population in the healthcare category or 18 of the overall population due to a small size of the population we decided to extract and study the entire population in this study to increase the credibility of the findings after extracting the written profiles of these 58 fellows from the ashoka web page we performed qualitative data analysis using the grounded theory approach the fellows profiles contain information on the problems that they seek to solve their new ideas and the solutions or strategies that they employ solve the problems as shown in table 1 the majority of the fellows were elected between 2000 and 2009 nearly 60 were male and they came from 19 countries which were mostly developing and less developed economies thus this article examines the entire population of ashoka ses working in the hivaids field insert table 1 about here data analysis prior to this analysis the two researchers conducted pilot facetoface interviews with the founder of ashoka and the deputy to the president of ashoka in 2013 and 2014 respectively to gain familiarity with ashokas ses work these interviews prove to be useful during the main data analysis stage as they provide contextual information next the two researchers read five randomly selected ashoka fellows profiles in the hivaids category and coded them as part of their coding training this was intended to build a deeper familiarity with the interventions employed by the ses and these training samples were later included in the main data analysis next in the actual analysis using rqda an extension of r programming for qualitative data analysis the two researchers independently coded the profiles of the fellows in the hivaids category using open coding to produce firstorder concepts and gradually abstracted them to the second order themes and then aggregated them into theoretical dimensions the open coding generated 238 initial codes for the intervention strategies employed by the fellows some of which were overlapping and had to be trimmed down after three rounds of coding and meetings to refine the codes the two researchers completed the data analysis after reaching theoretical saturation in the end we identified 46 unique se interventions finally the two researchers cycled back and forth between the emergent findings and cognate literature to make sense of the findings and position them in the literature we also presented the study in two international conferences to gain feedbacks which helped refine the findings and contributions findings social entrepreneurship interventions for hivaids problems our study reveals that social entrepreneurs employed four major intervention strategies the activities processes procedures and actions for hivaids problems relational service economic and policy figure 1 shows the analytical coding process that led to the findings insert figure 1 about here the term relational interventions are the ses strategies to improve the social relations and understanding between people with hivaidss and the public and healthcare workers by enhancing the dissemination of knowledge and information about hivaids to all stakeholders this stems from the ses realization that the first challenge in tackling hivaids is the stigmatization and discrimination problem that people with hivaids face relational interventions have three aspects i building public awareness ii educating healthcare providers and iii fostering crosssector collaboration these interventions are primarily micro in nature as they focus on helping individuals the ses connect with each other building public awareness is a common se intervention used to demystify the hivaids problems and improve public perceptions and attitudes towards people with hivaids it includes a range of tactics such as media and outreach campaigns sports events and curriculum changes to include information on hiv infection when society is better informed about hivaids its fear of hivaids sufferers generally decreases and empathy increases which lessens the fear of those with hivaids about seeking medical treatment we found myths about hivaids in the data the ses in our study aimed to debunk these myths and demystify hivaids by educating communities about reproductive health and safe sexual behavior and misconceptions about people with hivaids these ses interventions appear to align with the health awareness health outcomes hypothesis this is well illustrated in the following quote from ashokas website about catherine watson the founder of straighttalk newspaper and media in uganda she believes that only when the public openly talks about adolescence sexuality and stds that meaningful interventions will achieve lasting results she started the straight talk community newspaper to provide adolescents in uganda with frank information about sexuality and hivaids…around the radio shows adolescents have formed listeners clubs to discuss the issues and monitor each others behavior our study also found that the ses in the 19 countries educated healthcare providers to enhance their awareness sensitivity and empathy towards people with hivaids the following quote from ashokas website about glory alexander founder of asha foundation and a fellow of ashoka india illustrates this asha also provides sensitivity training to hospital staff and trains antenatal clinic nurses to act as counselors for hiv mothers she secures a place for the prevention of mother to child transmission program by drawing out doctors biases about hivpositive persons and calmly refuting their misconceptions … with moving stories and hard evidence importantly we found that the ses forged crosssector collaborations and leveraged them as resources for their ses these include collaborations with corporations and labor unions civil society ngos and the government to promote the wellbeing and rights of people with hivaids they did this by disseminating knowledge about hivaids and by utilizing crosssector partners expertise resources and networks to support their ses mission the following quote from ashokas web page illustrates these practices in presenting benjamin c mbakwems program ashoka nigeria by reaching out to local entrepreneurs… he gains business peoples trust and offers them technical assistance and trainings for their apprentices… he solicits their time to conduct education programs and workshops on sexually transmitted disease prevention and treatment leadership and counseling techniques service interventions are the ses strategies to improve healthcare services in and physical structures of hospitals healthcare clinics and communities to improve the wellbeing of people with hivaids these interventions focus on developing innovative healthcare services models and buildings some of these interventions are material in nature including new treatment approaches other interventions were symbolic to enable change and some were hybrid material and symbolic for instance the ses created mobile service outlets to provide direct medical care and education to those isolated from information and services or mobilized peers to counsel other people with hivaidss as quoted from ashokas website on christine du preeze and linzi smith developing a practical solution for reaching out to the farm workers on site with effective reliable and regular healthcare solutions on hivaids du preezes organization also has an outreach program through mobile clinics to ensure that workers even from distant farms… are accessing the services conveniently during these sessions linzi identifies potential peer leaders oneonone interviews are then held with linzi making selections based on criteria such as their willingness to speak about sex taboo topics in traditional zulu culture selected men are further mentored by linzi over a number of months they learn tactics to persuade other men to take responsibility for their sexual behavior and they learn to provide counseling and support for those in the company who are infected another type of service intervention is to innovate the existing healthcare processes by for example establishing standards and protocols for medical treatment as samsuridjal djauzi founder of yayasan pelita ilmu and fellow of ashoka indonesia notes djauzi …developed standard operating procedure sop for hiv diagnoses and therapy which years later became the national standards for all hospitals and health clinics in the country…the protocols… increased the staffs acceptance of aids patients in hospitals now almost every hospital accepts patients with hivaids and is able to conduct surgeries when necessary economic intervention is another ashoka se strategy that seeks to develop economic resources of people with hivaids and to sustain the ses operations and mission the economic interventions comprise capacity building and leveraging crosssector partners resources we found that the ashoka ses adopted two types of capacity building in the first ashoka ses provided free medication and basic needs such as shelter and food to people with hivaidss that enabled them to meet their basic needs the second capacity building type aimed to provide economic empowerment to the people with hivaidss and their families via vocational training and jobs with health insurance to help support themselves get medical care and to build their selfesteem and selfreliance support for starting or maintaining microenterprises and microfinancing the use of the empowerment approach in the ses suggests a growing need to increase clients capacity and empowerment to making their own decisions to improve the quality of life rather than just receiving care from social service agencies these interventions employ material resources to enable hivaids patients to improve their economic resources which in turn help them gain better access to health care these are illustrated in ashokas description of kallol ghosh of ashoka india and margrethe junker of ashoka uganda kallol has established a residential center that aims to meet their street childrens basic housing education and healthcare needs… protect them from the outside world but also help them integrate with surrounding social networks her margrethes model includes counseling hiv testing medical treatment and social support through microfinancing and other incomegenerating activities…to financially support themselves and their families as people receive early treatment for infections and antiretroviral drugs when needed and training and opportunities for selfhelp they continuously get stronger and healthier moreover they gain confidence and strength and take leadership roles in the community and defy social isolation another type of rarely discussed economic intervention is leveraging crosssector partners resources to render the ses hivaidsrelated treatments more affordable for example to lower the costs of hivaids medication georgina alvarado an ashoka from the united states has negotiated partnerships with pharmaceutical companies who are her natural allies in the quest to provide the latest medicines to hiv patients in prison at state expense lastly policy interventions are ses institutional strategies to promote policy changes to help people with hivaids they have grown as a response to government inefficiency in addressing hivaids problems especially due to the politically sensitive nature of stigmatized infectious diseases like hiv in some countries in doing so the ashoka ses employed advocacy published informationfact sheets and sought news media on aidshiv issues as tools to promote institutional and attitude changes to protect and better serve people with hivaids in these interventions the ses always collaborated extensively with various stakeholders such as with government agencies legislators lawyers patients stigmatized groups community leaders corporations labor unions and religious groups these interventions are essentially macro sw in nature as they focus on altering the social political and economic structure as a means to enable change at the individual level these are illustrated in ashokas description of ashok k rao from ashoka india and zackie achmat from ashoka south africa to provide the necessary legal support to people living with hivaids rao networks with the lawyers …in mumbai and …bangalore he has campaigned to guarantee womens property rights and nondiscriminatory education provided adequate public health services and implemented measures that will reduce the socioeconomic dependency of women he achmat is therefore building the grassroots treatment action campaign tac as a vehicle for poor communities to lobby collectively for free state provision of antiretroviral medications…to lobby the government to offer lifeextending medications to the public and especially to the poor… tac…sought to consistently and credibly challenge and dispel state arguments that hiv does not lead to aids and that there are unsustainably high costs to rolling out a national treatment plan theorizing a typology of se intervention in the hivaids sector the findings of the open coding process as shown in above figure 1 allowed the researchers to identify se interventions which provide a foundation for further theorization after cycling back and forth between the specific interventions employed by each of the 58 ses and the cognate literature in three rounds of iteration and to eliminate overlapping concepts we identified 46 unique se interventions and proposed a typology of se interventions in the hivaids sector based on three aspects the locus of change the type of resources used to enact social change and the nature of clientse relations insert table 2 about here we propose that the se interventions contain both institutionoriented and agentoriented practices parallel to macro and micro sw practices respectively some of these se interventions involve material or utilitarian resources to enable changes as well as symbolic or normative resources as clientse relations are central to both se and social workers social value creation we propose a distinction between se interventions that focus on clients as recipients and as cocreators some of the se interventions that we examined can be classified as hybrid and thus appear more than once in table 2 for instance the use of toy therapy by jackie branfield serves as a cultural tool to fight against discrimination and also as a counseling tool to assist sexually abused children cope with their psychic wounds accordingly toy therapy appears under both the institutionmacro and agentmicro sw categories as table 2 suggests se interventions are integrative as the ses embrace both institutionoriented and agentoriented aspects in sw as well as material and symbolic resources and also clientoriented overall we found that none of the fellows used a single intervention in solving hivaids issues rather all used multiple interventions for example tahir khilji employed hivpositive transvestites as peercounselors mobile research teams to collect data on the road mobilizing volunteer medical doctors and lawyers to chat with people with hivaids and used the research findings to educate policymakers on hivaids advocate for legal protection this shows the richness and multidimensionality of the se interventions to solve hivaids problems in response to the complex and multidimensional nature of the hivaids problems discussion building on the conceptualization of se as a hybrid of sw and business innovation practices and as a tool to improve societys wellbeing and health this article examined the interventions that 58 ashoka ses employed to solve hivaids problems by analyzing the 58 se intervention profiles using open coding approach this article first identified and summarized that ses have mainly used four types of intervention based on this finding the researchers further theorize 46 unique se interventions according to their characteristics in three aspects the locus of change the type of resources used and the nature of clientse relations it also explored how this study might advance sw research and practice our study is the first that examines ashokas entire sector of ses working in the hivaids area and offers at least three contributions to the sw literature first this article contributes to the sw literature by demonstrating that ashokas 58 ses solving hivaids problems use four major types of interventions 1 relational 2 service 3 economic and 4 policy these interventions solve individualand institutionallevel problems related to hivaids consequently we theorize that se interventions can be classified into a typology comprising the locus of change the type of resources used to enact social change and the nature of clientse relations this typology offers a good starting point to deepen our understanding of the nature of se interventions in the hivaids sector overall this article reveals that ses rarely employ a single or unidimensional strategy instead they employ integrated and multidimensional se strategies to tackle hivaids problems second the study is the first that shows that given the complexity and multidimensionality of hivaids problems ses did not merely combine macrosw practices and business innovations but also embraced micro sw work practices including helping people with hivaidss deal with economic difficulties and improving their health knowledge via capacitybuilding approaches and working closely with key stakeholders therefore we reconceptualize se as multilevel and multidimensional processes that hybridize social work practices using various resources and approaches to create social value for and through clients in a financially sustainable manner these findings may shed light on new avenues for future sw research and practice as they support the use of integrative and inclusive approaches to tackle hivaids issues and highlight the plausibility of combining macro and micro sw in sw research and to embrace new theoretical foundations into the heart of sw research and practice the client as cocreator concept suggests that not all solutions to hivaids problems should be developed by sw providers in fact clients could provide fruitful strategies and practices if included in the solution development process this is in contrast to most studies in hivaids that are rooted in the client as recipient model the client as cocreator model suggests the usefulness of partnering with clients such as people with hivaids as lead users clients can offer their deep insights based on their experience into the problems they face particularly problems for which the system has not yet found solutions additionally viewing the clientascocreator or leaduser enables sw scholars to define andor expand upon the role of clients particularly given the growing complexity of social problems their cost to society and the need to find workable innovative solutions that will benefit the clients and thus the broader society this is one area where se can bring new insights to sw research and practice the symbolic or soft resources from institutional and identity theory could also inform future sw research and practice about the importance of changing societys values mindsets and attitude about hivaids issues for instance grameen banks success in addressing poverty has not been solely driven by its small loans to clients but importantly the 16 principles that promote behavioral change for its clients as a selfcare tactic to prevent health problems that could reduce the efficacy of the small loans and the success of the program the symbolic resources identified in this study could be tested for their efficacy by comparing them with the use of purely material resources or a combination of the material and symbolic resources and thus could open avenues for future research the economic development approaches that the ses employed to enhance clients wellbeing health and social status such as workintegration programs supportingfinancing small businesses providing insurance to protect homeownership advocacy to protect people with hivaidss from being fired remain understudied and rarely practiced in sw field this gap separates sw from se it is well known that most ses employ economic development models where a job is not merely a means to generate income but a therapy itself current sw research and practice tend to focus on clinical and social welfare issues but overlook how and to what extent clients can be rehabilitated and reintegrated into a mainstream lifestyle through jobs this provides opportunities for future sw research to examine and test various job as therapy models drawing upon socialpsychological and management theories our study also suggests some partnership opportunities between se foundersmanagers and social workers for instance ashoka fellows could partner with social workers and clients to enhance the efficacy of se interventions or ses and social workers could train local residents or clients as social workers so as to work together or clients could train social workers and ses to view the problems from their perspectives currently we know very little about how social entrepreneurs and social workers can work together to improve the current interventions and to devise new ones this would enable researchers to compare the effectiveness of se interventions when performed solely by ses versus by social workers versus those that involve a partnership between ses and social workers our study further implies the need to lessen the gap between sw and se research so as to advance sw research amid the growing complexity of social problems and the increasing need to create workable solutions and sustainable impacts that each field alone cannot solve sufficiently for instance marketorientation bricolage and humanistic management concepts could offer new avenues to study innovations in micro sw approaches likewise emancipation and social movement research could infuse new perspectives about liberating the oppressed people and mobilizing the crowd to enact systemic change that offers breakthroughs for macro aspects of sw research lastly this article sparks questions about the plausibility and benefits of sw practitioners adopting the role of se practitioners during our analysis phase we observed that many of ashokas ses had sw backgrounds from a social position lens social workers have natural strengths in social resources and they can use their work experience in sw managementadministration to enhance the economic resources and add service innovation to their skills set hence social workers are well positioned to take up se work and to recognize that se is not that mysterious and in fact is aligned with much of sw values practices and goals some critics fear that the use of business and innovation practices in sesw might change how social workers work with clients or that it contradicts the purpose and values of sw the global trend of nonprofit organizations embracing the se model provides social workers the opportunities to experiment with sesw practice and to use evidence to assess its value to sw field obviously se is not a panacea for all social problems and more research is needed to understand its boundary condition this study is not without limitations the sample size of this study was limited to 58 ashoka ses although we analyzed the entire population of fellows working on hivaidsrelated issues in ashoka our findings may be an artifact of ashokas definition of se and its selection criteria which highly values innovativeness thus future research could examine the strategies employed by social entrepreneurs working in hivaidsrelated problems in other settings and nonaffiliated ses and in the developed world since most of ashokas ses studied here were working in developing and less developed nations future research can include larger samples and also surveys to test the efficacy of the se strategies identified here importantly future research can further explore the economic technology and new clinicaltherapy approaches adopted by ses working in the hivaids to understand their efficacy compared to existing approaches furthermore in sw research and practices se remains a contested terrain with scholars debating the boundary of se whether it is morally justified and ethically legitimate model to serve disadvantaged communities or possibly a fraud • attention grabbing posters and public announcement and innovative games on condom use • reach out programs to redlight districts discos public toilets xrated movie theaters • train young leaders from rural communities to raise awareness on hiv preventiontreatment via large sports tournaments • develop curriculum to educate community about mother to child transmission • develop a reginal network to facilitate information flow among decision makers and healthcare providers • build networks across sectors to develop a supportive environment for hiv aids patients • involve salon unions marketplace small business unions mechanic unions for prevention and treatment info • partnerships with government ngos religious groups traditional healers • use a toy as counseling methods • launch a mobile clinic to provide onsite medication and support to hiv positive farm workers • employ unemployed male leaders as hiv peer educators and counselor • provide vocational training and work opportunities to people living with hiv in hairdressing weaving farming internet cafe motorbike repair breeding rabbits and chicken with insurance cover • offer microcredit and insurance schemes and career plans to help women with hiv generate income • self employment projects for plwhas depending on their skills and interest • • advocate for rights of lgbt community through legal battle • publish hate crimes towards plwhas • fight to sanction companies that discriminate plwhas • use judiciary power to promote policy changes for the rights of hiv positive lgbt populations • lead a coalition to pressure government to subsidize or larger subsidies on antiretroviral drugs appendix i gioia method in this study we adopted the gioia methodology a methodology for doing qualitative research that extends the grounded theory tradition developed by strauss and corbin the gioia approach focuses on exploring and discovering new concepts processes or mechanisms the final product of this approach is a process model or a theory the gioias method starts with coding raw textual data to create firstorder concepts for examples based on the ashoka fellows profiles we coded openly these concepts hivpositive patients are sometimes rejected by hospitals and stigmatizing attitudes and acts of discrimination also come from nurses and doctors as firstlevel codes the next step is to merge the firstorder concepts with similar content or ideas into secondorder themes within a firmer theoretical realm for example firstlevel codes hivpositive patients are sometimes rejected by hospitals and stigmatizing attitudes and acts of discrimination also come from nurses and doctors created earlier can be abstracted into discrimination from health workers as a secondlevel code the last step is to aggregate the secondorder themes into aggregate dimensions for example secondlevel codes such as discrimination from health workers exclusion in the labour market and rejection by schools can be aggregated into society stigmatization and discrimination as an aggregate dimension we portrayed the threeorder of data analysis structure in figure 1 this data structure provides an intuitive way for researchers to convey findings and eases readers or journal gatekeepers to easily follow the researchers reasoning in transforming data to theorymodel appendix ii ashoka fellows ashoka is a global organization with a mission to find and support outstanding social entrepreneurs with pattern setting ideas for social change it provides funding mentoring and networking support to elected fellows ashoka has strict selection criteria and selects only the most outstanding ses worldwide as fellows based on five criteria newness of the ideasolution creativityinnovation social impact entrepreneurial quality and ethics each fellow has a profile that contains information about the new idea of the social entrepreneur the social problem that the se is trying to tackle the strategies employed by the se in solving the problems and biographical background of the social entrepreneur these profiles were written and maintained by ashoka based on multiple rounds of interviews with social entrepreneurs by multiple interviewers and presented in a uniform format in ashokas website a sample profile of the fellow fabián medina cabrera is provided below harley was elected as fellow since 2002 and he has been worked in the hivaids sector in colombia by providing an economic model that improves the quality of life of hivaids patients through workintegration and linking them to vital health benefits in this research our focal attention was on the strategies employed by the fellows as they represent the interventions employed by each fellow a sample strategy profile of ashoka fellow fabián medina cabrera the strategy fabiáns organizationfundación san josé obreroprepares people with hivaids for new sources of livelihood and advocates for their employment and viability as contributing members of society by reconstructing their daily routine with a productive gainful job at its center fabián helps hivpositive individuals and those living with aids in bogotá reintegrate into the mainstream with both social support structures including family coworkers and others living with hivaids and with access to crucial medical assistance through a health benefits package the core element of fabiáns strategy is linking people with hivaids to small businesses beginning with a weaving enterprise through which he trains them in textiles employs them and in many cases links them to other businesses for longerterm jobs employees produce highquality woven products and various other handmade items which fabián sells at colombian and international markets including swiss and brazilian besides much needed income and a sense of contribution among a team of coworkers fabiáns program offers access to healthcare realized through joint employee and employer contributions to state health benefits as this initiative continues to grow develops a market presence and increases its revenues fabián plans to pay into additional social security benefits including a pension that group members can leave to their immediate families upon death understanding that his program by itself cannot train and employ all people with hivaids fabián is using the model employment atmosphere created through the weaving business to advocate for more acceptance within the mainstream workplace through seminars held at companies where the participants usually include board members executives and office administrators fabián conducts activities geared toward eliminating the stigma attached to people with hivaids having already held seminars in 20 companies and with new workshops being planned fabian has evidence that these efforts are achieving success in overcoming the discrimination that often confronts people with hivaids in one workshop after listening to his coworkers say that they would accept someone with hiv or aids an employee stood up and said that he was both gay and living with aids the man was not only able to come to terms with his identity within the workplace but also able to continue to work there as a result of fabiáns workshops several people who had been working in the weaving microenterprise have been contacted by their former employers and invited to return to their old jobs with full job security and health coverage jobs provide more than just income and benefits because employment is often a key to social acceptance in colombia working helps people with hivaids reconnect with their families fabián fosters the reintegration of the family by incorporating family members into the microenterprises to work alongside their hivpositive relatives for cases of family estrangement however fabián has set up small group homes in which the residents and their children construct an environment that emulates a family unit these living arrangementsas well as fabiáns family reintegration initiativeshave had a profound effect on the participants behavior selfesteem and personal outlook like the health insurance program residents share the expense of the group houses with the foundation which contributes 10 percent of operating costs within five years fabián plans to establish new microenterprises and group homes in baranquilla medellín cali and several border townsall areas of high vulnerability for an epidemic spread of hivaids although the bogotá pilot strategy was to draw estranged people to the group homes first and then involve them in the microenterprise fabián intends to focus on the jobtraining and microenterprise components during expansion using profits to open houses only when completely necessary having already gained interest for his project in three new cities through promotional events and appearances with program beneficiaries fabián has entered the early launch stage of a new graphic arts initiative in cali a major component of fabiáns strategic plan for the coming yearsfundraising events and outreach to high schools and universitieswill garner new customers for the small business attract investors and increase public awareness of the issues surrounding hivaids fabián has also worked with the global health fund for the fight against aids the national university and unaids to advocate for larger health subsidies and sanctions against companies that do not abide by colombias laws protecting people living with hivaids fabián projects that his work will affect 10000 people annually per program site

her research focuses on social entrepreneurship nonprofit organizations and civil society in general

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introduction since 2015 thailand has driven the implementation of a longterm care the majority of them are senior citizens with severe health issues depression and fear about dying or leaving a massive burden 1 the village health volunteer caregivers sometimes experienced pressure from being in close proximity to those issues or losses and a deteriorating quality of life in order to emphasize the concern for caregiving motivation among village health volunteer caregivers of dependent people we sought out to better understand the linked mental health state methods a crosssectional study was employed to a total of 402 caregivers from 32 subdistricts from maha sarakham province the data were collected both socioeconomic status and the thai mental health indicator15 then transferred to spss ibm to analyze using descriptive statistics and chi square to test the relationship between sociology background items and the scores of mental health results the socioeconomic variables shown that most of caregivers were female age average 4989814 married education as secondary school time to look after the elderly for3 days a week experiencing for their profession 14 years over 59 have lower income than 5000 bath a month the association between socioeconomic status and mental health status however it was found that all variables indicated in the poor level of mental health status discussion and conclusions the gender of caregiver was a mainly association with mental health status in the past most women were often more depressed than men researchers 2 found that caregivers who have enough social support was marginally more beneficial for males and a feeling of control was beneficial for women

this crosssectional study aimed to explore the mental health status and the relationship between socioeconomic background and mean scores of mental health variables among caregivers cg in maha sarakham province northeast of thailand a total of 402 cgs were recruited from 32 subdistricts in 13 districts to participate with interviewing form data analysing used descriptive statistics and chisquare test for the relationship of the socioeconomic and the level of mental health status of caregivers the results shown that 9977 were female age average 4989814 range 2375 spent time look after the elderly for average 3 days per week worked experience for 14 years mean327166 years over 59 have lower income than 150 usd the gender of cg was a mainly statistically significant with the mental health status mhs p 0003 although the other variables were not significantly statistics test however it found that all variables indicated in the poor level of mental health status therefore the stakeholders who involves with cg should have concern to reduce their burnout regardless of compensation as well as set up the potential of family caregivers or young carers to help the elderly in the community

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introduction …sometimes i imagine the conventional academic essay as an overfurnished baroque drawing room designed to impress but hermetically sealed from the brute realities of the outside world …it is clear that we are not going to be able to distinguish fictional narratives from other kinds of narratives merely…in terms of what is made up invented or a product of the imagination…all narration involves making or structuring and it would be hard to deny a prominent role for the imagination in the narratives of science history or philosophy where once we were preoccupied with scientific rigor now we feel liberated to use our poetic imagination and literary license the quotations above reflect the themes that underlie the turn to fiction in social research the esoteric and alienating character of academic writing the difficulties of using truth as a tool to distinguish fiction from nonfiction and the importance of poetic literary forms in this article i look at how the debates around these issues are articulated by researchers who use fiction as a medium for reporting their findings and at the methodological and practical issues that arise from its use to be clear my interest is with the production of fiction as a means of reporting data rather than the analysis of fiction writing as a social practice analysing existing fiction as a form of social commentary or the use of existing fiction as a resource to teaching in the social sciences fiction as a practice of writing in research has a long history in ethnographic inquiry a slightly less well established one in sociology and psychology and an emerging one in other areas such as geography education organisation studies and the health sciences while it may be growing in popularity using fiction for dissemination remains a niche area in large part because of the durability of the distinction between fiction and nonfiction and the idea that social science deals with fact and not fiction this distinction is strongly embedded as a binary division in our production and consumption of cultural products such as books and films and it relates to other distinctions such as truenot true or realinvented nonetheless the differentiation between accounts that report on events or practices that are real and that did happen and those that did not and are inventions of an imagination is fragile the fragility has been recognised in qualitative research communities from at least the 1980s in what denzin and lincoln refer to as the fourth moment of qualitative inquiry characterised by a crisis of representation that emerged from the challenge to realist notions of research this challenge which takes form in diverse approaches including queer theory autoethnography alternative ethnography ethnographic fiction critical race theory indigenous methods feminism myriad postmodern resistance movements nonrepresentational theory and methodology and performative methodologies involves presenting theoretical and methodological reconceptualisations of positivistic notions of truth and representation the history of these debates is welltold elsewhere and i wont review them here nor will i discuss the relation between the various qualitative epistemologies and what are often roughly labelled as positivist approaches the important point for this discussion is that the debates have led to a variety of experimental forms of writing including fiction writing that have a commitment to different forms of textual representation academics have begun to adapt techniques used in fiction writing for the purposes of conveying the findings of their research these strategies include developing characters to exemplify certain social conditions and experiences using dialogue to juxtapose argumentspositions employing allegory to explore ideas through metaphor writing stories to create imagined plot lines that map out particular life experiences or to reflect on the relationship between the researcher and the research settingparticipants this paper is not concerned with the techniques themselves but with the motivations implications and possibilities of using them in pursing this i have deliberately chosen a very conventional style of academic writing there is an irony in this as a part of the argument i explore concerns the use of creative and unconventional forms however my aim is not to exemplify these practices but to think about their arguments and implications if there is one thing that an academic style should be good for it is that verisimilitude and the limitations of academic writing it is a common starting point in reflections on the uses of fiction in social research to juxtapose engaging and vivid writing in fiction and other creative forms with the more sterile prose of academia bensa and pullin refer to the unreal impression and tremendous boredom so often felt with anthropological and learned works while richardson confesses to the boredom of reading what should have been interesting academic texts similarly in the classic writing culture collection pratt notes that ethnographic writing tends to be surprisingly boring how one asks constantly could such interesting people doing such interesting things produce such dull books what did they have to do to themselves one of the ways that writers phrase this issue is in terms of the lack of emotion in academic work compared to the vivid personal narratives of fiction writing a part of this emotive deficit relates to the ways that research participants are represented through research for instance reflecting on her fictionalised representation of her research into women with eating disorders kiesinger notes that the dry clinical and highly analytical nature of these expert accounts fail to convey a sense of how anorexic and bulimic women themselves understand and make sense of their lives and conditions a similar set of issues is raised by reilly et al in their study of the use of poetry in representing womens experiences with breast cancer when we examined the codes and excerpts after we completed the analysis we noticed that the emotional resonance that affected us most deeply was missing though our conclusions were rigorously derived … the themes did not communicate the depth of lived experience feeling and selfdisclosure that these women had shared it is not just the participants lived experience that are stripped through such writing but also the experiences of researchers for instance douglas and carless give the following reflection on the experience of reading a research report that they had written when he read back what hed written he wasnt pleased in fact it was somehow devoid of the life hed experienced while he was talking with the womenin their homes the coffee shops standing in a queue at the post office where was the energy the humour the spirit of resistance he asked himself and where was the feeling when he looked at what hed written about the women and their lives friendships dogs activity hed somehow lost something hed known and felt when talking to the women in cornwall this absence of emotionality and depth is not just an aesthetic deficit but an ethical issue relating to the adequacy of representation as kusserow put it in relation to her research on refugees it seems unethical to dilute the horrors of poverty and aids in a slum bus station only through literature reviews homage to the academy footnotes and excess verbiage indeed the narrative form of academic writing is a strong area of critique in the turn to fiction banks notes that research writing often is disturbingly vacuous because it lacks the traditional qualities of good storytelling qualities like plot development there is as ingold puts it a lack of word craft in much academic writing with its formulaic concoctions of academic prose weighted down with arcane vocabulary honorific namecalling and everextending lists of citations the dialect of academic writing is seen by many as highly alienating as it relies on linguistic forms that are largely divorced from everyday talk the historical relation of this writing style to broadly positivistic conceptions of science means that even in forms of qualitative work writing often construes the author as a neutral authoritative and scientific voice this neutrality is embedded in language that avoids use of the first person makes generalised claims projects objectivity and certainty and produces closed answers and emphatic arguments academic writing is also characterised by stylistic devices such as organising arguments according to rationalised numerical lists frequent use of references to other texts and a highly technical and often verbose language in his discussion of the stylistic features of academic prose pinker argues that that such practices make academic work difficult to engage with and are turning our profession into a laughingstock indeed lancione points to the way that the academic language produces a gap between the researcher and the researched as he puts it through academic language i wasnt able to challenge marginalization but i was concretely enacting it…people were not able to understand to join in to make use of what i was saying and in the end a space of encounter was not generated in other words there is a paradox in academic writing which aims to develop innovations and new understanding but is also extremely conservative and alienating in its form and structures there is now a strong and sustained reaction to this conservatism that can be found in areas such as artsbased research autoethnograhy poetic representation performance ethnography creative nonfiction creative analytic process ethnography new ethnography narrative research and other unnamed esoteric areas of practice through such work researchers aim to redress the lack of emotionality and user engagement found in conventional academic work and to create more vivid research outputs such as music theatre poetry and creative writing poetry in particular has been used to turn data into more nuanced form using interview transcripts and other data to generate thought provoking writing reflecting on their use of this method in researching womens experience of breast cancer reilly et al note that the poems inject life blood and yearning back into the analysis these poems allow us to access deeper insights into the landscape of what it means to be a woman navigating breast cancer these forms of writing can give researchers a way to create engaging work that as adams and homan put it in relation to autoethnography …set a scene tell a story and create a text that demands attention and participation or in kusserows words …using the insights of poetrys acutely nuanced language and artistic aesthetic to bring a wider array of meanings work such as this is part of what clifford and marcus referred to as a turn to poetics and a commitment to finding new modes of narrative representation that can embrace ambiguity as an aesthetic in the telling of stories fiction is a form of writing within this general creative commitment that involves producing invented stories that move beyond data to tell stories in methodological terms fiction shares with other creative writing methods the commitment to verisimilitude ie to produce text that can simulate the social worlds being researched allow readers to imaginatively feel their way into the experiences that are being described by the author in the social sciences verisimilitude is closely related to the idea of empathy in that it facilitates engagement with the lived experiences of research participants moves beyond the epistemological question of fidelity to the methodological question as to how one can best create the appearance of truth or reality without however abandoning the ethical and political demands that even appearances may be judged by dadds concept of empathetic validity is useful as a way of characterising how empathetic research in general can transform the emotional dispositions of people towards each other such that more positive feelings are created between them in the form of greater empathy fictional reporting of data is seen by those who use it as a valuable form of empathetic prose in the next section i look at how the commitment to creating verisimilitude through fictional writing has created debate regarding the relationship of fictional accounts to data truth claims and research methodology data truth and representation fictional forms of writing may facilitate rich descriptions but they can also invoke the complaint that they are empirically baseless and simply the invention of a researchers imagination however a central theme in discussions of the analytic work of fiction is to describe them as representations of society this idea relates to the general claim that as nisbet notes the arts are … interested in throwing light upon reality and in somehow communicating this light to others researchers who produce fiction often also describe what they do in these terms referring to the invented but authentic representation of real social experience through fiction as miller puts it these invented stories are superordinate research narratives distillations of data that take form in fictionalised stories that present the data in a new fictionalised accounts drawing on her own experiences as a fiction writer and ethnographer christensen argues that the experiences of the lead character in her fictional account of homelessness in canada are representative of those experienced by many homeless women in the canadian north müller notes that in her fictional story of academics working in higher education the narrative explores the very real tension that academics might feel between their social identity and professional identity in the higher education context as a final example krizek offers the following reflection on the fictional narrative that he wrote as a part of his research dissemination all the individual details characterizations and experiences recounted in my narrative were witnessed by me at some time during my data collection although the events did not transpire in the precise order in which they are written the dialogue is a composite of various interactions written to represent the categories themes and cultural understandings uncovered in my doing of ethnography the idea underlying these characterisations is that fictional narratives present social experience in a new form they depict things that dohave happen and that have been witnessed as krizeks account highlights through a principled research process wade echoes this idea noting that instead of reporting the research findings in themes or even vignettes the writer invents a fictional account truthful to the findings but not necessarily to the original context of research rabbiosi and vanolo compare this kind of correspondence to the ways that weberian ideal types work as generalised descriptions of social phenomena without reference to specific instances the authors suggest that these ideal types function as metaphors and like metaphors are not true in the sense of corresponding to some specific reality but have analytic value in showing the general character of some feature of the world fictional invention then can facilitate greater leverage in our understandings of the world promising to reveal a more intractable and encompassing form of truth as pandian and mclean put it using fictional accounts to report research leads to questions about the relationship between the practices of fiction writing and academic social research vannini suggests that in embracing the creative turn researchers may become all but fiction writers indeed while fictional representation of data may blur disciplinary boundaries there are important differences between the activities of fiction writing and social research as richardson and pierre put it declaring that ones work is fiction is a different rhetorical move than is declaring that ones work is social science the two genres bring in different audiences and have different impacts on publics and politics and on how ones truth claims are to be evaluated bochner has noted that no ontological basis exists for drawing a line between newspaper articles novels and sociological research studies and that the differences can only be drawn by reference to practical matters and to arbitrary not empirical stipulations these practical matters relate to the conventions of practice through which researchers undertake their work in the social sciences these conventions are manifest in the enshrined methodological practices that define the various disciplines and paradigms of research work as strivers puts it the methods an investigator brings to the process and the interpretations she makes based on them are grounded in the consensual rules of the relevant knowledge community rather than in transcendental standards in other words what counts as social research and evaluations of its quality and worth are made by members of the research community there are various examples of evaluative criteria that in qualitative research and i focus my discussion here on two of the most influential richardson and st pierre and tracy richardson and st pierres criteria are whether a work makes a substantive contribution to knowledge whether it is credible has aesthetic merit involves reflexivity and has an impact on the reader for tracy high quality qualitative methodological research is marked by worthy topic rich rigor sincerity credibility resonance significant contribution ethics and meaningful coherence in insisting on the credibility of knowledge both sets of criteria prioritise research practice and the demonstrable relation between claims and research data similarly they both emphasise the importance of a reflexive relation between author and text which is equally critical to exploring the nature of fictional claimsmaking however at the same time the criteria emphasise the importance of writing as a practice of engagement with an audience and the possibilities of more innovative and affective writing when we compare these criteria with leavys criteria for evaluating fictionbased writing the extent of the overlap between the aims of fictional reportage and general qualitative aims becomes clearer still along with an emphasis on the role of fiction as a feature of publicly accessible scholarship leavys criteria are resonance aesthetics structure thoroughness trustworthiness verisimilitude and the writers personal style of writing the aims of creating impactful resonant aesthetically pleasing writing is by no means an unfamiliar idea in the qualitative research community the real controversy i suggest lies in the extent to which research claims can be shown to emerge from research practices as krizek argues creative writing cannot be employed as a methodological shortcut only the meticulous application of the methods of fieldwork including the analysis of the fruits of the fieldwork notes transcribed interviews audiotapes etc can direct with any fidelity the recording of the contexts characters and dialogic content of the cultural setting presented in the report similar rabbiosi and vanolo note that in producing fictional vignettes their logics and rationales have to be fully discussed the balance between the fictional and observed data has to be clearly stated and the overall result has to be judged in terms of its effectiveness and usefulness rather that sic realism or even more adherence to a supposed reality the conventions of academic writing particularly in dissertations theses journal articles conference papers promote structures that embed these methodological practices so that a reportpaperthesis typically starts with a literature review to frame a question which is followed by an explanation of method a description of the data and analysis and a review of how the study contributes to knowledge and society by far the majority of academic fiction work published in journals is conventional in its format and includes many or most of these contextualising elements the fiction is used for the specific purposes of verisimilitude in the reporting of data and it is based on principled research just like any data reportage as data remains the basis of fictionalised reporting researchers are faced with the challenge of whether to make that data visible one response is to present the original data alongside the fictionalised narrative although there are very few examples of this in the literature one project that adopts this approach is breens work on the life experiences of people with disability breen presents extracts of original interview transcripts along with his invented dialogue so that selections of coded text are shown next to the fictionalised story however breen does not explicitly state a reading of how one relates to the other leaving it to the reader to discern what the quotations might reveal as an alternate narrative the data does not authenticate the reading but acts as another narrative that also requires interpretation by the reader to establish its textual relation a different and much more common response involves emphasising the constructed nature of all research artefacts including data itself and to present the fictional account without the data on which it is based for instance richardsons early work in this area presents a playlike rendering of a discussion at an academic conference in which participants debate the relevance of a fictionalised reading as research knowledge through the dialogue and her reflections on it richardson opens up a question about the obsession with the relationship between research texts and the original data they relate to richardson problematizes the notion that research data such as recordings of conversation fieldnotes or transcripts are faithful renderings or are the true or correct account that the researcher needs to privilege in so doing richardson strips those methodological bogeymen of their power and resituates ideas of validity and reliability from knowing to telling this approach is strongly present in artsbased methods more broadly where research accounts are treated as one kind of performance among many other possible genres in this view any text is acted on through an interpretive frame and providing original transcriptions does not necessarily create more certainty about their authenticity as accounts and as a set of claims a component of this idea involves emphasising the complexity of relationships that emerges between researchers and research participants and the fact that formally recorded data is often only a small aspect of that as douglas and carless put it as important as it undoubtedly is to listen there is more to it than this it is not just the words captured by our digital recorders that tell the tale … our bodies can support and hold the kinds of insights that words cannot readily communicate or encapsulate the emphasis of the sensorial aspect of data collection the ways that researchers feel in research settings the sounds smells and textures of their environments the ethereal sense of the setting that researchers try to describe in rough categories like comfortable hostile relaxed homely tense further shows that data is only one part of the knowledge produced through research a very small subsection of work is more radical and adopts structures that are less conventional playing with the writing in more esoteric ways such experimental writing is restricted to outlets that are prepared to publish work that eschews normal academic writing practices notably the journal qualitative inquiry and in books such as banks and banks christensen et al clough pandian andmclean vannini in such work it is not just data that is invisible but also the very process of analysis as macdonald explains in his piece about a scottish archaeologist i do not see narrative and analysis as discrete projects stories being subject to a detached and instrumental interpretation analysis does not always declare itself as such it can find expression in allegory and be tucked away in the shadows of significant narrative detail the rejection of conventional forms of representation and expression that these kinds of practices represent can be seen as a part of a postrealist challenge to neoliberal discourses of knowledge and its technologies of evaluation they are often part of a critique of the idea that as pandian and mclean eloquently put it fidelity to the real may consist in acknowledging that it will always exceed the accounts we are able to give it discussion through the discussion so far i have shown that the ideals of aesthetic merit verisimilitude and userengagement have been central to the turn to fictional writing and i illustrated that these are also central to the aims of qualitative inquiry more broadly conceived furthermore the turn to fiction is not a turn against the idea that empirical research should form the basis of knowledge claims and notions such as rigour and reflexivity remain critical to the judgement of research worth i illustrated however that there are substantial divergences in how and the extent to which researchers make visible the relation between research practice data and fictionalised accounts this suggests that the question of whether or not fiction should play a role in research reporting may be much easier to answer than the question of how such accounts should be constructed it is well beyond this paper to make strong pronouncements on these matters but it is certainly clear that substantially more analysis around the epistemics and methodology of fictional reportage is critically important in the remainder of this paper i aim to contribute to these debates by illustrating three areas that require particular debate in the turn to fiction academic publishing and public engagement it should be clear that the motives of fictionalised reporting fit well not just with qualitative ideals but with much broader ideas about userengagement and widening participation that are now normal parts of the academic lexicon and which have their origin in debates about the relationship between academia and the general public these agendas have become embedded in regimes of research funding and in academic promotion procedures where engagement has become a core part of how academic success is judged given this there would seem to be a very important role for fictionalisation as a resource to dissemination however there are deep contradictions between this aim and the practices of research dissemination that underpin academic work while there are of course exceptions most of the work that uses fictional accounts is published in qualitative journals or in books produced by academic publishers these tend to be more special interest journals and not the larger journals with a broader disciplinary readership furthermore of the articles that i have referenced here nearly all are published in journals that require payment or institutional subscription there is an increasingly common practice of making individual publications available on institutional websites and on platforms such as academiaedu which undoubtedly helps to increase access however the broader point is that fictionalised reporting tends to happen inside of academias conventional dissemination routes and there are serious questions about how much engagement nonacademic audiences have with these and how likely they may be to actively track down work where it is not obviously accessible in journals one explanation for why this writing appears in journals is because publishing articles is a requirement for academics career maintenance and development many journals specify particular writing structures and even conventions of writing including grammatical preferences ways of presenting data the use of particular tenses person pronouns and so on further there are economic realities which mean that journals are restricted in the length of articles they publish which can pull against the presentation of long narratives or data extracts all of this means that there are limitations on the extent to which fiction or even just experimental writing can be a part of the work published in mainstream journals in short the academic publishing industries and the ways that publishing has been used as a metric of quality operate in tension with the aims behind the turn to fiction such practices may actually disincentivise the production of writing outside of academia and can both privilege conventional writing and marginalise the use of fiction as others have emphasised the publishing fetish places emphasis on publication as measurable output rather than on the experience of writing which pulls against much of the create exploratory ideas embedded in fictional writing this is perhaps partly what rhodes refers to when he describes the feeling of being bullied by audit regimes that try to wring out the passion and romance of though one of the central problems of fictional reporting relates to the ethics of representation the methodological issues around transcription have been a longstanding concern to researchers as all of our choices of representation in relation to research participants and how we show what they said and did all impact on our reading of the people behind the text and the meaning and significance of their actions if a character or invented plot device is to stand for some peoplebehaviours that have been observed then these dilemmas are even more acute one dilemma concerns the rhetorical power and purpose of fictionalisations as against those of empirical data we have seen that fictionalisation enables researchers to say things that may be troublesome if stated in more open and empirically grounded terms however as elliott reflects in relation to her own experiences of using a story format to report ethically complex issues must i hide behind composites behind fiction to tell an honest story … in fictional form a concrete set of events may become more like a parable than an example or evidence and as a result the report may lose its resonance and the sense of urgency of a real social problem a closely related dilemma concerns the idea that fictionalising may be disempowering for the participants themselves as it is not at all uncommon to find that participants want to be seen and heard which they often regard as empowering and important for social change freedom from the constraints of data may be empowering for researchers but it brings risks to participants who can potentially become absent voices in their own stories this brings us to a third ethical issue which relates to the writing process and the skills needed to produce affective fiction one response to the exclusion of research participants from writing fictional stories is to make the writing a collaborative process where researchers and participants work together in telling stories however writing fiction is a skill and it seems risky to assume that academics can automatically produce engaging fiction without trainingguidance or substantial practice …fiction can be as much a dead letter as academic prose and just because something is made up does not mean that it will be engaging one place where researchers have become quite vocal about this issue is in relation to doctoral education weatherall has clearly articulated the problems that early careers scholars face in adopting experimental forms of writing in the context of phds describing the challenges of trying to write messy confrontational and emotional writing in a different structure to the conventional academic form as she puts it from structure to grammar to tone and to content the conceptualisation of academic writing for a doctoral thesis is extremely orthodox these seemingly concrete boundaries maintained like the necessary chapters of a thesis are framed as obligatory in order to demonstrate sufficient scholarly aptitude one of the clear messages to come from this work is that in as far as they are supported in their writing students like all academicsare trained to write conventionally without wishing to undermine the importance of that training the point i wish to emphasise is that whatever level of their career they are at there is a serious question that needs to be explored regarding how well academics are supported or enabled in producing writing other than conventional publications concluding remarks fictional forms of data representation offer an important tool for researchers as they facilitate the production of nuanced empathetic affective stories that have the potential to engage audiences beyond conventional academic boundaries while fictional reporting remains a reasonably esoteric practice i have shown that its aims are consistent with those of broader paradigmatic criteria in qualitative inquiry but that there are also real and complex tensions in the uses of fiction found in the literature i suggest that these differences reflect extremely complicated questions regarding the nature of the epistemic claims that are made through qualitative inquiry and the divisions between academic work and other forms of knowledge producing practices these issues represent critical area of debate for qualitative researchers using fictional accounts in order to contribute to this discussion i showed that there are a number of issues that pull against the production of fictionalised work and argued that substantial discussion and development is needed in three areas first to explore practical ways to challenge academic publishing culture in order to create spaces where experimental writing can be undertaken and to facilitate forms of nonconventional publication second to substantially develop the creative engagement with writing for academics at all levels including for doctoral students in order to encourage a culture of experimentation and aesthetic curiosity towards writing third to deepen the ethical engagement with the issues surrounding fictionalisation which remains an under theorised topic in the publications reviewed here ethics and expertise

this article explores the use of fiction as a mode of representing data in social research i show that three of the key drivers for fictionalising research accounts relate to the ambitions of aesthetic engagement verisimilitude and userengagement i look at the different ways that authors have attempted to achieve these ambitions and the methodological tensions that arise from them i show that contemporary evaluative criteria in qualitative inquiry helps us to see that fictional reporting is an important tool for researchers in creating more affective writing however there are divergences in how researchers conceive of and use fictional accounts which highlight the importance of continued debate about the methodological practices of its use in order to contribute to these debates i point to three areas that need particular consideration for researchers working in this area 1 the structures of academic publishing and their embodiment in university audit regimes 2 the absence of engagement with alternative forms of writing in academic professional development and training and 3 the substantial ethical dilemmas in the use of fictional accounts

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racial attitude similarity and liking in samerace minority interactions views about race can profoundly shape interactions with both racial outgroup and ingroup members psychological research on race relations however has primarily examined ways in which negative or discordant racial attitudes undermine whiteminority interactions but not samerace interactions among whites or racial minorities the tacit assumption appears to be that racial attitudes cause friction between but not within groups in contrast realworld events suggest that deep disagreements within minority groups indeed arise and can lead individuals to denounce ingroup members whose racial attitudes deviate from their own for example black political and intellectual leaders have derogated the supreme court justice clarence thomas as an uncle tom for his allegedly more prowhite views and the civil rights activist al sharpton as a racial arsonist for his allegedly antiwhite views clearly ingroup status need not imply racial attitude agreement as social psychology expands to incorporate a diverse range of perspectives examining experiences of minorities in samerace interactions represents a critical advance our research investigates intraminority dynamics focusing on initial encounters and established relationships between minorities of the same race we test the novel prediction that disagreement about racial attitudes is especially disruptive to interpersonal liking in samerace minority interactions attitude dissimilarity even in arbitrary domains can impair sameand crossrace interactions and racial attitude dissimilarity among disadvantaged minorities may incur particularly negative interpersonal consequences undermining collective identity and perpetuating power disparities prior research suggests that people expect ingroup members to have similar racial attitudes to their own that dissimilarity in attitudes fosters disliking that attitude similarity or dissimilarity matters more for personally relevant issues and that racial issues and attitudes are especially important to minorities therefore we predict that disagreement will negatively affect minorities samerace interactions more than whites samerace interactions furthermore racial attitude dissimilarity should have more negative implications for minorities samerace interactionsin which attitude similarity is expectedthan crossrace interactions in contrast we predict that whiteswho typically report caring less about racewill comparably dislike whites and minorities with dissimilar racial attitudes to ground our argument theoretically we offer a brief overview of work on assumed similarity and dissimilarityrepulsion effects we then describe research on similarity in sameand crossrace interactions last we discuss effects of the attitude type and group on similarityattraction processes assumed similarity and dissimilarityrepulsion effects people often expect others to agree with them as evidenced by extensive work on assumed similarity social projection and false consensus individuals overestimate attitude similarity not only for strangers but also friends and assume that ingroup others share their attitudes and values more than those from outgroups even in minimal groups attitude similarity facilitates interpersonal attraction in initial contact and maintenance of longterm friendships although similarity increases attraction later work suggests that dissimilarity more powerfully decreases attraction producing greater shifts from default evaluations when people expect attitude similarity confirming a partners actual attitude similarity is unlikely to increase already high liking levels however when people expect attitude similarity but encounter attitude dissimilarity that discrepancy compels greater revisions to liking triggering a cascade of negative impressions due to perceived dissimilarity when people expect attitude dissimilarity learning that a partners attitudes are instead similar should increase liking more than confirming the partners attitudes are indeed dissimilar would decrease liking greater weight of unexpected dissimilarity implies greater disliking for samethan crossrace partners with dissimilar racial attitudes attitude similarity in sameand crossrace contexts intergroup research on similarity has found that assuming outgroup members attitudes differ from ones own can undermine crossrace interactions whereas learning that an outgroup member has attitudes matching ones own can increase liking and decrease aggression reduce intergroup threat and improve expectations for crossrace interactions for example whites varying in antiblack prejudice respond favorably to a black person perceived to share similar attitudes when choosing interaction partners whites and blacks prefer a crossrace partner whose attitudes match theirs to a samerace partner with dissimilar attitudes few other studies test effects of dissimilarity on interpersonal liking in samerace interactions or for minorities theorizing about reactions to dissimilarity in samerace interactions draws upon the black sheep effect which occurs when people derogate deviant ingroup members to a more extreme degree than outgroup members for example people more intensely punish and ostracize ingroup members whose attitudes or behaviors violate general norms most bse studies use normviolating targets but one set of studies found that attitude dissimilarity leads to greater disliking for an ingroup than outgroup member whereas attitude similarity did not consistently induce greater liking for ingroup members evidently attitude congruence matters as much or more in intragroup contexts and ingroup dissimilarities repel more than ingroup similarities attract we investigate whether these dynamics shift for attitudes directly relevant to group membership and whether repulsion asymmetries arise if the attitude matters more to one group than the other domain of dissimilar attitudes we hypothesize that people especially dislike ingroup members who disagree with them on attitudes directly related to their group identity most prior research on attitude similarity has assessed attitudes unrelated to group identity eg nonpartisan attitudes for democrats vs republicans chen kenrick 2002 intentionally superficial or linked to superordinate groups in a study manipulating gender attitude agreement between oppositesex small groups participantsespecially womenpreferred oppositesex outgroups with similar rather than dissimilar gender attitudes but this studys omission of samesex targets precludes tests of samesex repulsion for men versus women in a study addressing domain of dissimilarity participants in minimal groups supposedly based on preference for klee versus kandinsky paintings inferred that outgroup members differed from them more on aesthetic than general attitudes similarityattraction and dissimilarityrepulsion processes may be particularly potent when the attitude closely corresponds to the basis of group membership personal or vested interest in the attitude similarity domain amplifies attraction and repulsion targets with dissimilar attitudes on topics people personally find interesting elicit more dislike people assume greater attitude similarity when they believe a policy will personally affect them or they hold a numeric minority viewpoint potentially triggering disappointment when they learn others actual attitudes because racial attitudes tend to matter more to minorities we predict a repulsion asymmetry with dissimilar racial attitudes leading to greater disliking among samerace minorities than samerace whites racial attitudes are more personally important for minorities than for whites based on representative survey data blacks were 48 times more likely than whites to report race relations as one of the most important issues to them in 1983 to list racial problems as the most important challenge facing the country in 1992 and to cite racism and race relations as the single most important problem facing the next generation in 2000 occupying a lowerstatus societal position may make improved race relations a longterm security goal for minorities to meet their occupational income and even physical safety needs given greater personal relevance of racial attitudes to minorities assumed attitude similarity among ingroup members and heavy weighting of dissimilarity we predict the strongest dissimilarityrepulsion effects for minorities who disagree on racial attitudes with a racial ingroup member overview of studies two studies investigate the interpersonal consequences of having racial attitudes that differ from a partners attitudes in the context of ongoing friendships and facetoface interactions with strangers our research questions focus on agreement versus disagreement in peoples attitudes toward racial outgroups for both sameand crossrace pairs we examine outgroup racial attitudeshenceforth simply racial attitudesnamely the extent to which participants hold favorable or unfavorable attitudes toward other racial groups either in general or toward a specific relevant outgroup pilot study racial attitude importance representative national survey data indicate that on average blacks report personally caring more about race than whites do we used the same survey items to test whether this finding replicates at the university where we conducted studies 1 and 2 participants and procedures of 558 undergraduates initially recruited 357 selfidentified as white 64 as asianasian american 75 as african americanblack 56 as latino 2 as native american 3 as pacific islander and 1 middle eastern 1 the sample included 200 men and 358 women measures general social survey items assessed the personal importance and salience of race relations on 1to4 scales personal importance items were how important is the issue of race relations to you and how concerned are you personally about race relations the salience item was how often would you say that you and your friends in general think about race relations results and discussion as hypothesized minorities reported personally caring more about race relations than did whites t 444 p 01 d 040 a set of orthogonal contrasts indicated that race relations were significantly more important to blacks than to asians and latinos contrast 058 p 01 but that latinos and asians did not differ contrast 008 p 52 due to low power no tests were performed for subgroups with n 5 minorities also reported that race was more salient to them than did whites t 533 p 01 d 048 2the results from this university sample are consistent with our claim that attitudes about race relations are typically more personally meaningful and salient for minorities than whites3 study 1 racial attitude similarity between friends study 1 tests whether racial attitude similarity is related to the quality of established crossand samerace friendships sameand crossrace pairs of friends completed measures of racial attitudes and friendship quality consistent with prior bse studies we expected a slight preference for sameover crossrace friends when dyad members racial attitudes agree more importantly we predicted that participants would perceive samerace friends who disagree with their racial attitudes more negatively because race matters more to minorities than whites according to the pilot study and representative polling data this samerace dissimilarityrepulsion effect should be stronger for minorities than whites thus we predict that for friends with dissimilar racial attitudes minorities in samerace friendships will report lower friendship quality than whites in samerace friendships or minorities in crossrace friendships method participants initially 363 undergraduates completed a questionnaire about a specific sameor crossrace friend of the same gender attending the same university next participants were asked to invite their specified friend to complete the questionnaire for 5 in wave 1 participants and friends filled out and mailed back paper questionnaires yielding a friend response rate of 24 in waves 2 and 3 participants completed the questionnaire online and could email it to friends plus the researchers sent reminders to eligible friends 4 raising the friend response rate to 51 the overall friend response rate did not differ for sameversus crossrace friendships  2 146 p 24 data collection occurred in 3 waves across 3 years with a target of over 100 dyads and we did not test our hypotheses until all data collection was completed the target demographic included whites blacks latinos and asians oversampling blacks and latinos because only complete dyadswith attitude data from both dyad memberscould be used to test our hypothesis analyses excluded 212 solo respondents leaving 151 dyads of the 151 original participants we excluded 12 people not from the target population analyses excluded 24 additional friends who were ineligible because they were a different 4 over 15 of incomplete dyads included an ineligible friend gender a minor from another school a duplicate friend selected by a prior participant or from an other racial background 5 finally analyses excluded 10 participants for dyadcomposition issues 2 dyads in which one person misperceived their friends race and 8 dyads with minorities in the differentrace condition who selected outgroup minority friends the final 105 dyads contained 64 samerace friendships and 41 crossrace friendships participants selfidentified as white black latino and asian design and procedure we used a 2  2 betweensubjects design a randomnumber generator assigned participants to select a friend of the same gender and approximate age who attended the same college and whose raceethnicity was either the same as you or different from you the sample included 11 participants who selected an eligible friend whose race did not match their assigned sameor crossrace condition but who were retained for analyses in their selfimposed condition because this error did not interact with any findings of interest measures participants completed several measures related to their friendship and their racial attitudes the measures relevant to the present research question are described below background information participants indicated their gender raceethnicity age and 5 in most instances in which participants picked other for their friends raceethnicity they specified that their friend was multiracial in 3 instances participants named specific subgroups that could conceivably be categorized within the broader category blackafrican american including these 3 dyads does not change the reported results the predicted fourway interaction remains significant p 03 class year and this information for their friend in addition they indicated their relationship duration and how well does this person know you from 1 to 7 6racial attitudes participants evaluated two items indexing affective attitudes toward outgroups i feel negatively towards people of racialethnic group other than my own and i feel positively towards people of racialethnic group other than my own from 1 to 7 7 using an identical measure of outgroup racial attitudes for whites and minorities ensures that if dyad type moderates dissimilarityrepulsion effects this effect cannot reflect differences in measures across groups friendship quality the mcgill friendship questionnaire assessed friendship quality we combined 25 items from the respondents affection and friends functions subscales to create a friendship quality composite responses ranged from 1 to 7 results analyses of racial attitudes and friendship quality confirmed that dyad members who were initially recruited to participate by the experimenter versus nominated by a friend did not differ on the effect of actors attitudes on friendship quality the effect of partners attitudes the effect of disagreement the intercepts of quality or the error variances ∆χ 2 225 p 81 analyses collapse across this variable using the terms participant and friend interchangeably dyadic mixedmodel analysesthe indistinguishable actorpartner interdependence model controlled for nonindependence participant race is a mixed variable so dyad members are treated as indistinguishable in all dyadic analyses variances of dyad members are constrained to be equal adjusting for nonindependence using the satterthwaite approximation can yield fractional degrees of freedom model predictors included participant race dyad type actor racial attitudes and partner racial attitudes plus all interaction terms racial attitudes were grandmean centered background information the high intraclass correlation for length of relationship icc 78 p 01 indicates that dyad members provided convergent estimates and that dyads ranged in their friendship length length ranged from a few months or less or 6 months to less than a year to a year or longer but did not differ for sameversus crossrace friends t 057 p 57 nor did ratings of how well do you know this person reveal differences t 076 p 45 participants assigned to nominate a samerace friend did not select friends whom they had known longer or better 8racial attitudes dyad members showed abovechance similarity in racial attitudes icc 24 p 01 no significant differences in racial attitudes emerged for whites 285 p 01 racial attitude similarity was associated with higher friendship quality in samethan crossrace friendships b 027 t 278 p 01 whereas racial attitude dissimilarity was associated with lower friendship quality in samethan crossrace friendships b 017 t 151 p 14 though not statistically significant critically as predicted the strength of these effects differed for white and minority participants as indicated by a significant 4way interaction of participant race dyad type participant racial attitudes and friend racial attitudes b 019 t 300 p 01 the effect of dyad type on friendship quality did not differ based on the type of attitude similarity or attitude dissimilarity for either race so analyses collapsed across types of similarity and across types of dissimilarity 9 when dyad members racial attitudes agree friendship quality was higher in samethan crossrace friendships b 027 t 278 p 01 regardless of participant race b 012 t 139 p 17 however when discussion in study 1 we found evidence for a dissimilarityrepulsion effect among minorities in samerace friendships specifically in friendships minorities reported lower relationship quality with samethan crossrace friends where there was racial attitude dissimilarity in contrast when friends shared similar racial attitudes they tended to report better relationship quality in samethan crossrace friendships consistent with prior bse studies together with the pilot study data indicating that racial issues tend to matter more to minorities than whites in this university setting these results suggest that the relative importance of the attitude topic may affect the magnitude of dissimilarityrepulsion effects in study 1 we assumed friends had experienced ample opportunity over time to discuss racial attitudes and gauge agreement but study 2 tests whether the same dissimilarityrepulsion asymmetry for minorities versus whites emerges in facetoface interactions among strangers in shortterm interaction settings racial attitudes may be less salient or masked by other attitudes indeed whites often avoid discussing race in crossrace interactions between strangers limiting learning about each others racial attitudes study 2 therefore investigates whether the hypothesized disagreement pattern emerges primarily when people discuss race potentially providing more direct access to each others racial attitudes study 2 racial attitude similarity and discussing race in facetoface encounters study 2 connects racial attitude similarity to interpersonal liking among strangers in sameand crossrace interactions in the laboratory testing these processes between strangers is critical because disagreement on racial attitudes may undermine samerace minority friendships from the outset study 2 used the previously validated attitudes towards blacks and attitudes towards whites racial attitudes scales so accordingly we recruited only white and black participants black and white strangers completed an online measure of racial attitudes and interacted briefly with a minority or white partner we coded the extent to which dyads talked about race to investigate whether talking about race enhances the minoritywhite asymmetry in the dissimilarityrepulsion process method participants we recruited white and black undergraduates and randomly assigned them to samegender pairs with sameor crossrace partners of 172 dyads completing the study 19 were excluded from analyses 6 due to prior acquaintance 2 due to suspicion and 11 due to selfor partnerperceived identification with an ineligible racial group dyadic analyses necessarily excluded 26 dyads in which one or both participants failed to complete the appropriate attitude measure as described below the final 127 dyads included 44 whitewhite dyads 56 whiteblack dyads and 27 blackblack dyads sample size was based on participant availability across two academic years of recruiting to obtain over 100 dyads and we did not test our hypotheses until data collection was completed procedure to downplay our interest in racial attitude similarity and interaction quality without mentioning race we recruited participants to two ostensibly distinct studies an online attitudes and associations study for 8 or credit and a labbased task performance study for 12 or credit people who completed either study were invited to complete the other on a different day of all those who completed the lab session 85 completed the online measures afterward 10 beforehand and 5 never dyadic analyses of similarity require attitude data for both dyad members thus excluding 26 dyads in which one or both participants skipped the online measures or reported their racial background as other and were thus not routed to the appropriate racial attitudes measure no significant racial attitude differences emerged for participants retained versus dropped due to missing partner data t 1 online session participants completed an online survey described as an examination of personal attitudes social attitudes and associations on a different date from the lab session lab session a white female experimenter blind to participants racial attitudes seated participants together at a table after consenting to participate and be videotaped participants completed three interpersonally challenging tasks first they spent 4 minutes discussing a topic adapted from dovidio et al dating in the current era has some advantages and disadvantages to dating in earlier periods please consider and discuss what you personally feel are these advantages and disadvantages what are your experiences with dating in a racially religiously and economically diverse society next participants decided which items would be most valuable for an incoming student to bring to college participants ranked 10 items individually and then were instructed to please decide together which items would be most valuable emphasizing that it is important that you both agree about your joint rankings participants received as much time as needed to finalize joint rankings the final task involved playing connect four competing to get four xs or os in a row first participants played for 4 minutes completing up to three games after the interaction participants completed questionnaires about the interaction and their partner in separate rooms participants reported their demographics estimated the interaction duration recalled the connect four game outcome reported their partners demographics and indicated any prior acquaintance last participants were debriefed thanked and compensated measures participants completed a measure of explicit outgroup attitudes in the online session and measures about their interaction with another participant in the lab session 10racial attitudes white participants reported their attitudes toward blacks and black participants indicated their attitudes towards whites these widely used wellvalidated scales were developed in tandem to enable precise assessment of outgroup racial attitudes held by whites and blacks respectively to equate the scales our analyses used only 8 parallel items from the two scales responses range from 1 to 7 interaction satisfaction after the interaction 4 items assessed satisfaction i enjoyed working with the other participant i was satisfied with our interaction i like the other participant and the other participant was comfortable to work with on scales from 1 to 7 partner positivity participants reported how positively they viewed their partner with 5 items about whether the partner was an efficient problem solver seemed very intelligent appeared to be very considerate seemed trustworthy and appeared to be nervous from 1 to 7 11behavioral coding three coders blind to condition listened to the audio recordings and independently coded the extent to which each participant discussed race during the interaction using a 7point scale because discussion of race by either dyad member can reveal similar racial attitudes a dyadlevel indicator of discussing race was created by computing the maximum of the two dyad members scores on that coded behavior results we again used the indistinguishable apim to account for nonindependence in dyadic interactions model predictors included participant race dyad type actor racial attitudes and partner racial attitudes plus all interaction terms racial attitudes were grandmean centered notably these lowerorder effects were qualified by the hypothesized 4way interaction of actor race dyad type actor racial attitudes and partner racial attitudes b 020 t 11 metaperceptions were also measured using a 3item scale similar results to interaction satisfaction and partner positivity emerged for metaperceptions but metaperceptions do not bear directly on our predictions about how attitude disagreement undermines peoples own liking for others 221 p 03 this interaction indicates that implications of racial attitude similarity for satisfaction differ for sameversus crossrace dyads and for blacks versus white participants 12when dyad members racial attitudes agreed participant race was unrelated to their satisfaction actor race b 001 t 011 p 92 dyad type b 007 t 081 p 42 actor race by dyad type b 003 t 036 p 72 however when dyad members racial attitudes disagreed there was a significant interaction of actor race and dyad type b 023 t 327 p 01 such that black participants with black partners felt less satisfied with the interaction than white participants with white partners b 048 t 328 p 01 and less satisfied than black participants with white partners b 056 t as expected the disagreement pattern tended to be stronger when dyads discussed race more this 5way interaction was significant for interaction positivity b 030 t 212 p 04 and marginally significant for partner positivity b 021 t 168 p 097 tests of higherorder interaction effects involving measured predictors tend to be lower powered so although the latter interaction was marginal together they suggest that dissimilarityrepulsion processes for minorities in samerace dyads may be intensified when strangers discuss race and can readily infer each others racial attitudes indeed for dyads who discussed race more actor race partner race actor racial attitudes and partner racial attitudes significantly interacted to predict interaction satisfaction b 056 t 252 p 01 and partner positivity b 057 t 287 p 01 in contrast for dyads who discussed race less this 4way interaction was not significant for interaction satisfaction b 017 t 107 discussion study 2 provided support for the dissimilarityrepulsion hypotheses for minorities but not for whites during a facetoface interaction with a stranger in the lab specifically when dyad members racial attitudes disagreed blacks in samerace dyads liked partners less and felt less satisfied with the interaction a pattern not evident for whites analyses of coded behavior provided initial evidence that such asymmetric ingroupdissimilarityrepulsion effects are stronger for dyads who discussed race more suggesting that such effects are more likely when interaction partners exchange information about racial attitudes thus repulsion effects may arise from discovering dissimilar attitudes an emergent property of dyadic interactions more so than from individual differences associated with racial attitudes general discussion two studies using varied relational settings and attitude measures provide evidence for the dissimilarityrepulsion effects in samerace interactions for minorities when the object of agreement is racial attitudes representative polling data and our pilot study from the university where studies 1 and 2 were conducted reveal that relative to whites minorities report greater personal importance and salience of race relations studies 1 and 2 revealed especially low levels of friendship quality interaction satisfaction and partner positivity for minorities whose samerace friends or interaction partners racial attitudes disagreed with participants attitudes finally study 2 implies such effects may depend on opportunities to discover others racial attitudes disagreement led to disliking only when samerace minority dyads discussed race this research extends the literature on similarity and attraction by investigating varied types of interpersonal encounters across facetoface first encounters and extended friendships we found negative effects of attitude dissimilarity for samerace minority pairs investigating facetoface interactions without confederates advances work on similarityattraction processes particularly in intraand intergroup contexts our work also makes a novel contribution by to our knowledge presenting the first studies to test attitude similarity effects on dyadic intergroup processes when the attitude in question relates directly to group membership when navigating unfolding interactions and anticipating future encounters people may especially value attitude similarity in domains that are more chronically relevant and crucial for collective identity limitations and future directions one challenge inherent in testing specific outgroup attitude differences in an intergroup context is some inevitable variation in the attitude object depending on ones own racial ingroup in samerace dyads the outgroup attitudes of both people likely pertain to the same group but in crossrace dyads outgroup attitudes likely pertain to each others groups in sameand crossrace interactions people may also consider thirdparty outgroups the two studies address this potential ambiguity from different angles study 1 which draws on a more diverse participant sample preserves generality and consistency in measurement by asking all participants about their positive or negative attitudes toward other racial groups in general this approach draws on empirical work showing that prejudice levels directed at distinct outgroups tend to correlate highly and shift in tandem by contrast study 2 which includes only white and black participants clearly specifies the relevant outgroup using established measures designed for this purpose this more focused approach still retains attitude object consistency insofar as almost half the items are constant for all participants such as racial integration has benefited both whites and blacks indeed we neither theorize nor operationalize racial attitudes as showing a zerosum relationship in attitudes toward racial ingroups versus outgroups people can express warmth toward outgroups or embrace diversity and contact with outgroups without disliking ingroup members moreover members of the same or different racial groups can readily agreeor disagreewith each other about whether racial integration benefits society finally ambiguity within dyads about the outgroup attitude object is less relevant for the most theoretically important comparison the dissimilarityrepulsion asymmetry between samerace minority dyads and samerace white dyads although study 1 included several different racial minority groups we lacked sufficient power to test for differences in this repulsion asymmetry across racial minority dyad members or among their white partners in crossrace dyads insofar as some minority groups may assign relatively more importance to racial attitudes than others do they may experience stronger repulsion effects future research is needed to investigate variation across minorities these studies do not directly manipulate awareness of an interaction partners racial attitudes during an interpersonal encounter to examine interpersonal interactions and friendship as they naturally unfold we opted not to expose participants explicitly to each others racial attitudes so we cannot know exactly how participants become aware of their partners attitudes notably in study 2 this pattern was stronger when dyads discussed race future work may investigate how people verbally and nonverbally convey racial attitudes in crossand samerace interactions our findings suggest that for minorities in a mostly white context communicating congruent racial attitudes to ingroup others may enhance interactions or relationships whereas concealment may be more adaptive given incongruent attitudes lastly one question that remains is the extent to which discovering that our attitudes differ from those of fellow ingroup members can carry intrapersonal costs depending on the personal significance of that attitude individuals may ignore disagreement if an attitude domain does not seem especially important a process that may be at play when whites hear another white person make an antiblack racist comment but neither confront this ingroup member nor experience negative affect and are indeed more likely to select the racist white person than a black person as an interaction partner conversely when an attitude is personally important or definitional for the group intragroup disagreements may jeopardize ones sense of ingroup belonging and feelings of deviance may threaten the self belongingness concerns may be greater for minorities who tend to identify more strongly with their raceethnicity particularly if the disagreement pertains to group membership disagreement in racial attitudes among samerace individuals may undermine collective identity particularly for disadvantaged racial groups conclusion the present work contributes to a small but growing body of work on relations within and between minority groups expanding our understanding of how samerace interactions may succeed or fail based on similar or dissimilar attitudes towards outgroups if racial attitude dissimilarity for samerace minority interaction partners especially undercuts interaction quality and ingroup friendship development these dynamics could adversely affect the wellbeing of minority individuals and communities believing that key targets share our attitudes is theorized to serve needs for social support and selfesteem maintenance particularly when attitude issues are personally involving or when one holds a minority position samerace minority friendships may thus be particularly critical for racebased social support and better understanding these interaction dynamics can inform efforts to create environments that foster these relationships appendix a friendship quality items imagine that the blank space in each item contains the persons name that you selected for this study with himher in mind decide how much you agree with the item use the scale below appendix b racial attitudes items parallel items from attitudes towards blacks and attitudes towards whites scales with wording for atw given in brackets and r denoting reversecoded items instructions please use the scale below to indicate the extent to which you agree with each statement from 1 to 7 1 i favor open housing laws that allow more racial integration of neighborhoods r 2 racial integration has benefited both whites and blacks r 3 whites should support blacks in their struggle against discrimination and segregation r 4 i think that black white people look more similar to each other than white black people do whites are so touchy about race that it is difficult to get along with them

two studies investigate the relationship between racial attitude dis similarity and interpersonal liking for racial minorities and whites in samerace and crossrace pairs in nationally representative and local samples minorities report personally caring about racial issues more than whites do pilot study which we theorize makes racial attitude divergence with ingroup members especially disruptive both established friendships study 1 and facetoface interactions among strangers study 2 provided evidence for the dissimilarityrepulsion hypothesis in samerace interactions for minorities but not whites for minorities disagreeing with a minority partner or friend about racial attitudes decreased their positivity toward that person because minorities typically report caring about race more than whites samerace friendships involving shared racial attitudes may be particularly critical sources of social support for them particularly in predominately white contexts understanding challenges that arise in samerace interactions not just crossrace interactions can help create environments in which samerace minority friendships flourish

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cancer screening and perceived themselves to be at higher risk than men who did not have a fdmr with prostate cancer however fdmrs may not be aware of their risk status if they were never informed that a family member had prostate cancer that lack of information can impair fdmrs ability to fully participate in informed decisionmaking about screening communication about prostate cancer by men with prostate cancer is poorly understood particularly among minority populations such as latinos much of the literature on cancer diagnosis disclosure addresses physician communication with patients and not patient disclosure to family and friends however in exploring gender differences in disclosing a cancer diagnosis to family and friends the literature shows that men are more reluctant to disclose their diagnosis because of social expectations that perpetuate the myth that men are strong stoic and selfsufficient when considering ethnic differences in cancer communication papadopoulos and lees found similarities in family communication regarding cancer diagnosis among ethnicities with most restricting communications to the very immediate family ethnicities included in the study were bangladeshi greek irish montserratian jamaican and caucasian english two studies specifically investigated diagnosis disclosure among men with prostate cancer gray fitch phillips labrecque and fergus found that men were very cautious about disclosing their prostate cancer diagnosis because the idea of needing support and the need to control their anxiety about their diagnosis were linked to discomfort in the other study investigators found that men who told members of their social network about their diagnosis received positive support and felt they had done the right thing however the men in both studies were predominantly caucasian minorities were underrepresented in all of the studies reviewed prostate cancer is the most commonly diagnosed noncutaneous cancer among men in the united states and latinos are the fastestgrowing minority therefore understanding how and with whom latinos communicate about prostate cancer is important in addition latinos are disproportionately uninsured when compared to caucasians and for many english is not their first language prostate cancer and issues surrounding its treatment including incontinence and erectile dysfunction are not generally accepted topics of conversation among latino men and latinos with prostate cancer may not understand the need to communicate with fdmrs or may be reluctant to do so because of unique cultural issues therefore the purpose of the current study was to develop a descriptive framework of the communication processes used by latinos with prostate cancer when communicating with others about their diagnosis methods the authors used a constructivist grounded theory approach to analyze and construct a descriptive framework from semistructured interviews with latinos who had been diagnosed with prostate cancer sampling and analysis were continued until categories and relationships among the participants were identified and completely described from the data constructivist grounded theory approach is ungirded by symbolic interactionism which posits that meaning is made in interaction procedure data were gathered using semistructured indepth interviews the interviews were conducted by bilingual male interviewers in participants homes participants were asked to talk about their experience with treatment with whom they talked to about their cancer before and after diagnosis and what and when they told others prompts were used to elicit indepth explanations followup interviews were conducted with 10 of the participants theoretical sampling was used to select participants who could provide additional information about theoretical concepts as they emerged all interviews were tape recorded and transcribed verbatim in the language in which the interviews were conducted spanish transcripts were translated using the rigorous process developed by the research team for qualitative research analysis started with linebyline coding and constant comparison among codes from that process categories were identified described and labeled description of categories involved developing properties and dimensions for the categories which led to the discovery of relationships among the categories analysis continued until no new categories were discovered and no new properties or dimensions in categories were found as categories were described they were amplified and verified in the followup interviews as the framework was described the remaining 14 transcripts that were not used for the framework development were reviewed to verify that the framework was applicable analysis was conducted by the authors individually and collaboratively and agreement on categories was reached by consensus and from consultation with the interviewers analysis notes and memos were maintained throughout the study results the analysis uncovered an overarching process of purposeful interacting components of the process included spheres of communication with each sphere connected to purposes and content some spheres had partial overlap with others the crosscutting processes of respectful silence and selective disclosure were balanced and influenced by the spheres spheres of communication spheres of communication emerged when men identified different groups with whom they communicated about their prostate cancer the purpose of the communication in each sphere guided what was told how it was told and when it was told the investigators identified the spheres as experts inner circle work beneficiaries and outer circle expertsthe expert sphere was used to determine the best treatment understand the treatment and its effects and to develop expectations following treatment included in this sphere were healthcare providers and men who previously had prostate cancer most of the participants related that they wanted to know the physicians recommendation for treatment which carried the most weight in their treatment decision for earlystage prostate cancer he said that for me there was the operation the surgery was the the best because i had the age to get a surgery yes and uh there was another treatment but for me surgery was the the right one i told him that it was best for him to operate me the men in the current study also talked about consulting with prostate cancer survivors survivors were viewed as experts by participants because they had been treated for and survived prostate cancer experienced survivors were consulted regarding what to expect during and after treatment particularly side effects and whether symptoms being experienced were normal compared to the survivors experience one participant said i did not know anything about that and i started to talk with my friend and coworkers also participants consulted more with experienced survivors about symptoms related to sexual function and physical sensations more often than with healthcare professionals i found friends of mine in the hospital that also had the the operation and yes sometimes i go to visit them we talk about that only that yes every time we see each other we talk about that how do you feel do you have a symptom or anything no well we are fine inner circlethe inner circle consisted of those who a participant considered closest to him who were told first about the illness and were involved most with his prostate cancer treatment and recovery for married men this included the wife and very often adult children who lived nearby or with the couple of the two unpartnered men in the study ones inner circle was his mother and the others were his close friends workthe work sphere was comprised of bosses and coworkers the boss in particular had to be given a reason for requested time off men reported giving limited information about their diagnosis in that situation such as needing treatment for a serious condition but not always telling the boss about their cancer diagnosis no well i said that i had some tests done and they had shown that there was a problem with my prostate and that i was going to get operated that if they could give me permission to to go to the operations they said yes that i could go the same was true for coworkers when limitations at work existed after returning from treatment well the same comments that what i was going to go do that is why i wasnt going to go to work for some days that i was going to get my prostate operated beneficiariesthe beneficiary sphere consisted of people the men thought could benefit from knowing about their experiences with prostate cancer including sons other male relatives male friends and sometimes male coworkers the goals were to educate and encourage others to be screened to save their lives men saw screening as a way of preventing prostate cancer or of others being able to prevent what had happened to them one participant explained like i told them you gotta get that psa so you dont get cancer like me the men talked of telling others to not be concerned about the digital rectal examination because it would save their life outer circlethe outer circle consisted of those with whom men felt no need to discuss their diagnosis including family members who were geographically or emotionally distant casual friends or coworkers men did not want to impose a burden on those who would be unable to help or in other cases felt that it was none of their business therefore the diagnosis was not disclosed in this sphere interactional processes the interactional processes of respectful silence and selective disclosure operated in and among spheres in each sphere a balance of respectful silence and selective disclosure was achieved respectful silence was respecting peoples feelings and privacy or maintaining ones own privacy instead of talking purposefully about topics that would be embarrassing to another person relative to prostate cancer respectful silence was exercised by men with prostate cancer when they did not talk about their prostate cancer because they felt it would cause others discomfort they received respectful silence when others did not introduce prostate cancer issues that might be embarrassing most men disclosed all the information they were aware of to their wives including the possibility and actuality of ed and incontinence when talking to their adult children coworkers or acquaintances however they may have disclosed that they had prostate cancer without the details particularly the possibility of side effects such as ed or incontinence also some men did not tell geographically or emotionally distant relatives because they saw no need to burden them the men received respectful silence from people they believed knew about prostate cancers side effects but out of respect for the participants feelings and privacy did not mention it participants mentioned this happening with coworkers and bosses who did not share with others that the participant had prostate cancer or did not ask questions beyond what they were told family members such as adult children and inlaws exercised respectful silence when they knew that side effects included ed and incontinence but were careful not to talk or joke about those topics participants expressed appreciation for the respectful silence selective disclosure and the selection of what to tell to whom which were influenced by the spheres and purpose of the interaction participants were selective in the disclosure and discussion of ed and incontinence wives in particular were affected by ed but provided the most support to men in dealing with this side effect therefore it was unavoidable and necessary for them to know about ed a number of men shared their story with male relatives and male friends in an attempt to illustrate the importance of prostate cancer screening information selected to be disclosed in this context was about the importance of the screening process and the need to overcome concerns about the digital rectal examination the integration of the spheres of communication and interactional processes is depicted in figure 1 discussion the major findings of this study described a process by which latinos with prostate cancer purposefully interacted with others about their prostate cancer through selective disclosure and respectful silence in spheres of communication this was consistent with and extended the previous studies on disclosure of a prostate cancer diagnosis to latinos and articulated the process of prostate cancer communication the explanatory framework that emerged is consistent with the tenets of symbolic interactionism in particular the notion that interaction is purposeful with individuals choosing how to interact with other individuals in various contexts that clearly was demonstrated by the spheres of communication each of which had unique purposes and content participants communicated different content about their prostate cancer to different groups of people which represented different reference groups in symbolic interactionism terms reference groups are the multiple social worlds in which individuals interact how an individual presents himor herself in various groups can and often does differ based on the views of the group and how the individual perceives the group to view him or her the spheres of communication represent different reference groups with whom latinos interacted regarding their prostate cancer the processes of respectful silence and selective disclosure can be viewed as participants enactment of social interaction using and choosing words based on the symbolic meaning the men intended for the people in each of the spheres of particular concern is the outer circle no information about the prostate cancer diagnosis was disclosed to individuals in this group in addition to individuals who did not need to know about the mens prostate cancer the outer sphere contained fdmrs for a number of the participants participants gave many reasons for not communicating the diagnosis to members of the outer circle such as not wanting to inflict worry the members could not do anything medically helpful for the participants or they were estranged by geographical or emotional distance that creates the potential for a group of fdmrs who may not be aware of their heightened risk for prostate cancer it also suggests that the men diagnosed with prostate cancer were not aware of fdmrs increased risk and the need to communicate the diagnosis to them because the current study focused on latinos in southern california the results cannot be generalized to other groups however the concepts related to communicating about a prostate cancer diagnosis may be transferable to other groups and warrant additional investigation previous studies have identified that men are reluctant to communicate their prostate cancer diagnosis however the current studys results provide evidence about the selectiveness of that communication although reluctance exists in some spheres of communication a sense of helping others by communicating about the prostate cancer experience was seen in the beneficiary sphere implications for nursing practice results of the current study suggest that latinos with prostate cancer and their inner circle should be targeted for educational interventions by nurses caring for men with prostate cancer an initial focus might be ensuring that latinos understand the need for disclosing their diagnosis to all fdmrs a second focus could be providing culturally appropriate strategies to assist men with prostate cancer and their inner circle in informing all fdmrs about the prostate cancer diagnosis culturally appropriate strategies might include involving spouses and adult children in the education and disclosure process and providing them with appropriate resources such as written and electronic information in spanish those types of interventions have the potential to reach highrisk latinos and provide them with the necessary knowledge to be active participants in informed decisionmaking regarding screening interaction patterns for latinos with prostate cancer relationship status living with spouse or partner 18 in a significant relationship but not living together 3 not in a significant relationship 7 unknown 2 education level grade school or less 16 some high school 3 high school graduate 4 some college 1 college graduate 4 unknown 2 n 30 oncol nurs forum author manuscript available in pmc 2013 june 19

purposeobjectivesto develop a descriptive framework of the communication processes used by latinos with prostate cancer to communicate about their diagnosis research approacha constructivist grounded theory approach was used to analyze and build a descriptive framework from semistructured interviews settinga universityaffiliated urban hospital in southern californialatinos treated for prostate cancer who had at least one firstdegree male relative fdmr and who lived near the medical center methodologic approachsemistructured interviews with bilingual latinos were conducted in participants homes in the language they preferred individual and collaborative analyses of translated transcripts were guided by constructivist grounded theory findingsanalysis uncovered an overarching process of purposeful interacting components of the process included occasionally overlapping spheres of communication which were connected to purposes and content balanced in and influenced by the spheres were crosscutting processes of respectful silence and selective disclosure conclusionsmen communicated different content about their prostate cancer to people representing different reference groups respectful silence and selective disclosure could be viewed as mens enactment of social interactionusing and choosing words based on the symbolic meaning the men perceived would have their intended meaning for the people in each of the spheres interpretationculturally sensitive educational interventions should be targeted at latinos with prostate cancer to understand risk and encourage disclosure to fdmrs communication about the diagnosis and treatment of prostate cancer is critical to shared informed decisionmaking the need for communication is magnified by the uncertainty surrounding the survival benefit of mass prostatespecific antigen psa screening for prostate cancer and definitive treatment for all earlystage prostate cancers the need for information about prostate cancer risk screening and treatment is particularly relevant for men who are at higher risk for prostate cancer because they are a firstdegree male relative fdmr of a man with prostate cancer mcdowell occhipinti gardiner baade steginga 2009 in reviewing literature on the prevalence and predictors of prostate cancer screening among fdmrs investigators found that fdmrs had higher rates of prostate nih public access

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preview this is a screen shot from a video recorded at helsingung a small danish municipal agency where social workers 1 help young people with social problems that include issues with drugs we see two persons in conversation the young person on the couch legs drawn up anonymised the counsellor wearing appropriate glasses and turtleneck leaning forward add to this the presence of the paper sheets and the fact itself of the photo directing our clinical gazeand we recognise a space of counselling a therapeutic space this version is fairly uptodate hollywood gives us images of the psychoanalyst sitting with his notebook behind the couch or of the direct openface encounter in more clientcentered humanistic approaches but clinical and social work practices have moved on not long after the above picture was taken michael the counsellor wants to discuss how emily the client is doing emily has been filling in the outcome rating scale that lies in front of her in this as in several previous sessions and michael has ascertained a declining curve emily reports doing worse he finds this worrisome since statistics show that a declining ors curve is correlated with likely dropout michael tries to intervene with standard techniques in solutionfocused brief therapy 1 professional categories vary between countries more than often realized social worker is used here as a generic term for people working in the broad social field they include in the cases discussed here psychologists and other academics secondary school teachers case managers pedagogues and unskilled andor selftaught counsellors introduction this article emerges from a longterm research collaboration with two agencies for young drug users called uturn and helsingung the research project is called userdriven standards in social work we investigate how standards of youth life and standards of social work are reflected modified and created through experimental activities for which users recognition and participation are considered crucial on a grant from the danish ministry of social affairs helsingung implements the uturn model which is described as a new way of helping young people who use drugs our contributions are to record articulate and problematise those practices accordingly the main aim of this paper is to contribute to discussions in social work psychotherapy and counselling through empirical and productive analysis using theories of space and subjectivity the hope is that our analysis can serve in a hermes function between what is often thought to be conceptually methodologically distinct disciplines therapy social work and cultural geographyand make these traditions intersect and reflect each other productively this is both exchange transformation and translation of references empirical as well as theoretical and thereby a production of theoretically informed descriptions that can serves as models or prototypes for future practice one set of reasons for prototyping new ways of working with young people are the problems we saw michael encounter in the preview it is quite common for young clients to be extremely passive and reply in one syllable or with the impenetrable i dont know the problem is reported in the danish clinical literature the prevalent approach to the problem in the clinical community focuses on individualistic or therapeutictechnical explanations these could suggest that the young clients are perhaps not sufficiently motivated for counselling that the relation or therapeutic alliance between client and the counsellortherapistsocial worker is not good enough or that the specific methods used are inadequate but the social workers at helsingung and uturn experiment with more radical ideas which call into question some basic assumptions in counselling one of the ways they do this is by modifying how counselling is spatialisedhow counselling spaces are constructed and performed even as spaces that are no longer spaces of counselling to give a few examples they furnish one room with a buddha statue and low couches and another room with classic leather furniture from the time of freud they devote resources to giving their entry a friendly and inviting atmosphere they teach while leaving the door open to the corridor they hold meetings with professionals from other agencies in the open space of the kitchen where their young clients are allowed to interrupt as they make themselves some tea they set up representational artefacts such as flipovers that the clients snapshot with their smartphones to take home they connect to the internet and write letters to colleagues together with clients etc our intention is to analyse the spaces of our social worker partners as disciplinaryfollowing a long tradition in social theorybut also perhaps more interestingly as at least sometimes different from disciplinary spaces and most to the point we aim to understand those different spaces positively as affective spaces spaces of hope as workshops and public spaces initially we will sketch how theory and research in psychotherapy and social work have dealt with spatiality historically the relations and intersections between spatial theory and identity practices and politics or subjectivitynot to mention their relations to psypractices and social work have a long complex and famously messy history within social theory and are inextricably linked to questions about power this will provide us with some historical background about theoretical analyses of spatial practices and bring attention to how we might be able to contribute to these discussions analytically and empirically in the first analytical section we will use phenomenological descriptions of counselling in two different places the office and the buddha to analyse how these are spatialised though material artefacts discourse and other cultural aspects this will show us how these spaces predispose towards different subjectivities and ways of relating in the next analytical section will use video recordings from a counselling session to analyse how a counsellor and a client through their activities dialogues and bodily movements perform and spatialise a living room differently through these analyses we will show how spatiality conducts counsellors and clients actions and subjectivities sometimes implicitly and unnoticed sometimes deliberately by conducting two analyses that in turn focus on what we might call material and performative aspects of space spatialisation and counselling respectively these contrasts will make it possible for us to articulate our social worker partners ideas of how some of the difficulties in producing selfreflexive speaking subjects in counselling and therapy are related to spatialisation and how these problems can be worked with by transgressing some of the fundamental spatial dogmas in therapy the therapeutic setting as space of reflexivity and psychological insight as the primary means for change in this way this article will point toward what a posttherapeutic technology of the self might look like spatiality in counselling and social work space is fundamental in any form of communal life space is fundamental in any exercise of power spatiality have a long history of being used in governing and regulating subjectivity health and deviance in making subjects objects for knowledge and power indeed the historical development of spatial dispersion of subjects in monastic cells army units hospitals asylums social work facilities and counselling spaces can be said to be a genealogy of the modern subject drawing on foucault there are in particular two spatialised technologies of power that are relevant for our present inquiries disciplinary and pastoral power these forms of power are never found in pure form but blend modulate and transform into specific institutional practices and spaces by drawing on a plethora of different elements exemplary fields of discipline are the armies schools and hospitals where spatial dispersion of subjects is an important part of what makes it possible for individual subjects to be objects of power and knowledge the diagram the ideal standard form of disciplinary subjectification crucially includes individualisation through cellular dispersion this makes policing surveillance and regulation in detail possible and it installs a permanent reflexivity the internalisation of a normalising gaze so that subjects engage in selfsurveillance and regulation of their behaviour in relation to norms in foucaults genealogy discipline as a technology of power does not remain limited to particular institutions but becomes dispersed and proliferates as the modern states subjects and institutions emerge from and produce each other in what is termed the carceral a generalised disciplinarisation and policing of society one might think that in this generalisation of discipline beyond the confines of particular institutions spatiality would evaporate in fact however it is reestablished and reperformed in ever new ways and in ever new places pastoral power prototypically found in catholic practices of confession works through articulation of truth about inner mental states or actions this establishes reflexivity and subjectifies as the subject engages in a number of truth relations to the self these relations are mediated by an authority either directly to god as in prayer mediated by men of the church as in confession or in more contemporary pastoral relations to parents schoolteachers employers friends therapists etc here the submission to certain moral or ethical standards is effected through dialogue and identification rather than surveillance and allocation yet of course in many forms pastoral power includes disciplinary elements and vice versaas we shall see pastoral technologies were to a large extent dispersed stabilised though spatial technologies in the modern disciplinary institutions the cell the confession booth the interrogation room the social workers office and designated spaces for therapy and counselling are spatial technologies that seclude the subject from the world and the eyes and ears of other people this makes articulation of intimate details both possible and required and strengthens the relation between truth telling and power in this way disciplinary and pastoral powers work by combining spatial material arrangements and discursive procedures and categories in such a way that discourse and materiality are connected expressed in and gain power from each other we might say that in the foucauldian analyses of relations between truthtelling subjectivity and spatiality in disciplinary and pastoral power subjectification occurs through a doubling of language thought and knowledge by practices power relations and material spatial environments thus the ubiquitous renderings of foucauldian discourse analysis as exclusively focused on written and verbal language in our view miss important potentials in foucaults texts obviously this does not mean that these texts have no shortcomings some of these limitations become apparent when foucault and his texts are read as resources for the creation of new prototypes for spatialising social work for one thing the preoccupation with disciplinary and pastoral spaces rarely leads to viable alternatives that is positive characterisations of spaces that may be judged productive beyond being otherspaces this is an implication of foucaults negative epistemology of refusing what we are secondly foucauldian analyses are largely unconnected with contemporary research and literature about psychotherapy and counselling where spatial aspects are treated very sparsely or only viewed from within given therapeutic standards we will now turn briefly to this tradition modern forms of psychotherapy are all indebted to freuds talking cure and his invention of a particular psychoanalytic space although psychotherapy counselling and similar practices can be seen as prototypical modern pastoral techniques they have a difficult and precarious relation to disciplinary and pastoral forms of power both in the wider society and as these are played out and handled in the therapeutic encounter according to freud the psychoanalytic setting with the therapist sitting behind the client lying on the couch is a technology of comfort supporting the body dampening external stimuli and enabling the client to relax the body and the mind relieving the client from gaze of the therapist in order to disrupt the ordinary rational normative demands from any combination of superegosocietyfarthertherapistgod viewed as a spatialised psytechnology this can be read as attempts to overcome the negative effects of disciplinary power by unsettling standard formats of conversation that facilitate coercive dominant forms of power and to some extent inverse the direction of power and agency another reading however could regard the setup as an extension of these forms of subjectification by staging reflexivity and insight as means for normalisation suited for liberal subjects a form that only appears to be opposed to or distanced from given normative demands this difference can also be recognised if we look closer a freuds practice in terms of spatialisation where an interesting oddity or discrepancy appears in freuds few writings about the psychoanalytic space he emphasises how the therapeutic space should dampen external stimuli and intensity and be a neutral space extending this we could see it as space that in certain respects have similar qualities as disciplinary spaces in the clinic or the hospital where the subject and her disease is purified a spatial arrangement that has largely been taken up and passed on in modern clinical practices but when we on the other hand look at pictures and descriptions of freuds actual therapeutic setting we see a space filled with cultural reference archaeological items figures handwoven carpets books and other paraphernalia a heavily impregnated cultural space in this way we have prototypically two very different spatialisations of the therapeutic setting a clinical and a cultural spatialisation in psychoanalytic practices this prototypical spatial setup still exists in different versions but many forms of psychotherapy have moved on and experimented with new configurations of space in clientcentered therapy carl rogers had client and therapist sitting in chairs facing each other to produce a more authentic and less asymmetrical relation in systemic family therapy tom andersen recounts the development of the idea of a reflecting team from the original tradition of systemic family therapy with supervisors as experts behind the oneway mirror occasionally telephoning with the therapist with advice then experimenting with turning the lights and microphones around and having the family watch the supervisors discuss and finally the inevitable conclusion that the whole setup with walls and windows is superfluous a similar movement can be discerned in seikkulas open dialogue these experiments with spatial arrangements can be read as a way of working with and changing who are positioned as experts in positions of power and destabilising patriarchal pastoral and disciplinary positions where clients are in need of advice truth and knowledge fromand manipulation bypowerful professionals they generally appear to move toward dissolving the particular spatial arrangement rather than create new spaces along with this spatiality gradually recedes into the background and evaporates as an object for analysis and research in psychotherapy this development is reflected in the contemporary literature on psychotherapy and counselling that typically focuses on technique methods or the relationtherapeutic alliance while spatial aspects are sparsely investigated digging a bit deeper the neglecting of spatial aspects can be seen as an expression of the deepseated dualism that haunts psychology and is implicit in most research in psychotherapy where the active mind is separated from the relatively passive bodies and matter this leads to seeing therapeutic spaces as neutral inert and passive euclidian containers in which stable selfenclosed subjects act and think and to neglecting their cultural and productive aspects but as we have seen many professionals are already on the move away from these epistemological premises often with a foucauldian awareness of the double language of traditional forms certainly but also by creating new kinds of space our task is to go along with them and articulate what those might be for this we need to expand and deepen the conceptual arsenal resources for rethinking space in this article then we try to move away from space as a kantian epistemological a priori an euclidian container a passive site a given context for actions we seek a processual and culturalhistorical understanding of subjects and spaces as continually produced we also as mentioned wish to avoid dualisms by analysing both how spaces are active in producing subjectivity and agency and how subjects enact and spatialise places as well as transform these spaces by engaging in projects that reach beyond the confinement of the particular place one place to start is in a reading of foucault which similar to derrida in cogito and the history of madness finds him addressing theoretical problems that are more general than the specific genealogical configurations he describes the space in which we live which draws us out of ourselves in which the erosion of our lives our time and our history occurs the space that claws and gnaws at us is also in itself a heterogeneous space in other words we do not live in a kind of void inside of which we could place individuals and things we do not live inside a void that could be colored with diverse shades of light we live inside a set of relations that delineates sites which are irreducible to one another and absolutely not superimposable on one another if we take foucault to thus contribute to a theoretical current we can see spaces and places theorised as something active dynamic both produced by and producing subjectivity but first of all heterogeneous multiple defined by relations or connections and constituted as much through the flows that link it to other locations persons things as it is through what goes on inside it one way to articulate this approach is to portray space as an assemblage composed of multiple heterogeneous elements in cultural geography actornetwork theory nonrepresentational theory and poststructuralism spaces are analysed using a plethora of different analytical or metaphorical concepts such as network fluid fire smooth or striated in addition broadly phenomenological approaches take up foucaults invocation of our living in spaces of such heterogeneity before beyond or below the spaces given to us and reproduced in our spontaneous rendering of their discursive forms we exist as alwaysalready emplaced place is given to us existentially before any structured space the two approaches can be seen as internally related since in research that phenomenological place even if it may be a precognitive existential is always arrived at by way of a reflection of the heterogeneity of spaces of moving between transforming or being inbetween spaces and conversely the general idea of a heterogeneity of spaces over and above their mere differences basically must appear to us from the point of view of our emplacement rather than from any one of those spaces our plan for this article is not a detailed discussion with these interesting theories and concepts nor are we authors necessarily agreeing on how to understand them although we do both commit loosely to a practical relational cultural and historical understanding of spaces where spaces are constructed and defined by connections rather than essences but leaving these discussions aside we will with a wellworn phrase use these concepts as a box of tools2 that allow us to analyse the relations between spaces subjectivities and becoming in social work practices bearing in mind how as with other tools our use of them in turn forms our commitments intentions and subjectivities methodologically we agree with dovey that an analysis of placepower issues require multiplicitous methodologies linking phenomenology spatial analysis and discourse analysis in order to do this we pay attention to different parts of spatial assemblages in the different analyses focusing both on how artefacts signs and other materials spatialise and how spaces are enacted through activities in order to do this we will draw on heterogeneous materials videos and pictures of a live counselling session phenomenologically reflexive interviews and participant observations done by our research team we have taken up the space place distinction although in academic discourse space and place are highly contested terms that show little consistency in this article we use the term space for designated structured places such as the office for counselling the living room or the classroom generalised as kinds of space such as disciplinary spaces private spaces etc in this definition we are close to de certeau space occurs as the effect produced by the operations that orient it situate it temporalize it and make it function in a polyvalent unity of conflictual programs or contractual proximities … space is a practiced place yet when we refer to a specific place by the concept for its space eg the living roomwe also indexically point to a place that is potentially polyvalent and can become a counselling space and thus may be or become a disciplinary space a pastoral space or a public space etc the term space and the verbs spacing or spatialisation allow us to analyse these processes of performing space and how different activities articulations and forms of subjectivity become possible the materiality of spaces in the preview we saw how the social worker michael was struggling to have a therapeutic conversation with emily emilys body as we see her crouching in the second screenshot could be read as a sign that she does not like to be there doing that and her response i dont know to michaels questions confirms us in this interpretation how might this be a matter of space as mentioned we intend to make this point in two steps first we analyse the phenomenological and reflexive account of another young client molly of her experiences with counselling in two quite different places an office at the general drug treatment facility and a particular room at helsingung called the buddha this will serve to highlight spatialisations as material configurations that afford affect and predispose subjectivities molly is a young mom who has had 12 counselling sessions with the social worker terry during the last months as helsingung have recently moved to new premises and furnished new rooms for counselling her openness to an interview gives us a unique opportunity to inquire about natural experiments with spaces for counselling in the interview we investigated together mollys experiences with being in the places we term respectively the office and the buddha the office in the picture we see an office similar to the one molly talks about in the interview just outside of view to the right is a desk with a computer a phone and different papers behind the desk on the wall is a whiteboard that can be used to take notes and visualise during counselling for an ordinary danish citizen this could be a standard neutral somewhat boring office at any danish municipality let us see how molly describes it molly there it was a lot like emh you got in and sat down there and it was really very much an office… mads yeah molly …that you got into so it was like hard to let go and relax right mads mm molly …emh because there was the computer and the telephones where ringing and… on no matter where you looked you were reminded about where you where and things like that the computers and phones are signs that spatialise this room as an office and not just an office but really very much an office for many readers of this article this may not seem so problematic but when we place molly statements in the context of the general difficulties reported by practitioners in counselling young people and through the foucauldian understanding of disciplinary space it seems like the office frames mollys situation as to do with drug problems and subjects her to the category of being an addict as molly says molly you are more conscious that it … that you are the addict who has to sit and talk with the adult professional in this way it is a disciplinary space which installs a reflexivity in the subject as being deviant this is of course not a matter of the specifics of that office as such but rather of its significance as functionally discursively and symbolically connected to other disciplinary spaces classrooms schoolmasters offices welfare offices and rooms for counselling therapy and testing where molly emily and many others have experienced being observed assessed corrected and marginalised in this way the specific spatialisation emerges processually as the subjects particular experiences and the material cultural and historical references produce this specific disciplinary assemblage still the material affordances of the place do matter molly points to the furniture molly well you are being pigeonholed can you… well i did feel a little well that but you just feel very small when you enter a room where you just have to sit straight up in some plastic chair you know in the office the plastic chairs force molly to sit upright and direct her eyes to meet the professional gaze this materiel and spatial setup emphasises enhances and stabilises the asymmetrical relations between molly and her counsellor terry installs a reflexivity and a way for molly to understand herself through the addict category but the computer and the phone are not only signs indexing this as office but also technical means for inscribing and circulating discursive statements about drug use personal history behaviour and identity beyond mollys reach and control these statements are objectified and removed from the context were they were articulated as truths that at a later point can be read and confirmed by other professionals in order to reorganise the guidance of her behaviour thoughts and subjectivity as a node in a network the office is a spatialising disciplinary technology that through discourse artefacts and relations to other spaces stabilise social categories subject positions and relations of power this way it is quite reasonable to attribute seemingly exaggerated forces to disciplinary spaces in duffs discussion of young peoples creation of private spaces an informant talks of how the school spaces have their use hammered into us in a similar vein molly talks of really very much with an excess of affectedness which leads to an overload of selfconsciousness to being more conscious about that that you are the addict disciplinary spatialisation works as particular forms of temporalisation too molly because somehow i think when i sit and think back about it then perhaps i didnt much feel like being there mads no molly because i became very attentive to what it was that i had been doing in my past in the interview the past situation is reconstructed as a possible unwillingness which highlights the fundamental ambivalence typically experienced by clients who have reluctantly chosen to come but as connected to beingattheoffice rather than to a motivation within her or in her relation to drugs it was being there which directed attention to the actions of her personal past as problematic and made it hard to relax and let go on this account molly is very directly expressing a problematisation that the helsingung social workers have often articulated the orientation to the past as problematic closes down useful ways of talking taking inspiration from narrative systemic and solutionfocused approachesas they describe their approachthey try to achieve a movement toward a focus on what the young people dream about or wish for without necessarily being preoccupied with the past in the disciplinary space the present is interpreted in relation to the past and the future is absent empty except in the negative form of the absence of the problems of the past mollys experiences of being judged and just wanting to leave resonate with other accounts of how youth in institutions react to counselling in such places be it offices or designated rooms for counselling performed as disciplinary spaces metaphorically the youths are caught in the headlight of the panopticon the light is too strong every movement can been seen and their bodies freeze up and words dry out and their shadows are cast out behind them drawing the outlines of their pasts on the screen behind them identifying them with their past this analysis shows power but also a breakdown of the pastoral space as a technology of power in the sterile empty standard space for counselling the disciplinary gaze is too strong and this closes rather that enhances the possibility for subjectification through the subjects articulation of truth in a pastoral relation the potentially pastoral space is overcoded by the discipline that produces silence marginalisation inferiority resentment and perhaps resistance rather than subjects who can follow their dreams and wishes and projects without being restricted from this by their drug use as a contrast let us see how molly describes the buddha a room for counselling that the social workers have manufactured and analyse this both in relation to cultural and material aspects and also extend the analysis to include affective enabling aspects of space molly is articulating the commonsense discourse about psychotherapy and counselling as the talking cure here she can get her problems out in order to be relived of them as in a confession the buddhaa space of attunement but why is this pastoral technology not overcoded by disciplinary forces here in the buddha when we inquire about this in our interviews with molly and terry they say one tendency in psychology and therapy has been to try to establish legitimacy and credibility by engaging in science and treatment discourses about neutral objective experts and by developing standardised methods and instruments this has an obvious tendency to produce disciplinary connotations as we likely witnessed in the preview where michael tried to use a standardised instrument the outcome rating scale in his interaction with emily molly in contrast to this humanist psychology and more recent narrative and systemic traditions are critical of psychology and therapy as a neutral science with objective experts and they try to establish a therapeutic encounter which is more authentic clientcentered or even makes the client the expert in order to disrupt asymmetrical relations and reconfigure the roles and objectives for both the client and the therapist this can be said to be aligned with discursive rules that according to philp governs the form of knowledge in social work as a distinct discursive field the holistic focus on the person instead of the problems deviances or diseases and the recreation of a social subject with full discursive rights as participant of a social community from mollys descriptions talking with terry is like a conversation the assemblage mollyandterryinthebuddha allows molly to become a speaking social subject and she is recognised as such by both herself and terry even though the buddha is a designated room for counselling and there is an asymmetrical relationship in terms of knowledge and power molly can relax open up and engage in conversation in explaining this molly points to artefacts molly where i think down here in the buddha there there its more relaxed well there are couches chairs pillows all over and … like candles too right well all that wasnt there the other places so it is much more relaxed too be down here one way of understanding this it that the couches chairs pillows and candles and the buddha statue are artefacts and symbols that do not connect this place to carceral institutions and involuntary confinement but rather connects it to a broader culture and commonplace cultural practices such as meditation yoga and hashsmoking all practices that have a significant overlap in terms of both symbols persons cultural connotations and places the buddha is constructed as designated room for counselling but compared with the office it seems to have a greater capacity for being spatialised in different ways perhaps because for young users like molly it can connote both counselling homeliness drugsuse and nondisciplinary practices of selfdevelopment or spirituality this is supported by the furniture the comfortable couch that makes it possible for her to relax her body there are obvious parallels to the picture of freuds office and for molly and many other youths3 the spatialmaterial configuration of the buddha seems to help establishing a new kind of pastoral space or what duff terms an enabling environment that does not force molly and terry into strongly asymmetrical subject positions overcoded by descriptions of deviance molly it is more like… … not friendshiplike but but more… well relaxed like… its not as … it is professional obviously but it doesnt feel like that when you come to a place like this molly establishes a distinction between what she knows that this is still a professional conversationand that it does not feel like that and indicates that these interesting differences do not rely solely on knowledge but about bodily or emotional ways of being affected when we ask her about the difference she has difficulties in explaining it and turns to a more phenomenological and affective phrases molly how can i explain it well i… it is just a totally different atmosphere we might articulate mollys experience as special atmosphere attunement vibe or spirit or through what anderson terms an affective atmosphere that affects her bodilyemotional way of being and allows an emotional reordering here bodies relax subjects become more open permeable and receptive and words flow more freely in this way positioning is not just a discursive but also a material and spatial matter the buddha seems to make it possible to forget and to feel opening an affective hope the utopian horizon of creating a social subject as key dimension of social work is far from merely a mirage or a cognitive scheme it exists concretely as a carefully crafted social material and spatial technology that makes possible futures present in a way that does not predestine themrather than conceptually specifiable affordances the space seems to embody a derridaean lavenir performing liminal spaces matter matters to how space is performed how it finds its place and how place is spatialised as we have seen material affordances and openings become part of more or less intentionally constructed spatial technologies of affect and attunement further these technologies are temporal and processual in that they facilitate anticipations and becomings following drawing on a long anthropological tradition we can regard the spaces performed in helsingung as liminal in that their undecidedness and hybridity call forth general issues of existence and community yet are nevertheless constituted as moments of processes that connect affect with hope and fear this can be viewed both in terms of the personal narrative of participantswho for instance find themselves inbetween childhood and adulthood deviance and rehabilitation etcand in terms of the social work facility that defines itself as developing new standards the workshop the buddha was thus temporally contextualised by having been materially constructed in the process of physically establishing the facility recognised as new molly steps into a new place still smelling of fresh paint but also a new space and thus perhaps most importantly a space of novelty material production as architecture building and interior decoration should never be lost from sight when we analyse performance and spatialisation 4 yet the performance of space also takes place at more micro scales and with more modest alterations of material objects as our first example we will return to emily and michaels counselling session that we began with before michael the counsellor took up the standard solutionfocused scaling techniques that performed a disciplinary space which he failed to turn pastoral the two of them were engaged in a quite different kind of activity 4 in danish performance should be translated as fremstilling which also means production in heideggerian lingo it resembles and unites the german terms herstellung darstellung and vorstellung construction might be a good retranslation were it not for the fact that most readers would associate it with a constructionism that is characterized as only linguistic and only social as opposed to material spatial affective etc michael look we have a few things we should look into this music project emily yes michael uturndo you know uturn in copenhagen emily no michael i just had to make this website appear michael and emily are sitting in the same place as when later they perform therapy and resistance to therapy but the space they perform is different first we should notice how the technologies that connect here with there and now with then are very present just as they were in mollys description of very much an office but in a very different way in the office they belonged to the professionals as the tools of their power and belied the confidentiality of a pastoral space embedded in a disciplinary network of spaces here they invite emily into a public that watches websites and into an emergent music project establishedbefore our very eyesin an equally emergent collaboration between professionals in two agencies there the technological network is outside of the conversation that molly is participating in yet frames it deeply hammering its excess meaning into molly even as it remains silent here it is directly the object and medium of the projects they are starting up together michael this space is one of production overall what they are beginning is a project that will end up having produced a cd that will be distributed and heard by emilys friends and family as well as michaels colleagues and researcher collaborators and in this particular situation they are directly cocreating an email that is one of a myriad of intermediate objects in the project the process of objectification is crucial to the professionals the way that performances and representations of emilyin terms of a preferred narrative such as that of a music talent rather than a drug abuser or a clientare fixed or frozen in material artefacts and become stabilised and socially recognised more widely even the little email is a text that can be reread forwarded etc and represents an institutional commitment much more than would any words spoken eye to eyeas michael and probably emily too are well aware when michael invites emily into writing the email he is quite deliberately continuing a tradition among counsellors inspired by narrative practice to experiment with the ways that preferred narratives can be objectifiedusing simple techniques such as writing on flipovers of which the client then takes a snapshot with her smartphone writing letters or diplomas to clients etc emilys cd is not simply something else beside and unrelated to the counselling it is a transformation of counselling viewed as a process of creating and objectifying narratives the main point in the context of the present argument is the configuration of space the space that is constituted as a node in a network is radically different when however modestly it works to transform that network and reaches out to other networks that are performed as emergent one aspect of this is production the space we have seen michael and emily constitute can be likened to a workshop where products are constantly in the process of formation put together of things brought in from elsewhere and on the way to some more or less welldefined public of users in yet other places but the fact that another part of what was performed in that same conversation was solutionfocused brief therapyor rather an attempt at itimplies that it is a liminal space it is a space of neither therapy nor music productionor both one and the other and it is a space of hope for and becoming of new standards of a social youth work that fuses counselling with music production as a way of objectifying preferred narratives and transforms counselling in the process public spaces the stage and the agora this implies another aspect that is equally importantthe space of public display public spaces as designed and performed arenas of political deliberation and participation have evolved in multiple forms since the athenian agora not least with on the one hand the rise of civil society and its variable distributions of private domains markets and commons and on the other hand emerging technologies for representing community the theatrical stage evolved as a technology of display separated from political deliberation entertaining a sovereign and later a civil society but in modernity politics increasingly unfold mediated by technologies derived from theatre so that even extraparliamentary action often takes the shape of demos that are supposed to represent a broader public and stage its protest this development is lamented by who regards theatre as key to the emergence of the permanent liminality which corrodes modern culture since authenticity can no longer be assumed or even required5 disciplinary and pastoral spaces have in various ways been carefully controlled as nonpublic although foucault speculated that the disciplinary panopticon might eventually open the position and the gaze of the guards to the public and it is possible to find examples of this 6 the seclusion of disciplinary spaces from public surveillance is still the rule in primary school classrooms hospital wards group counselling and up to guantanamo social work spaces like mollys office protect the privacy of its clients while also breaking it open to the disciplinary gaze blocking democratic scrutiny and securing professional hegemony however the gaze of the professions is potentially a form of public eye too in our example with emily and michael we owe the very fact that we can watch the scene to a tradition emerging mostly in systemic counselling traditions and derivatives of videorecording sessions as part of professional supervision and training but the space is opening further michael is presenting the video to researchers as part of a collaboration that seeks beyond therapy inviting uswriters and readers of this very textas witnesses and participants in a discussion that is not limited to the knowledge domain and the ethics of a professional discipline but rather that of critical sociocultural theory and philosophy and the video connects as we saw counselling with new forms of selfdisplay that include website publishing and the production of a cd with emilys recognisable face and name in short our case is a small part of the radical changes currently taking place in the configurations of discipline with the publicprivate divide and in this helsingungs development aspirations are crucial it is a liminal space of hope and becoming which is subjected to public debate and this makes of it a new kind of public space as a fusion of the stage and the agora whenin a kind of secondorder reflexivitywe include our own witnessing of the scene as part of it we can see that the power flows and the potentials are different from most disciplinary or pastoral spaces thus emilys resistance to michaels attempt at framing therapy is no longer just another selfexclusion it connects with her enthusiastic participation in the music project to become a potent move in the transformation of the practices of helsingung toward new standards of social youth work once we came to this hypothesis we could see other more or less unfolded instances of such public spaces of course the websites of helsingung and uturn themselves as including various videos and other materials where the young clients present themselves and thus not only addressing but also accountable to a mixed public of youths relatives professionals researchers managers and the general public as agencies developing new standards of social youth work but 6 for instance some danish kindergartens have webcams that allow parents to surveil children and teachers at any time also the simple fact that most meetings between professionals at helsingung were set in the kitchen where youths would be welcome to pop in and make themselves a cup of tea and the helsingung professionals making a point of it by interrupting the meeting to address the youths in a friendly and welcoming manner and even the micro fact that the door to the classroom at helsingung is generally kept open the immediate reason is that youths are distracted more by the closed door but the implications can be articulated also in terms of an accountability to a wider public which is premised by helsingungs identity as development agency conclusion one prototypical narrative of the uturn model is about a young client who was all i dont know in a counselling session at the uturn but who suddenly began to talk about his problems and hopes when later on the same day he was with the same counsellor in a swimmingpool sitting on the poolside and on the way back on the bus that story is not about the specific qualities of the swimming pool or the bus as spaces arranged or used for counselling or for any other specific practice rather it is a place other than that of the institution a space thus negatively defined as a way of pointing to the problems with the regular spaces at uturn further however that negativity can itself be positively conceptualised as an outside space that constitutes a neutral ground on which to meet the youth both these negative spacesthe space that is other than the disciplinary and pastoral spaces of the treatment institution and the outside spaceare very valuable as conceptualisations for the development or transformation of social work and counselling since any such development must include a problematisation of how that work is spatialised but we have pushed on to suggest also some positive articulations of spaces constructed and performed by professionals and users at helsingung and uturn as part of their development of new standards of social youth work spaces of attunement and production and public spaces these positive articulations are meant to endow the material constituents and the processes and performances of spatialisation with an agency that is absent from the euclidian container space the point of this in terms of relevance is to provide professionals with prototypes in a more demanding sense as concrete practices and technologies that have evolved and made differences in these particular places and at these particular moments but which could be worth considering elsewhere and later without ambitioning to make an understanding of those singular circumstances completely irrelevant as such they could still be thought of as tools that can be applied in a range of somewhat similar situations bearing in mind those differences of circumstance yet it is an important morale of these prototypical narratives that the agencies of these spaces are never simply mastered by a given subject within an intentional rationality each of the three spaces considered reach beyond not only counselling but also any such spatial instrumentalism attunement is about being in the world in a more fundamental sense production is about creating something that lasts beyond its maker and the public is an expansion of who we are these are not arguments against space as such but aspects of how spaces are constituted that can be usefully reflected as part of creating spaces beyond counselling we have also noted that in all these three aspects the liminality of the spaces as being constituted in a temporality of transformation and becoming is important being in these spaces is to find oneself in the hope of new ways to perform social youth work but conversely it also points to a very earthly version of hope hope is rendered as quite sensuous practical and for all to see hope too is something that takes place

the article articulates experiments with spatial constructions in two danish social work agencies basing on a a sketchy genealogical reconstruction of conceptualizations and uses of space in social work and counselling b a search for theoretical resources to articulate new spaces and c data from a longstanding collaboration with the social workers beside the classical disciplinary and pastoral spaces we find spaces of attunement spaces of production and public spaces as forms of spatialisations which might be taken as prototypical in attempts to develop social work and counselling

19841_0

introduction feminism must exist independently of and as part of the larger struggle to end all forms of dominance as a liberation struggle we must acknowledge that patriarchal dominance is ideologically rooted in racism and other forms of group oppression and that it cannot be eradicated while these systems are in place according to hooks this data ought to always guide feminist theory and practice 22 according to james feminism is based on the idea that women are less fortunate or oppressed than men and that their oppression is in some way illegitimate or unjustified it is incorrect to consider feminism to be a single philosophical doctrine or to imply an agreedupon political program even though there are numerous interpretations of women and their oppression that fall under this general description feminism is an effort to ensure that women in all cultures and professions receive the same respect and opportunities for advancement as men do feminism is centered on the idea that womens full and spontaneous participation is necessary for genuine social progress according to david o poetry elicits a vivid imagination and conveys strong emotions and experiences through the use of figurative language feminist is derived from the french word femme which means a woman who champions the rights of women as a social class there must be a distinction made between men and women in terms of psychological and cultural differences as well as biological differences clare burton stated that in his book subordination he uses three terms they are 1 liberal feminism discrimination against all women in our society is a central concern of liberal feminism liberal feminism focuses on legislative reforms that seek to develop attitudes that support womens equality this should be done taking into account the existing situation if this is done without considering different situations then the activities implied in feminism can be carried out only to benefit special women and that applies in the world of work or in the world of paid work 2 radical feminism radical feminism is related to its main proposition that the relationship between the sexes is more fundamental and is a source of oppression that is more often carried out in society 3 socialist feminism socialist feminism relates to the gender and economic aspects of the oppression of women women can be seen as residents of the economic class in marxs view and sex class that is women display valuable service to capitalism as both a worker and a devoted wife receive no wages for their domestic work according to socialist feminists the patriarchal and capitalist systems exploit women lady mary wortley montagu and the marquis de condorcet were the pioneers of the feminist movement fighting for what is now known as a universal sisterhood in european colonial nations charles fourier came up with the term feminism in 1837 and john stuart mills 1869 book the subjection of women helped spread the word due to numerous instances of womens rights being restricted in a variety of areas the feminist movement grew quickly at that time and a social group this feminist movement began to spread to the american mainland in response to the emergence of social and political revolutions after rapidly expanding in europe womens rights started to get more attention after mary wollstonecraft published vindication of the rights of woman it is common knowledge that in the 1840s resistance to the practice of slavery in the united states began eventually leading to its abolition this brought attention to the rights and positions of women who now enjoy better pay and working conditions as well as opportunities for education and political representation like men using a feminist perspective for instance the theme of discrimination the place of women in society and the image of women bhasin and khan define feminism as an awareness of the numerous ways in which men oppress women and a set of strategies for countering this oppression from a society that believes that only men are qualified to be leaders and that not many women can we can see how men hold the dominant power and have a place at the top of the social structure both globally and in our own country be someone you can rely on as a leader because it is commonly held that women only consider their emotions by publishing a poem titled we sinful women kishwar naheed demonstrated her empathy for women the poem raises the issue that all women are sinful and deserve to be treated badly and describes the situation as a whole using a variety of key poetic devices throughout the poem naheed employs sarcasm to emphasize that the woman is not the one who chooses to be treated in this manner additionally contemporary valences overlap in naheeds poetry naheed demonstrates that pakistani women continue to prioritize late 19thcentury models of femininity from her perspective she goes beyond historical times the term temporality refers to things that happen in time or are related to time naheed argues that social expectations have transcended historical divisions by departing from the ephemeral naheeds argument demonstrates that womens social roles remained unchanged despite the end of formal colonialism and the partition of india in 1947 despite historians theories that there was a time lag between the events this line of reasoning is very critical of the liberal nationstate model which says that all citizens should have the same rights naheed goes one step further in this feminist argument by looking at how women oppress other women by imposing feminine norms on generations of women naheed refers to the unquestionable propagation of social norms as the feminine myth perpetuation at the time it was written this iconic poem was both shocking and explosive it is a way for women who dont follow social and cultural norms to say they are independent many of these oppressive and restrictive standards for women are still in place in pakistan today even with greater researcherity as a result naheed finally made his point by publishing this poem in this research the researcher decides to analyze feminism in kishwar naheeds selected poems which have the same theme of caste inequality between women and men the researcher has a curiosity about the content of the poem and the message the poet wants to convey the researcher wants to convey his perspective on feminism in poetry to readers and connoisseurs of literature methods this research method makes use of qualitative data analysis denzin andlincoln define qualitative research as the study of natural phenomena joubish et al the articles researchers 2011 qualitative research looks for reasons and explanations rather than simply describing the research method and summarizing its findings according to fraenkel and others qualitative research observes and gathers data by directly targeting a specific set of interests six characteristics are shared by qualitative methods according to bogdan and biklen the research must begin in a natural setting first the second research instrument serves as the primary one the research becomes the primary instrument of the research because the researcher directly collects the data thirdly the data are words rather than numbers and the research is written in a descriptive style fourth the process of conducting research is more significant than sang pencerah jurnal ilmiah universitas muhammadiyah buton martina 9 445455 the product itself five the significance of the research is the primary objective the majority of research is inductive last but not least one could make the argument that qualitative research does not first test the hypothesis in inductive analysis according to thomas the data are determined by the research objectives in addition to multiple data readings and interpretations the descriptive method of research as defined by creswell entails gathering information about the current circumstance the objective of the descriptive method according to creswell is the systematic discovery of a comprehensive explanation and description of the subject of the study findings and discussions findings the part life of kishwar naheed kishwar naheed is a feminist urdu poet she has written several poetry books she was born in 1940 in india later she migrated to lahore in pakistan after partition in 1949 with her family she also was a witness to the violence including vape and abduction of women associated with the partition of india all those blood shells had left a lasting impression at a very young age all those gruesome sights which she had to witness accompanied her throughout her life and it is a driving force that led her to write many famous feminist poems and works at a very young age she also faced struggles to receive an education from society where women were not allowed to go to school she has written 12 volumes of her poetry and published both pakistan and india many of her works were translated into other languages as well and this particular poem we sinful women it was first published in lahore in 1990 and later in london in 1991 and this poem was referred as womens anthem among pakistani feminists she has also written several children books and had one unesco award for children literature and her love for children is a much as her concern for the woman she expresses this concern through her poems she focuses on the plight of woman maledominated society and this vision for women is that particular kind of woman in a maledominated society and the need for women empowerment and emancipation in a male dominated society analyzing kishwar naheeds poetry in the poem it says that they are women fighting for the empowerment and emancipation and they went to get out from the exploitation of men as well as the society the religion and all thesystemsm that suppreses women ane conventional women to which kishwar naheed is comparing herself and other feminist women ise streostereotypicaln who are living by the rules of the ety and those women are praised by the socifor living a suppressed life inferior to men there women theseeaving to please the society please the in their 2012 study the position of pakistani women in the 21st century dr jaweria shahid and khalid manzoor butt defined feminism as equality for women and freedom from gender discrimination in all aspects of life those who dare to break the conspiracy of silence about oppression unequal relations between men and women and who want to change it is their definition of feminists a social movement for womens social rights is the ultimate goal of every feminist endeavor given this one could argue that pakistani feminism is nothing sang pencerah jurnal ilmiah universitas muhammadiyah buton martina 9 445455 more than a myth ovais unfortunately many people are not aware of the origins of pakistani feminism feminism in pakistan did not originate in a concept novel or researcher islam and feminism are subject to various superstitions they see the ideology of feminism as an antiislamic movement in islam women enjoy economic spiritual and moral equality the muslim holy book has discussions about womens rights to education marriage divorce property and life many quotes from islamic scholars and hadiths are included recent advances in education and media reflect feminist standards there is ample evidence of feminist standards in politics thanks to recent advancements in education and media women have fought for their rights ever since pakistan gained independence and fatima jinnah and mrs liaqat ali khan were outstanding women at the time who demanded equal rights for women mehsud fatima jinnah inspired numerous women to bravely fight for their fortune even before pakistan gained independence following pakistans founding in 1949 begum rana liaquat ali khan established the all pakistan womens association to promote womens economic equality and respect in september 1981 the womens action forum was established with theto defendhts of women radical feminism sees it logically that women from oppressed social groups face a variety of forms of abuse in various deadly combinations status race and incapacity have a systematic structural effect on the lives of various women writers from pakistan feel like they belong to their community their literary works poetry autobiographies novels and essays all depict this relationship feminist kishwar naheed has a spiritual connection with the women of her community naheed wrote numerous poems that were widely read her poetry has frequently received praise for its depiction of womans beauty asian womens strength and the human spirits call for social justice for all she is wellknown for her poetry all over the world through her writing she imparts numerous lessons however the majority of reviewers commend naheeds poetry for addressing gender social economic and political issues that are significant to pakistani women and their nation in her poems kishwar naheed portrayed the idea that despite the many challenges that people face in life they should not give up indeed kishwar naheed fought for herself from a young age fighting for her rights and basic needs which made her the most admired and influential figure in pakistani literature kishwar naheeds writings embody radical feminism in its essence because she stood up for her rights kishwar was subjected to racial and gender discrimination from an early age in her poetry she depicted this as a feminist poet kishwar naheed has also emphasized the instrumental identity that society had enshrouded women in the marginalization an instrument used for the benefit of another naheeds writings go over a lot of different aspects of the subject of objectification we sinful women who do not bow our heads fold our hands together or sell our lives are not awestruck by the grandeur of those who wear gowns kishwar naheed slams males in her country who view females as corrupt and immoral in this poem as a result they view women as separate entities men are permitted to exploit women as long as the rules are made by men women are viewed as suppressed objects if women spoke out against the cruelty of men this socalled maledominated society would label them as sinful women and punish them sang pencerah jurnal ilmiah universitas muhammadiyah buton martina 9 445455 450 kishwar naheed write the poem about women becoming their own liberators andstrivinge to break the rules and free themselves from their chains in her poems the researcher see women crossing the lines of marginality and ascending to heights previously unattainable the following is a verse from the poem we sinful women by kishwar naheed table 1 analyze of stanza the poet is meaning that there are women out there who are living with the conventions they are stereotypical women who are living by the norms of society and they wear gowns to cover the parts of their bodies the poet is saying that sinful women including herself are not intimidated by the magnificence of those who wear gowns since they just dont want to just confine to merely a gown they want to wear different clothes they want to enjoy their life and they just dont want to waste their life in just a piece of gown not just by owing with the grandeur of a gown we dont sell our lives this means that in stereotypical society in a maledominated society women are actually selling their lives to males because they do not have their own wishes they dont independent they dont have a word of selfexpression they were just living to please society as well as men they are not leaving for themselves the poet is proudly saying that we are that women do not sell our life that has meaning is we dont live for other people we dont live for society and we dont live for male folks but instead we live for ourselves and the poet proudly says that we are sinful women and we love to live our life this way a way which does not exploit their life we dont bow out heads this means these sinful women are not ready to bow their heads to anyone not to society not the male this poet literally means just pouring the head it means that they are not ready to live their whole life inferior to a society that is entirely dominated by males who dont fold our hands together this means we are not that sinful women are not ready to fold our hands in suppression this stanza actually means that they are not ready to surrender any of their rights to pleahe society or to please men they are living for themselves and they are not ready to compromise their lives for the sake of others the who in the poem describes that women cannot be treated arbitrarily a job demands responsibility but does not mean that women become lowly slaves who have to bow their heads over things that are not pleasing in this context the term who refers to all women who oppose patriarchy and do not wish to live as servants or serve others women want their own rights and proper social status because they are also an important part of the world she uses sarcasm throughout the poem to emphasize that women do not want to be treated in this manner men wanted women to act like slaves and other small creatures and forced them to do so because they lack selfdetermination independence and the right to speak women are actually selling their lives to men the third stanza tells about women who protest the norms and customs imposed by men and try to defend their rights naheeds language shows that women who are truly sinful are those who oppose male vices the speaking tongue has been cut out said the poet kishwar refers to the way many women who have ability education power or opportunity are cut off stunned and prevented from fighting for their own rights in many countries seen from the point of view of men towards women who state that women are unfit to lead this creates the impression that women have a degree far below men positively naheed concludes her poem these eyes will never be shut now that the past is behind us she asserts that the woman of this century will not be afraid of the psychic of angry men and will fight for her rights the sinful women will tend to their own needs now women will uproot the worlds extreme patriarchy and live the lives they want discussions the feminism of poem this seminal poem was both a revelation and incendiary at the time it was written it is a declaration of the independence of women who did not subscribe to societal and cultural norms these norms imposed on women are oppressive and confining and for the most part still exist today in pakistan if not in even greater forcein her poem we sinful women she criticizes the idea that all women are sinful and are viewed as objects and properties that can be abused by manmade laws of intensity and equity the same theme can be found in another of her poems khud kalami if i survive you might lose face so punish me punish me because you will die if my sons raise their hands i deserve retribution because i adore the new life with each breath i will live my life and double my life after my death punish me because you will die if only one sword opens to speak your sentence or punishment will end if you punish me this story of a sinful woman is closely guarded and practiced in a patriarchal society it is a story for everyone black feminism is used to promote womens suffrage in some countries but religion is used in pakistan to promote womens suffrage kishwar naheed wrote poems like khud kalami and we sinful women to address the root causes of womens discrimination in society although patriotism is regarded as a fundamental topic in the writings of the east kishwar naheeds works sadly lack this essential element it was because women were never considered to be a part of the country before nationalism can be enjoyed it needs to be nurtured sadly womens literature has never been included in the political or historical archives writing has contributed to womens awareness of politics and religion their aspirations setbacks and even triumphs have all been documented and disseminated through poetic metaphors the fact that kishwar naheed addresses sensitive issues of self emotions sex and gender discrimination under the banner of historical events is an important aspect of her poetry these issues could not otherwise be expressed in its sociopolitical context consequently kishwar naheeds work not only reaches a larger audience but also articulates pakistani feminist politics when we look at kishwar naheeds works from a broader perspective we find that despite being portrayed as a writer who advocates for women she quietly drew connections between men and women sexual orientation and patriotism in pakistani literature because the poems title makes use of the inclusive noun we it makes reference to all radical women because it demonstrates that it includes all women who are concerned with these manners the poems repetition of it is we sinful women at the beginning of each stanza is effective in accordance with the manmade law of energy and mens equity naheed criticizes men for treating the women of the country as wicked ladies and treating them as assets that can be misappropriated for no apparent reason womens bodies can be exploited by men women demonstrate because they are oppressed the materialistic world is ruled by wicked and sinful women whereas the men who harvest our bodies turn out to be glorious and wellknown the lyrics line number not awed by the grandeur of those who wear gowns which refers to the poem in appendix a 2 demonstrates that not all women are stereotypical in the sense that they are afraid of the rest of society and care a great deal about what other people think of them the poet talks about the women who spoke up in the following line saying the poet makes use of irony contrast and just a position to demonstrate that the most devoted and pious women are the ones who are called sinful naheed discusses socalled men who are praised by the social order if they torture women in their homes while those who sell the harvest of our bodies in the second stanza of the poem naheed discusses individuals who still enjoy social acceptance despite selling women out of lust or hatred they develop wickedness and a lack of character because no one holds them accountable at the end only women are mentioned men commit crimes like selling harassing looking at selling or considering women to be toys as they become the just princes of the material world the rest of society follows in their footsteps it is effective for men everyone speaks highly of them and regards them as a campaign table 3 the feminism of poem however the poet asserts that all of their efforts are now futile women will lead this age because of their strength intelligence and determination in his ballad we sinful women kishwar naheed uses a profound significant and capable subject she wanted it to achieve her objectives the same number of women acknowledge what she says with the intention of making changes and are encouraged by her words most people view a woman who works at night who serves as a dirty and adulterous woman people dont even care about the background behind someone doing that thing peoples thoughts are always negative about prostitutes in this poem naheed explains that even though they work as prostitutes they do not deserve to be insulted and treated as they please the woman in this poem does the job to provide for them financially in this literary work naheeds mission to promote feminism in pakistan is clear kishwar naheed has kept herself informed about political and social developments for more than fifty years naheed has emphasized the status of women from a gynocentric rather than an androcentric perspective in her scholarly contributions to this nation in addition the overall goal of her writingin verse as well as composition is to emphasize womens humanity a normal human being with feelings thoughts and potential in point of fact they are distinct individuals just like every androgenic member of society naheeds poems are delightful fresh and moving despite the radical spirit that can be seen in her verses she has contributed significantly to urdu writing both in the form of measured lyrics and free stanzas her verse and exposition bring to light a number of issues associated with women that were prevalent in pakistan after independence such as abuse in the name of securing womens educational rights physical violence against women and even prejudices in our socalled islamic nation she has established herself as a straightforward advocate for womens rights in the country thanks to her unwavering commitment to the cause she writes from the heart and that shows in her work in pakistani literary society naheed is more than just a symbol she is the epitome of contemporary urdu writing across the entire subcontinent of south asia conclusion the poem we sinful women by kishwar naheed was interpreted in this study as a poem that defies time form and the nationstate there are undoubtedly many possible interpretations of his poems some of which i have presented here the researchers analysis of we sinful women reflects the course themes of womens agency as female protagonists womens agency as writers and transgressive literature deemed dangerous in their own society contrary last but not least the researcher wants to make it clear that mona eltahawys recent argument that naheed and other women from thirdworld countries oppose an inherently patriarchal religion is overly simplified and reductionist instead it appears that culture is to blame for womens oppression which also grants naheed and for the wall which have been razed dont insist now on raising it again in the given lines naheed addresses societys radical men who continue to coerce women through a variety of means other writers permission to write transgressive literature recognizing the nationstates role in societys cultural and legal organization and oppression as well as the difficulty of understanding culture as a concept and challenging reforms within a generational framework in which customs and traditions are endlessly reproduced is becoming increasingly important from this perspective naheeds social criticism can be interpreted as feminine rather than pakistani the researcher wants to keep looking at culture as an intellectual space and pervasive zeitgeist in the classroom which makes it possible for transgressive literature to be written read contested banned and ultimately influenced in a way that is unprecedented acknowledgement first and foremost the researcher would like to express their gratitude to god almighty for helping us the researcher surrenders entirely to god for the strength he gave in carrying out this research the researcher would like to say thank you to our lecturer mrsmartina girsang for the opportunity and willingness to guide us so that we can be able to complete this research properly sang pencerah jurnal ilmiah universitas muhammadiyah buton martina 9 445455

the researcher decides to analyze feminism in kishwar naheeds selected poems which have the same theme of caste inequality between women and men this research method makes use of qualitative data analysis qualitative research looks for reasons and explanations rather than simply describing the research method and summarizing its findings james 1998576 says that feminism is based on the idea that women are disadvantaged or oppressed compared to men and that their oppression is in some way illegitimate or unjustified kishwar naheed disagrees with the idea that all women are sinful and are viewed as objects and properties that can be abused by manmade laws of intensity and equity according to some interpretations the poem we sinful women defies time form and the nationstate many different interpretations of her poems exist some of which i have presented here the topics covered in the course emphasize the significance of womens agency as writers as female protagonists and in transgressive literatureliterature that is regarded as dangerous in their own society in her poems women try to break the rules and free themselves from their chains by becoming their own liberators women breaking through barriers of marginality and achieving previously unimaginable heights

19842_0

background tuberculosis is an important public health problem worldwide 1 who estimates that 2 billion people or a third of the worlds population are infected with m tuberculosis roughly eight million of these individuals develop the disease and three million die from it every year 2 aimed at reducing morbidity and mortality from tb dots is highly recommended by who to control the disease moreover dots is recommended because of its goal of detecting 70 of all new smear positive cases and its 85 success rate when implemented in order to meet targets this strategy comprises a set of actions eg sputum smear microscopy among symptomatic patients directly observed treatment monitored and standardized regular provision of drugs information and registration system and even the governments commitment to prioritize tb among health policies 1 brazil has high tb incidence which places it among the 22 countries most affected by this disease in order to broaden and strengthen diseasecontrol strategies the country has established the programa nacional de controle da tuberculose anchored in decentralization and flattening of tb surveillance prevention and control mechanisms pnct guarantees free distribution of drugs and supplies needed for tb prevention and control providing citizens with universal access to health services for tb treatment 1 despite tb being a curable disease in almost all of new cases 1 professionals such as psychologists anthropologists sociologists and tb analysts have repeatedly indicated that talking about the disease still causes discomfort and unease in the population especially within the poorer communities 3 understanding the meanings conferred to tb by patients within their social settings enables one to approach this disease beyond clinical and conventional care patients lifestyles and thinking modes have an effect on how they respond to healthcare workers interventions and actions however this discussion is usually limited to evaluating these responses from the healthcare professionals standpoint thereby disregarding how patients see their own condition 4 tb is surrounded by intense grief with implications to different spheres of life including social relationships this is due to longstanding negative representations about this disease which result in stigma and discrimination 5 since ancient greece the term stigma has stood for bodily signs denoting something rare and evil about the signifiers moral standing 6 from patients and healthcare professionals perspective tb dimensions indicate that besides its physical impact on patients lives this disease has also a strong emotional impact given that debilitating symptoms evoke disability impotence and selfdiscrimination 7 in view of this emotional social and economic impasse socialemotional support is crucial to treatment completion this support can be accomplished by means of patients interaction with their families and friends volunteers and healthcare professionals and by promoting patients selfesteem trust and sense of belonging 8 the authors of this study presuppose that eliciting tb patients experiences from diagnosis to completion of treatment is extremely relevant to better choosing actions that can improve their quality of life increasing their adherence to treatment minimizing undesirable results facilitating the resumption of their daily lives and promoting a shared language amongst health professionals and patients therefore this study aimed to investigate psychosocial experiences reported by patients who had successfully undergone tb treatment in são carlos são paulo state brazil methods this studyof a clinicalqualitative natureadopted a humanistic design in that it sought to scientifically interpret the meanings participants conferred to their life experiences in their natural settings 9 qualitative researchers study phenomena in their natural settings in an attempt to interpret it in terms of the meanings people confer to them 910 qualitative methods have their own specificities as regards sample composition data analysis and possible generalizations from results 10 the research method utilized in this study is known as clinicalqualitative method it is considered to be a particularization and refinement of generic qualitative methods used in the human sciences herein applied to a healthcare context 9 data were collected by means of interview with openended questions this approachappropriate for qualitative research in the field of healthcare according to the literature 11 was adopted in order to ensure indepth interviews with the participants 9 the sampling method utilized in qualitative research designs 910 involves the intentional search for individuals who possess information about the matter in question and are able to articulate it data is produced with the purpose of reformulating deflecting complementing and or helping to clarify initial assumptions as is desirable in any scientific construction the sample in this study consisted of patients that had successfully finished their tb treatment in são carlos são paulo state brazil the following selection criteria were established patients had undergone tb treatment for the first time did not have hivaids had completed treatment within the allotted time were older than 16 years were intellectually emotionally and physically capable of undergoing a clinicalpsychological research interview and had agreed to participate in the study transcripts from the interviews composed the study corpus which was then subjected to qualitative content analysis according to themes 12 freefloating readings of the interviewees answers were conducted by the researchers so as to acquaint themselves with the material after applying the categorization strategy the categories for this study were selected the phenomena thus identified can then be interpreted to generate concepts that can be generalized to other settings 910 the researchers made use of a theoretical framework based on the basic concepts of health psychology such patients usual psychocultural adaptive handling of unfavorable events in their lived experiences the saturation criterion was employed to limit the size of the sample in other words it appeared clear to the researchers that after interviewing 15 patients further interviews would contribute little with regard to the objectives initially set for this study 10 this project was approved by the committee of ethics in research with human beings of federal university of são carlos process nº 4132010 the limitations of this study are inherent to qualitative methods that is this is a scientific study that advances concepts that can be generalized by its readers when they compare their lived situations to similar ones depicted in this research ie they engage in naturalistic generalization or comprehension by resemblance results and discussion sample characterization participants had mainly pulmonary disease mean age of 47 years and were predominantly male ten of them had eight or more years of schooling thirteen lived with their families and nine reported to be married at the time of the interviews regarding their marital status eight respondents were married three divorced three single and one cohabiting as to their occupation at the time of diagnosistreatment most interviewees were working two on sickleave for other health problems four retired two studying and one unemployed suffering caused by disease in this study suffering was primarily caused by fear of dying of transmitting the disease to others and of being discriminated against which is in accordance with the literature 13 suffering was mainly due to stigma and ignorance about tb however acceptance and resilience were essential to ensure completion of treatment fear of transmission reported by the participants is characterized by anticipatory angst of transmitting the disease to others especially to family members fear of transmitting the disease led the patients to shy away from social interaction most interviewees accounts indicate deficient knowledge about tb transmission modes which contributed to their fear of transmitting the disease to others in addition families did not seek the necessary knowledge about the disease so as to avoid reproducing discriminatory actions and to establish procedures based on real transmission risks this was evidenced by tb patients family members averting sharing objects or immediate surroundings with them it was perhaps … i moved to a room in the back of the house family members would pass me food through the window to avoid coming in my room in addition to fear of infecting others participants in this study remained isolated from friends and family for fear of being discriminated against thus they hid their disease and suffered in advance by shying away from social life in agreement with other studies 51415 the suffering experienced by these respondents was primarily linked to the idea of contagion and likelihood of being discriminated against which made them feel lonely and stigmatized nobody knew just my family who live with me … for this reason i was able to complete treatment without anyone knowing only my family knew about it tb was perceived by patients as a source of suffering since they experienced social isolation treatmentrelated difficulties and changes in body image this may be represented as loss suffering sadness and anger 5 in a brazilian study conducted about general aspects of tb patients sexuality in são paulo state negative feelings such as fear shame prejudice loneliness and contempt were mentioned by most respondents 14 social isolation due to fear of transmitting the disease to others drives patients away from their families thereby promoting further isolation and loneliness 14 the findings of this study confirm that tb patients beliefs can lead to selfdiscrimination in order to avoid embarrassing situations patients resorted to hiding their illness from work colleagues and friends ie they resorted to silence when dealing with these situations their choosing to hide the disease from others appears justified as several studies report embarrassing situations experienced by tb patients 51315 fear of death was also reported in other studies according to some authors 5 physical debility caused by tbassociated with the longstanding image of incurable diseaseleads patients to believe that tb is unescapably fatal and to see their death as imminent conversely in the context of this study respondents regarded treatment as a way to stay alive and healthy which may have contributed to their adherence to treatment because when wed hear about tuberculosis it was said to be a deadly disease i felt that i had to do my very best not to skip a single day of treatment it is thus believed that healthcare professionals should propose strategies to mitigate this suffering amongst possible activities is providing opportunities for groups of tb patients to discuss their condition spaces where they can voice their fears and concerns thereby helping them to think through their own prejudices and to find new ways of coping with their disease in spite of their suffering participants in this study confronted and overpowered the disease overcoming all obstacles to successful treatment completion acceptance and resilience seem to have been critical in this process its hard but you got to get yourself together and move on you just cant give up if you succumb to the disease things can get really complicated religious faith was reported to be essential to treatment completion respondents said that despite all suffering they were able to iron out difficulties because they accepted their disease and believed that god would help them through you feel so small and tall at the same time faith helps you through treatment but you have to take responsibility for your treatment as i did it wasnt easy but i fought hard and accepted the disease and thank god im cured in order to be able to deal with suffering and minimize pain other patients took charge of their own healthillness process during treatment they tried not to think about the disease and to move on with their lives … i tried not to touch the subject not to remember constantly that i had the disease … i tried to lead my life as if i didnt have it… life as usual… to live as if everything was normal as if i didnt have to take any medicine the same as before thats how it was for me religion appears as a means of coping with adversities such as tb 16 this author suggests that religionreligious beliefs and practicescan be a determinant in the healthillness process since those individuals who practice it benefit from it by adopting healthier habits and behaviors as evidenced in this study impact on familial and social settings this category represents the support given by families friends and work colleagues which was shown to be ambivalent this thematic category also depicts effects of tb on patients work and financial situation family support appears to be of paramount importance patients statements suggest that it is present from the moment of diagnosis of the disease to its cure participants in this study reported that they had family members on whom they could depend emotionally they also reported that this emotional support was vital to completion of tb treatment 17 since it enabled them to share and cope with difficulties posed by the disease 18 i think that family support counts the most in a disease like tb no doctor no medicine nothing suffices family support is essential … so that cheers you up you are not forsaken if you feel neglected thats the end thank god that didnt happen to me as to friends and colleagues that learned about the disease the interviewees reported that not all of them were supportive although there are accounts of friends support patients most common experience regarding colleagues is that of isolation which persists even after patients return to work after medical leave the fact that colleagues distanced themselves from the interviewees was probably due to the formers ignorance about transmission modes and enduring stigma and discrimination against tb patients in society at large in the case of participants in this study knowing that other people they knew had had tb and had been cured promoted their adherence to treatment people distance themselves from you after they learn that it is a catchable disease friends distance themselves a little one friend told me that he had had it and was cured that was great that cheered me up a little … but just friends i only talked about it with friends but that wasnt always a good thing to do… you may lose a friend tuberculosis is difficult because people tend to shun away from you to keep their distance depending on where you arrive… especially people who worked with methey just walked away … people are afraid … when i first returned to work people looked at me and sort of took a step back now its back to normal the way that family and friends relate to tb patients interferes with their everyday life tb patients do not feel stigmatized when their spouses families and friends do not start acting differently 17 this was corroborated by this study families can promote patients adoption of healthier habits behaviors and attitudes leading to a successful therapeutic treatment 18 however 19 indicate that there is poor interaction between healthcare professionals and families which concurs to deficient information about patient disease and treatment thus this study suggests that healthcare teams should work together with tb patients families friends and colleagues so as to mitigate stigma and ignorance about the disease with regard to repercussions at the workplace the interviewees who had jobs at the time took a medical leave from their work until treatment completion in these cases their salaries were paid by brazils social security system i took a leave from work … i didnt work i only returned to work when the treatment was over i did nothing for six months participants attribute their need to be away from work to the distance between their workplace and the healthcare clinic where the tb medicine was taken as well as to their physical debility and inability to keep working studies 1920 indicate that patients deem supervised treatment as an impediment to work since it implies their dailyweekly visit to the healthcare clinic to take the medicine this makes it difficult for them to reconcile treatment to daily activities it should be remarked that since tb is a chronic and debilitating condition requiring lengthy treatment it ends up causing ruptures changes in individuals everyday social production and reproduction 20 it may also be gathered from the interviews that this time away from work may have been necessary to prevent embarrassment and discrimination at the workplace i stayed home for six months because place of work is in the countryside i couldnt come to the clinic to take the medicine also it was too far for them to bring it to where i worked so i took it at home or at the clinic i was six months away from work because of the treatment you cant work anymore its really stringent to avoid contagion … to prevent contact with people and contagion also people sort of avoid you… hes sick so lets not go with him lets go with someone else… selfemployed and underemployed patients are the ones that suffer the most as their income is affected brazilian and international studies 1821 indicate that dismissal from work does occur after patients return from sick leave it seems to derive from discrimination however regularly employed patients in this study did not lose their jobs neither did their income drop as they kept on receiving their salaries from social security since tb treatment in brazil is free of charge the impact of the disease on participants financial situation was irrelevant 1 interviewees only reported having to spend more on food as they and their families were more concerned about buying quality products ah you end up spending more money we spent more money because since i was very weak we had to buy more fruit more wholesome food support from health service vs deficient cultural knowledge in order to complete their tb treatment patients considered the relationship with healthcare workers vital in that it provided them with opportunities to share and cope with diseasederived difficulties besides emotional support patients were also supplied with information and orientation about their health conditions it was great i was very well taken care of the girls there … helped me a lot as you arrive there they cheer you up talk to you joke around … that brightens things up a little we got there and they referring to healthcare professionals treated us like their friends … so as to the healthcare service the team who took care of me helped me a lot i had no problems i was well taken care of however despite the respondents in this study feeling well taken care of by the healthcare service and reporting to have received information their description of the relationship with the healthcare service and staff was vague it may be inferred that these patients did not feel comfortable enough to voice their concerns and problems during treatment which agrees with another study 22 the literature reports that effective communication empowers patients and families with respect to the disease and assists in changing equivocal meanings that have been constructed and internalized by different individuals throughout their life 522 by crafting an emotional bond between practitioner and patient their relationship no longer constitutes mere provision of service it becomes more intimate it promotes more personal conversations many moments to share experiences these moments allow patients more freedom to express their anxieties and doubts which in turn helps to demystify this disease they also alleviate patients anxiety and pain which are known to affect psychological economic spiritual and physical human dimensions 5182324 it may be inferred that an emotional bond was not established with every respondent despite its being one of the expected results of employing dot nonetheless in spite of feeling welcomed by the healthcare service participants in this study provided inaccurate information about the objectives of supervised treatment modes of contagion and basic knowledge about tb hence it is evident that friends coworkers and family are not the only ones illinformed about the disease this lack of knowledge affects everyone and can be considered a feature of brazilian culture … i got it from someones cup somewhere i dont know i cant explain i really have no idea how it starts this stuff must be deeprooted something that accumulates and expands … because they said its not catchable its inherited respondents stated that their illness was related to work conditions health conditions lifestyle habits air quality and even to contact with contaminated objects and utensils it appears that in the context under investigation adjuvant clinicalepidemiological factors are considered to be of central importance as if they were etiological factors ah i think i got it at work theres a cold chamber there i used to come in and out of it all the time i think thats how i got it my work conditions and schedule helped to bring it about i didnt eat well sleep well then immunity dropped stress increased… its not easy the doctor said that the virus may have been there already the disease manifested because i had lost too much weight thats how it may have happened lifestyle habits such as smoking and drinking were cited as probable causes of tb however unconvinced one of the participants believed that he had caught it because of his unhealthy lifestyle this shows that the population under study is uninformed andor misinformed about the difference between causal agency and comorbidity im not sure i smoke and used to drink a lot i dont know whether it was caused by my drinking or my smoking habit but i think it had nothing to do with that… i dont know given that participants in this study had been in close contact with healthcare professionals for at least six months it is worrying that they still reproduced concepts laden with prejudice and lacking in knowledge about transmission modes especially because this fact does not seem to be related to patients years of schooling as ten of them had eight or more years of formal education on the other hand the participants with 12 or more years of schooling stated that although tb had been incurable in the past it was curable nowadays they also reported concern about large concentrations of people because of increasing risk of contagion and remarked that after 15 days tb was no longer transmissible among other pieces of correct information about the disease 1 … i think about são paulo at rush hour… on a bus on a rainy day everybody coughing windows closed… i dont know… … some say that it can lie dormant in the lungs for a long time it should be remarked that in this study informative support was essential to facilitate adherence to treatment and minimize the suffering caused by distressing situations and lack of knowledge 18 some authors believe that greater disclosure is needed about tb its transmission modes signs and symptoms so as to promote early diagnosis and prevention 18 and that these actions should not be limited to healthcare professionals 25 it is important to devise educational programs directed to society at large as well addressing different aspects related to tb treatment and patients they should promote patients and their caretakers health and safety 26 thereby increasing the communitys scientific literacy however increasing patients scientific literacy should not be limited to physicians teachings concepts of tb etiology and contagion and representations of the healthillness process there is a wide array of possibilities and explanations 4 in a study conducted in the same region of são paulo state nurses denounce deficient training of healthcare professionals as one of the weaknesses of the local programa de controle da tuberculose it should be remarked that this deficiency may delay diagnosis and as a result increase the risk of transmission thereby compromising the success of this program 27 however the success of pnct is determined by the following conditions human relationships empathy and the bond established among health professionals and the target population as well as the patients willingness to express their anguish and report their needs 1 however some brazilian studies show that health professionals still find it difficult to incorporate interventions that take into account tb patients unique realities into their work process 28 implications to patients posttreatment life the experience of having been through tb may have several ramifications the way the healthillness process is understood by individuals is paramount to their perception and to the emergence of these implications the analysis of the data suggests that after treatment completion most patients personal and professional life returned to what it had been before the disease notwithstanding some participants cite changes in different spheres of their life it seems that brazilian people are immersed in a psychoculture with a broad and heterogeneous spectrum which gives rise to markedly polysemic meanings negative posttreatment implications are generally related to physical issues however having gone through a serious illness such as tb with all its implications enabled the respondents to reflect on their own health although studies indicate that these effects are limited to changes in lifestyle and health conditions it should be emphasized that changes at the psychosocial level were also identified in the participants answers at the mention of the disease and the changes caused by it it appears that tb has left everlasting impressions in their life especially because of the suffering involved in the course of the disease a brazilian study on social representations about living with tb confirms that the disease diagnosis changed their patients lives these changes however laden with negative perceptions were not always spoken about directly they were subliminally understood from patients accounts of their preand posttb lives 29 which corroborate the study in question conclusions this study only considers the perspective of patients who completed the treatment which may lead to biased results however eliciting the views of individuals that have been able to overcome all the obstacles posed by tb treatment and resume their daily lives can shed light on another facet of this complex disease ignorance about tb along with stigma suffuses all of the thematic units in this study people suffer from and are victims of prejudice due to continuing stigma and lack of knowledge about the disease on the part of patients themselves and society at large social support is also influenced by unfamiliarity and negative preconceptions about tb since distancing of friends and colleagues was reported by the participants it is evident that those going through this illness and those who are not are bundled together in the same large group of individuals immersed in tb myth and pseudoscience although patients and nonpatients bodies may experience tb differently their understanding of clinical phenomena does not seem to differ substantially it was noted that the stated criteria for being on medical leave from work during treatment consisted of a combination of epidemiological and sociological reasons which did not always seem clear to patients to be sure tb caused changes in the respondents lives notwithstanding after treatment they reported to have resumed their daily routines they also reported that small physical changes had persisted and that habits had changed after treatment they began to take their health more seriously it also was found that the tbrelated suffering still lingers after treatment and cure it resurfaced when the participants spoke about the disease acknowledging the emotional distress caused by tb throughout its course which persists even after treatment is essential to bring about muchneeded changes in healthcare it is up to healthcare professionals in line with the dots strategy to use empowerment strategies and create opportunities to discuss the disease with patients and families in order to break the vicious cycle of misinformation and prejudice competing interests the authors declare that they have no competing interests

background despite being curable tuberculosis is still a stigmatized disease not only is tb patients suffering due to its clinical manifestations but also because of societys prejudice embarrassing situations and even selfdiscrimination this study aims to investigate psychosocial experiences of patients who have completed tuberculosis treatment in são carlos a municipality in the interior of são paulo state brazil methods this study of a clinicalqualitative nature sought to understand the meanings provided by the participants themselves fifteen individuals who had successfully completed tuberculosis treatment participated in this research the sample size was established using the information saturation criterion data were collected by means of interviews with indepth openended questions data were treated by categorizing and analyzing content according to themes results regardless of all progress this study found that tb still causes patients to suffer from fear of transmission social prejudice and death despite the fact that the emotional support provided by families and healthcare professionals is considered essential to treatment adherence and completion participants in this study reveal that friends and colleagues have distanced themselves from them for fear of contagion andor prejudice ignorance about the disease and its transmission modes can be found in the interviewees statements which seems to indicate that they have become vectors of transmission of stigma themselves patients medical leave from work during treatment may be due to both their health conditions and their attempt to avoid socialemotional embarrassment there are accounts that tb has caused psychosocial damage to patients lives and that they feel more fatigue and lassitude and have begun to pay more attention to their own health conclusions healthcare workers should be aware of the ways tb treatment affect patients psychosocial life and develop strategies to mitigate these effects and provide opportunities for them to share their anxiety suffering and biopsychosocial changes in addition healthcare professionals should seek to educate and as a result empower tb patients and their families with regard to this disease so as to break the existing vicious cycle of misinformation and prejudice

19843_0

suicide is one of the most common causes of death among young adults in western societies and for each completed suicide there are several people who attempted to end their lives although mental illness and substance misuse contribute to a high proportion of suicides impulsive behavior in moments of crisis poverty and serious physical illness are also important risk factors recent studies have indicated that birth order is associated with suicide risk with laterborn children experiencing an increased risk of suicide whereas maternal age at child birth may be inversely related to risk among the offspring it has been estimated that more than 20 of suicides might be attributable to the combined effects of maternal age at child birth and birth order if these estimates are correct a better understanding of their underlying causal nature could provide important information about the familys role in the complex etiology of suicide the relationship between siblings and the relationships of siblings with their parents are unique for each individual within a family and these interindividual differences may have profoundly different effects on a childs development and later suicide risk thus it has been suggested that older siblings benefit from receiving more parental attention than younger siblings furthermore it has been speculated that short intervals between births may be associated with poorer mental health because of fetal undernutrition due to depletion of maternal nutritional reserves during the preceding pregnancy which impacts neurodevelopment such effects are likely to be stronger in thirdborn children than in secondborn in fourthborn children than in thirdborn and so on in relation to maternal age the offspring of young mothers are at higher risk of several adverse psychosocial outcomes this may be due to the limited social psychological and economic resources available to them confounding due to familial socioeconomic position and genetic and environmental factors could also contribute to the observed associations for example the birth order effect could be confounded by family size and young mothers themselves have an increased risk of psychiatric illness and low socioeconomic position it is difficult to adequately control for the possible confounding effect of socioeconomic position and genetic influences on mental health with the limited data available in large record linkage studies in previous studies researchers have compared individuals from population samples in which information on family characteristics and possible confounders was often not available one way to overcome this limitation is by carrying out a sibling comparison that is comparing risk in relation to maternal age and birth order within families because a family design will control for shared factors that could have confounded the results of other studies we studied the associations of maternal age at child birth and offsprings birth order with the offsprings risk of suicide before the age of 42 years in norway our main aim was to assess suicide risk among siblings within families in which a suicide occurred during followup for comparison we also studied suicide risk in the population as a whole materials and methods the study was based on linkage of data from the medical birth registry of norway with information on suicide obtained from the norwegian cause of death registry the medical birth registry was established in 1967 and information on virtually all births that have taken place in the country since then has been registered the registry includes health and demographic information on mothers and their offspring at the time of birth followup for suicide was conducted among participants who were born between january 1 1967 and december 31 1996 and were alive at 12 years of age a total of 1690306 people were eligible for followup from the age of 12 years because suicides before the age of 12 are rare our analyses were based on 2 samples the first sample consisted of the population as a whole and the second sample consisted of siblings within families with at least 2 children in which at least 1 sibling committed suicide the exposure variables of interest were maternal age at child birth and the birth orders of siblings we also included information on the offsprings sex and year of birth the time interval between births maternal marital status and maternal and paternal educational levels at the time of birth suicides that occurred from when the offspring were 12 years of age until the end of followup were identified through individual linkage with the cause of death registry in norway we used codes e950e959 from the international classification of disease ninth edition and codes x6084 from the international classification of disease tenth edition to indicate suicide in most cases of sudden unexpected death forensic autopsies were conducted to determine cause of death siblings of the deceased were identified using the unique identification number of each mother this enabled linkage of information between siblings within families with at least 2 siblings the present study was approved by the regional committee for medical research ethics in central norway statistical analysis in both the population as a whole and the sibling cohort we assessed suicide risk using cox proportional hazards models with age as the time axis the participants were followed from the age of 12 years until death by suicide death from another cause emigration or the end of followup whichever occurred first the oldest participants in the cohort were born in 1967 and were 41 years of age at the end of followup in both the population as a whole and the sibling cohort we studied suicide risk related to birth order and maternal age at delivery in multivariable analyses we controlled for offspring sex year of birth maternal marital status and maternal and paternal levels of education in the analysis of maternal age at child birth we also adjusted for birth order and in the analysis of birth order we also adjusted for maternal age at child birth in the analysis of the population as a whole we used a standard cox regression approach but in the sibling cohort we used stratified cox models to control for factors that were shared within families this approach enabled us to compare associations with maternal age and birth order within sibships in such an analysis characteristics that are shared by siblings cannot have confounding effects on the estimated associations we also carried out a test to investigate the possibility of effect measure differences of maternal age and birth order between sons and daughters in a separate analysis of the sibling cohort we assessed whether the association of birth order with suicide risk differed depending on the timeinterval since the prior birth in additional analyses we studied whether maternal age at child birth as well as sibship size could influence the association between birth order and suicide risk among siblings the proportional hazards assumptions were assessed on the basis of schoenfeld residuals and there was no evidence against the proportionality assumption we used stata version 11 for the statistical analyses results characteristics of the study population and the sibling cohort are presented in table 1 in the population as a whole 3005 suicides occurred during more than 25 million personyears of followup among these suicides 2458 maternal age birth order and suicide 639 am j epidemiol 2013177 638644 occurred within the cohort of 6741 siblings eighteen families experienced 2 suicides the risk of suicide was over 3 times higher in males than in females and was increased in the offspring of mothers who were not married or cohabiting and in those with less educated fathers the crude hazard ratio of being an only child versus being in a sibship with 2 or more siblings was 099 086 115 table 2 shows that having a higher position in the birth order was positively associated with suicide risk in the population as a whole in the unadjusted analysis suicide risk increased by 11 for each increase in birth order category and after adjustment for maternal age at delivery offspring sex time period of birth maternal marital status and parental educational level the corresponding risk increase was 26 126 95 ci 120 131 in relation to maternal age at child birth there was an inverse association with suicide risk among the offspring for each 10year increase in maternal age the unadjusted risk reduction was 14 and after adjustment for birth order offspring sex time period of birth maternal marital status and parental educational level the corresponding risk reduction was 30 in the sibling cohort the unadjusted hazard ratios for birth order and suicide risk were similar to those observed for the total population but we found no clear association for maternal age at child birth however after adjustment for maternal age at child birth and birth order in the same model the associations among siblings were substantially stronger than were those observed in the total population for each increase in birth order the adjusted risk increase among siblings was 46 in relation to maternal age at child birth and offspring suicide risk there was a risk reduction of 57 for each 10year increase in maternal age there was no strong evidence that associations between suicide and birth order differed in male and female siblings for each increase in birth order category the adjusted risk increase was 44 among brothers the risk declined by 60 with each 10year increase in maternal age the corresponding estimate for sisters was 49 in table 4 we stratified the analysis of birth order by time interval between births the results showed that the positive association with suicide risk was strongest if the time interval between births was relatively short thus the crude hazard ratio per birth order category was 140 if the time interval was less than 2 years compared with 120 if the interval was between 2 and 3 years and 102 if the interval was 3 years or more the effect measure modification was attenuated after adjustment for maternal age in separate analyses we stratified the association of birth order by sibship size the positive association of birth order with suicide risk did not substantially differ by size of the sibship a model excluding 90 multiple births from the sibling cohort gave almost identical results as those shown in table 3 discussion in the present large prospective study of suicide before 42 years of age we found a strong increase in suicide risk with increasing birth order and a strongly reduced risk with increasing maternal age at child birth we analyzed suicide risk among siblings within families and therefore the results cannot be explained by early life factors that are expected to have similar influence on siblings strengths and limitations the main strength of these analyses is the large sample size that makes chance an unlikely explanation for our findings another important strength is that we could assess suicide risk among siblings within families and therefore important factors that are shared between siblings were taken into account by the study design these factors include parental educational levels the socioeconomic situation of the household parental mental illness and other shared factors that could be relevant for suicide risk however we cannot exclude the possibility that comparisons within families may be vulnerable to timedependent factors that could influence the internal family environment and have different effects on the siblings relevant examples include parental divorce placement into foster care the onset of serious mental illness in a parent domestic violence or other events that have occurred at different stages of the siblings lives when age is related the effects of such factors however these factors could also be considered as possible mediating factors rather than confounders because they can be neither causes of maternal age at child birth nor determinants of birth order naturally birth order is highly correlated with maternal age and in the analyses of each factor careful adjustment for the other factor is essential this is particularly important because the results of birth order and maternal age show opposite effects on suicide risk thus without adjustment for maternal age the positive association of birth order would be much weaker than the adjusted association because of the underlying inverse effect of maternal age at child birth it is possible that suicide is underreported in the cause of death registry but this would only bias our results if the underreporting were associated with maternal age at child birth or with birth order however the prospective approach of the study makes such a bias unlikely previous studies the results of a few previous studies have suggested that maternal age at child birth is inversely associated with suicide risk in offspring and that birth order is positively associated with the risk of suicide it has also been suggested that low maternal age at child birth is associated with an increased risk of suicide attempts the association of maternal age at child birth in our study was stronger and displayed a linear relation with suicide risk whereas the results of other studies suggested that the increased risk may be restricted to the offspring of very young mothers family designs with comparisons of siblings have not been previously used in relation to suicide risk and the advantage of controlling for shared family factors provided by the sibling design of our study may have contributed to the stronger associations furthermore more than 80 of the suicides in our study were included in the sibling cohort making the results fairly representative of families being exposed to a suicide possible mechanisms the results from the present study indicate that the associations of maternal age and birth order with suicide are not confounded by socioeconomic or genetic factors there are several possible mechanisms for the observed associations the linear reduction in suicide risk associated with increasing maternal age at child birth may seem surprising because both maternal and paternal age are positively associated with the offsprings risk of serious psychiatric conditions including schizophrenia that are associated with increased risk of suicide although serious mental illness is an important risk factor for suicide these conditions may be too rare to compete with the impact of low social psychological and economic resources faced by many young mothers the inverse association of maternal age with the offsprings risk of suicide could also be related to the possible stressful situation for younger mothers as young mothers are more likely to have mental health and family problems as well as problems at school and with education employment and housing furthermore it has been suggested that stressful pregnancies may influence fetal brain development and possibly influence the psychological development and mental health of the child the results from the present study support the view that family relationships and bonds made in early childhood may have an influence on psychiatric morbidity and suicide risk later in life many studies have suggested that firstborn children have a more prominent position in the family than subsequently born siblings and it has been consistently reported that birth order is inversely associated with intelligence possibly our findings related to birth order may be relevant within a similar context suggesting that the older siblings may benefit from this position by a higher degree of stimulation and support during their early years it is also possible that younger siblings are more easily bullied by older siblings and it has been repeatedly reported that bullying is a strong risk factor for suicide the strong positive unadjusted association of birth order with suicide was stronger in families with short intervals between births which supports the theory that decreased nutrition has an impact on the developing brain however this finding could partly be explained by the protective effect of increasing maternal age implications although several twin studies have found only marginal effects of shared family environmental factors on mental health the results of our study strongly indicate that family factors that are not shared by siblings might operate from an early age and influence suicide risk furthermore early motherhood especially teenage pregnancy is associated with several adverse psychosocial outcomes in their offspring the incidence of early motherhood varies considerably worldwide and the results of the present study underscore the potential importance of offering support to young mothers and their offspring conclusion the inverse association of maternal age at childbirth and the positive association of birth order with suicide risk among siblings strongly indicate that family factors that are not shared by siblings may operate from an early age and influence suicide risk our study suggests that confounding due to familial factors is not likely to explain the associations of birth order and maternal age at child birth with suicide risk institutet stockholm sweden and school of social and community medicine bristol university bristol united kingdom johan håkon bjørngaard is financed by the norwegian research council and by the liaison committee between the central norway regional health authority and the norwegian university of science and technology imre janszky is financed by the liaison committee between the central norway regional health authority and the norwegian university of science and technology the swedish council of working life and social research and by the ansgarius foundation david gunnell is an nihr senior investigator conflict of interest none declared

previous studies have reported strong associations between birth order maternal age and suicide but these results might have been confounded by socioeconomic and other factors to control for such factors we compared suicide risk between siblings and studied how maternal age at child birth and birth order influenced risk in a cohort study of 1690306 norwegians born in 19671996 who were followed up until 2008 using stratified cox regression we compared suicide risk within families with 2 or more children in which one died from suicide altogether 3005 suicides occurred over a mean followup period of 15 years 2458 of these suicides occurred among 6741 siblings within families of 2 or more siblings among siblings a higher position in the birth order was positively associated with risk each increase in birth order was associated with a 46 adjusted hazard ratio 146 95 confidence interval 129 166 higher risk of suicide for each 10year increase in maternal age at child birth the offsprings suicide risk was reduced by 57 adjusted hazard ratio 043 95 confidence interval 030 062 our study suggests that confounding due to familial factors is not likely to explain the associations of birth order and maternal age at child birth with suicide risk epidemiology family characteristics parity public health siblings suicide abbreviations ahr adjusted hazard ratio ci confidence interval

19844_0

knowledge and organize it according to their patterns of thinking which ultimately depended on their value orientations this creates a clear link between the widespread value orientations within the society and the average performance of students in international studies that assess the achievements of fourth or eighth graders i argue that there are specific values related to a societys dominant beliefs which have a positive impact on student achievement in test the hypothesis at macrolevel using countrylevel data derived from values surveys to predict the average achievement scores registered in various clssas i focus on how socalled childrearing values or parental values influence a countrys average scores in the pisa timss or pirls parental values explicitly refer to what people think kids should learn at home and generally indicate the value orientation towards what people consider useful to be preserved by future generations they include aspects like religious faith independence responsibility and obedience i argue that such values have a strong impact on a countrys average performance in the clssas i expect that autonomy values such as responsibility and independence have a positive impact while orientations toward authoritysuch as giving precedence to religious faith and obediencedecrease average student achievement particularly in math and science even if the importance of context factors in explaining school outcomes is recognized empirical analysis rarely underlines the impact of such determinants this paper contributes to such yet to be written literature by adding to the few papers that consider and empirically test the impact of countrylevel cultural traits on student achievement if considering that teaching patterns and all classroom interactions are aligned with their national cultural beliefs expectations and values the findings also provide insights for curriculum development the paper also contributes to the literature describing the impact of social values particularly of the childrearing values the results and the method add knowledge which increases clssas usage in a field almost unexplored until now and increases the potential of such tools to investigate crosscountry differences and inform education policies education2 225 rise international journal of sociology of how values influence school achievement determinants of effective models of successful education may exist at various levels family and students classmates and teachers school culture and contextlevel factors are important contributors to the schools outcomes in this paper i focus only on contextual determinants at the societal level my assumption is that what happens at this level is likely to be reflected in daily classroom activities and influence the schools outcomes this is in line with creemers and kyriakides dynamic model of educational effectiveness however i explicitly extend the explanation to consider widely shared social values as part of the factors operating at the contextuallevel which define the wider educational environment discussed in the mentioned work the idea of school embeddedness in society is a common concept in the sociology of education education systems serve societies by providing socialization and training but they also depend on the society in which they are embedded teachers students and parents are part of a societythey share its values and life styles and behave accordingly social learning theories argue that people learn by observing the relevant behaviors and attitudes of others children tend to imitate adult behavior and the values that they daily observe adult models are not necessarily parents or teachers but these actors are the most relevant since they are the most salient part of the students daily environments their pervasive influence goes far beyond written laws and formal regulations and is embedded in the hidden curriculum the hidden curriculum manifests in attitudes values beliefs and behavior it relates to how teachers parents and children use and decode various communication stimuli following snyder one can define what happens between students and educators as being structured by formal curricula and as being dependent on the teachers behavior and the students support formal curriculum is also shaped by common social norms and value orientations teachers behavior is at least partially a manifestation of the respective persons values creemers and kyriakides call the ability to increase opportunities for learning and develop positive values for learning it is likely that the interdependence between social values and the educational process is reflected in student achievement fensham argues that the national average school performance as recorded by international largescale projects such as pisa or timss should be explained both by directly observable factors measured at the countrylevel and by cultural factors the first are manifestations of more fundamental values and complex mores which may be partially found amongst cultural determinants fensham insists on separating directly measurable factors which he labels as contextual variables from cultural factors this does not mean that culture is outside the context on the contrary since fensham pledges to consider the national context as an explanatory variable for the timss or pisa national average scores the different labeling underlines the role of culture as an important contextual trait both types of determinants create the context in which education occurs culture is primarily considered a set of educational practices but as i have already mentioned such practices are manifestations of the more general cultural context this discussion could be extended to the community level but for the sake of simplicity i prefer to treat society as a homogenous entity minkov notes that crosscountry differences are not sufficiently explained by stocks of education wealth or education policy and concludes that culture should be considered a predictor for student achievement in the timss and pisa birenbaum et al propose various cultural explanations for the high achievements of the singaporean students revealed by the timss in 1999 they include a strong examination of culture and meritocracy as the basic principle for societal structure leung also formulates hypotheses regarding the superiority of southasian students in mathematic achievement proven by the results of the timss 1999 he suggests that cultural values that they the respective countries share such as stress on modesty may explain these results but the mechanism through which such values impact student achievement remains unknown i argue that dependency on widespread social values may be part of this unknown mechanism givvin et al found that despite crosscountry similarities national patterns of teaching exist which they have hypothesized that comes from a cultural nature of teaching one may also say that a teachers behavior and beliefs depend on their societys shared values in summation my assumption is that the social values shared in a society directly influence the types of values that children learn which in turn are reflected in student achievement societal value orientations also influence teachers values and beliefs which influence the students patterns of thinking student achievement is the visible outcome of this process and may be assessed in a comparative manner through the clssas clssass may only partially reflect student achievement for instance ignoring social skills and student wellbeing but they have the merit to provide comparable crosscountry measurements of school outcomes culture as determinant of achievements can be seen as a multidimensional phenomenon various social values may underline the patterns in which people price school and education its role in social life how skills form and permanently improve when learning ends if ever does it some may trigger higher achievements other may deter the quality of education the scope of this paper is limited to a narrow set of values the parental ones relevant for the education process as i argue in the next section the role of parental values social values scholars treat the parental or childrearing values as part of a mix of value orientations which contrasts two sets of preferences regarding what children should learn the first includes values related to autonomy such as responsibility and independence while obedience and religious faith are part of the second set which refers to complying with authority parental values are said to be of high importance for directing the early socialization processes and the relation that children develop with school and society therefore they are essential for the attitudes towards learning and should be reflected in student achievements the basic mechanisms were described in the previous section and further support for selecting parental values as relevant for culture are to be found in the education science uks plowden report popularized childcenteredness and creativity as basic attributes that lead to effective learning in the early 1980s governments become reluctant to such approaches but these ideas are currently back as dominant paradigm in schooling teaching approaches based on promoting responsibility independence and creativity are regarded as beneficial in classroom activities they are said to enhance personal traits and harmonious development of students stimulating their capacity to learn and to understand the world obedience and strict respect for authority are regarded as destructive to personal initiative and to explicit orientation towards knowledge pascal and bertram identify autonomy as a key adult value orientation that promotes desirable learning outcomes autonomy implies children creativity independence and responsibility and leads to highquality thinking and development other empirical findings suggest that approaches related to encouraging responsibility and independent thinking lead to higher achievements for instance in their analysis of school achievements in science lavonen laaksonen show out that frequent use of interactive teaching including teacher demonstrations practical work and students drawing own conclusions lead to better outcomes therefore my first hypothesis is societies that share value orientations towards autonomy such as independence and responsibility are likely to better perform in comparative surveys of students achievements orientations toward authority particularly religious faith and obedience are likely to have the opposite effect firstly widespread beliefs that children should learn religious faith with its old commandment to belief without investigation imply a general inhibition of curiosity of the predisposition to selfdiscover how the world works obedience follows the same line of thought but may be particularized to a more tangible authority secondly it is likely that teachers who are oriented toward obedience prefer lecturing and are not prone to promote teaching paths based on selfdeveloping and participation both mechanisms lead to less independence and responsibility a complementary hypothesis results from these assumptions average student achievement is higher in societies that are less oriented toward values of authority such as religious faith and obedience student achievements are commonly measured by tests that produce scores varying within a certain range any of the tested subjects cannot be classified bellow the lower bounder or above the upper limit let us imagine a society that is indifferent to respect for authorityautonomy value orientations a small increase in orientations towards autonomy will have some impact on student achievements however after a certain point due to the upper limitation of the test scores the marginal contribution to achievement will start to decrease although the overall effect will remain positive the same is valid when one considers the negative impact of the orientations toward authority therefore the second hypothesis holds that the effects described by and will be logarithmic clssas test achievements in reading mathematics and science of the four types of specific value orientations religious faith may have particular effects depending to the topic the rational approach which assesses situations considering all implications and available facts and knowledge may be seen as opposed to the religious explanation which often assumes the existence of indubitable truths that cannot be subject to debate or research due to its specific connection to rational explanation and exact sciences i expect that orientations towards religious faith have a stronger negative impact on achievement in mathematics and science as compared to the impact on reading overall i claim that childrearing values are part of the context in which schools and pupils evolve their impact on student achievements is described in the three hypotheses that i advanced the next section reviews the other factors that should be controlled for as they derive from existing literature however i am not insisting much on the mechanisms that underlie their influence since the focus of the paper remains the impact of social values other countrylevel determinants of student achievements cultural reproduction theories provide strong reasons for controlling for parental education stocks of education including the education level of the adult population extend the scope of the indicator it also provides rough information about the societal aspirations related to the trajectory of education institutional arrangements are important leverages that might determine more effective teaching and are of high importance to researchers and decisionmakers investments in education tap for the amount of resources allocated to education curricular aspects are the easiest to change in terms of policy implications schooling age also reflected in the age at the time of testing teaching quality inequality of access to quality teachers the pupilteacher ratio and classroom size are additional potential determinants clssas have different approaches in what is being tested ieas timss and pirls include curriculumrelated testing while the oecds pisa tests the students ability to use knowledge in their daily lives therefore when using information from different comparative surveys it is important to control for their provider the level of economic output is an indicator of countrys ability to convert wealth into human capital wealth means having abundant resources including resources for education but also implies higher material security and more focus on selfdevelopment richer societies are more complex in daily life people need to deal with various situations and have higher amounts of information to process facing such daily challenges increases people ability to grasp complex information data and methodology i put together information on student achievements and childrearing values the clssas provided information on the dependent variable while the main rise international journal of sociology of education 2 231 independent variables were derived from the values surveys information on the other control variables was collected from various official statistics this section briefly describes the data sources and variables used in this study when explaining the process of producing the variables i gradually introduce the structure of the resulting dataset also depicted in table 1 dependent variable each clssas wave provides information on a limited number of educational systems in order to have access to a larger number of countries i considering several largescale surveys conducted over a reasonably short amount of time allowing drawing conclusions for a broader population the resulting dataset includes at the first level countrysurvey observations figure 1 describes how the dependent variables were derived from the surveys for each surveycountry pair the mean value of the respective sample represents the value of the dependent variable for this study such average scores correspond to the squares in figure 1 and result from the combination between a country and a survey voicu achievements social values therefore the dependent variable is a series of 1076 average country scores registered in the pisa timss and pirls surveys between 1999 and 2009 timss is a largescale comparative survey of math and science achievement that tests eighth grade students from various countries every four years this paper uses results from the 1999 2004 and 2007 waves the pirls is conducted by the same iea team and collects data from fourth graders by assessing their reading achievement i employ the pirls from 2001 and 2006 the oecd conducts the pisa survey every three years primarily in oecd countries by testing eighth graders in mathematics reading and science this study employs the pisa scores from 2000 2003 2006 and 2009 overall i have considered 24 surveys that represent combinations of providers grades and topics these surveys may be labeled as timss 1999 math grade 8 pirls 2001 reading grade 4 etc for each country and each survey i collected the mean scores each countrys original mean score was rescaled in order to get an average of 500 points for the set of countries in the study respectively for the oecd members therefore in order to compare the country averages across the surveys it is necessary to control for the characteristics of the surveys independent variables childrearing values for each of the 1076 countrysurvey pairs i have employed evs and wvs data to compute independent variables tapping for parental values despite being different studies the methodology and questionnaires of the two values surveys generally overlap the 1990the 1993the 1995the 1997the 1999the 2001the 2005the 2006the and 2008the 2009 waves included a set of items on parental values they asked the respondents to indicate from a list of qualities the top five vales they would like children to learn at home among these qualities four choices are of interest for my aim responsibility and independence stand for an explicit value orientation toward autonomy while religious faith and obedience go in the opposite direction tapping for orientation toward authority 233 1997hagernaars et al 2003 a sem analysis proves that it is difficult if not impossible to achieve even partial measurement invariance across countries and across evswvs waves for a model using all four items 1 for the purposes of this paper i computed the proportion of respondents who selected each of the four items for each country and each datacollection year this produced four indicators for each country and wave of the value surveys next i associated these indicators with the countrysurvey pairs for which clssas has provided estimates of student achievement since the years of data collecting in the clssas and in the value surveys do not coincide my option was to consider those estimates of value orientations that were closer in time for instance the austrian timss 2007 average achievement score is associated with the results from evs 2008 because this was the closest datacollection year for austria in the value surveys for each surveycounty pair i added the gni per capita measured in ppp data is available from the world banks world development indicators database except for taiwan for which the gnicapita was estimated using imf including gdpcapita the impact of social values on countrylevel estimates of student achievements is cleaned out of potential distortions due to betweencountries differences in wealth the pupilteacher ratio in primary education and public spending for education are average values of the available 19992010 indicators provided by the wdi when missing i have completed the ptr data with indicators reported by unicef for switzerland norway iceland and the netherlands the closest accessible indicator was for 2005 while for turkey bosnia and montenegro data was only available for 1999 missing information on public spending on education was derived from world bank for montenegro respectively and izvorski for bosnia i used the barrolee estimates for 2005 to assess tertiary attainment and average number of completed school years of adult population these indicators describe the country more stable context and i have kept them fixed at country level regardless of when the clssas data was collected methodological approach some of the above variables have incomplete information for specific countries listwise deletion led to a final sample of 919 cases covering 67 societies 2 most of them advanced economies since the selection depended on the availability of data the sample is not probabilistic the data describes a crossclassified pattern as visualized in table 1 with the average scores nested both in countries and in clssas therefore i run crossclassified multilevel models with all of the effects fixed in order to test the social value indicators were transformed into logarithmic scales the same transformation applied to gnicapita imposed including interaction terms between the logarithm value of religious faith and the math and science variables five types of models were tested first the empty model shows if there is variance across countries the second model includes all controls except for parental values the third model adds parental values as predictors by contrasting the second and the third model it is possible to assess if childrearing values contribute to a better explanation of the variation a fourth model which includes only the parental values as predictors evaluates the magnitude of their impact when nothing else is known about other sources of variation the logarithms of the respective indicators are used in all these models when the parental values indicators are included as required by finally i have built a fifth model identical to the full model without employing logarithms in order to test h2 more accurately each model used the lmer procedure in r and all of the effects were fixed one may question if learning religious faith might have the same meaning in different religious cultures to prevent such bias the models were repeated including covariates for the percentages of christian muslim buddist confucian and hindu in the total population 2 they control for the effect of religious culture and bring religious faith closer to indicate same concept in every country all results remained unchanged proving the robustness of the analysis findings considering the average results from various clssas several asian countries are among the performers along with western societies while african societies tend to lag behind if looking only to europe the best represented region in surveys like pisa and timms western societies tend to receive higher scores as compared to eastern ones the same being valid for the northsouth differences similar polarizations are noticeable when inspecting the parental values the percentage of those who declare that responsibility is important to be learnt reaches 90 in several east asian societies and in some of the european countries it goes as low as 3050 in african countries like nigeria burkina faso tanzania mali ethiopia etc but also in kosovo great britain bosnia and bangladesh independence is also priced mainly in northern europe and east asia while several easterneuropeans most african countries latin america but also hongkong and france gives it less importance religious faith is supported as parental value by more than 80 of the adults in egypt pakistan romania jordan macedonia irak indonesia and several othersmainly muslim of orthodox southeast asia northern europe france and most of nonorthodox or catholic postcommunist societies are at the opposite stance with 10 of less stressing the importance of learning religious faith obedience is considered more important by over 50 of respondents to value surveys in african countries india romania indonesia and several latina american societies less than 15 of northern europeans japanese chinese germans and czechs value obedience all these descriptive suggest a certain match between countrylevel aggregates of childrearing values and student achievements bivariate pearson correlations separately estimated for each clssas indicate that religious faith and obedience as inversely related to achievements with typical negative correlation coefficients of 0607 and 0405 independence and responsibility seems more loosely connected to achievements but the sense of the relation is the expected one in their cases the pearson correlations are around 03 respectively 02 multivariate analysis can show if these observations hold true when considering all the clssas and controlling for their characteristics the empty crossclassified multilevel model reveals that most of the variation occurs across countries while only a small part is derived from the differences between surveys adding the controls for the characteristics of the surveys and the countries but not the parental values indicators decreased the total variation by 52 including the social values indicators the total unexplained variance decreased by an additional 10 to a total of 62 on the other hand as compared to the model with no predictor there is decrease in unexplained variance in the model that includes only childrearing values all these indicate that parental values add to other contextual explanations and survey characteristics to explain the variance of countryaverage scores in various clssas results in other words the cultural characteristics that they measure are important in determining crosscountry differences in achievements to show the direction of the impact of parental values table 3 presents the estimates of the fixed effects in the full model wealth the education of adults lower pupilteacher ratio and the average age at the time of testing showed positive effects the average age at the time of testing is an indicator of the starting school age its strong impact which manifests when controlling for the grade of the tested population produces important consequences for assessing the performance of different educationalsystems through the clssas results this means that countries with low achievement scores where students were older than average should give even more attention to their education policies specifically to the adequacy of the entry age and to preschool education surprisingly public spending on education seems to have a negative impact on achievements however it is necessary to point out that this is an incomplete indicator as it only reflects public spending while in many countries it is the total investments in education that 240 voicu achievements social values make the difference considering the impact of the survey characteristics curriculumbased tests produce higher scores than the pisa the same is valid for surveys that test achievement in mathematics or of the 8 th graders newer clssas produce lower average scores among childrearing values the two indicators for orientation towards autonomy are positively associated with higher achievement the more a society is oriented toward such values the higher the average clssas score in the respective society the opposite holds true for religious faith and obedience however the effects of independence and obedience are not very strong if the sample had been random and statistical inference had been possible these effects would have been insignificant nevertheless this does not change the conclusion related to the first hypothesis societal orientation toward autonomy values in childrearing leads to better achievements while an orientation toward authority values has a negative impact on the countrys average clssas scores the second hypothesis relates to the shape of the effect a logarithmic dependency was expected the autonomy values produce positive effects but after a certain level their marginal impact began to decrease the same occurs with authority values but the relation is negative the full model presented in table 3 uses logarithms of the social values indicators the results provide support for the hypothesis however in order to check if the effect is linear i have constructed an alternative full model in which the measures of the childrearing values were not on logarithmic scales the results do not change much the deviance is 8073 the total unexplained variance is slightly higher in comparison to the full model in table 2 and the total decrease of unexplained variance compared to the empty model is 54 when considering the tvalues of the parental values and their interactions with the type of survey these fixed effects are slightly lower except for responsibility which has a marginally stronger impact overall the logarithmic full model performs better which supports computing the effect size one may notice that for a country where only 40 support responsibility as important value to learn an increase of the figure to 50 determines the average score in clssas to grow with almost 9 points an additional 10 increase brings other 8 points to the average score when support for religious faith is as high as 90 a 10 drop increases the average performance in clssas by 3 points this is similar to the expected increase of average test score in a country that increases its gdpcapita of 15000 usd ppp with 2000 more to match the abovediscussed 10 increase in support for responsibility gdpcapita should increase its value with almost a half although changing values may be appealing for policy makers interested in boosting achievements one should also remember that values are resilient to change however there are still ways to foster change as i suggest in the final section of this paper the third hypothesis proposed a differential impact by comparing math and science to reading the two crosslevel interactions in table 3 show that the negative impact of religious belief is multiplied in science achievement and particularly in mathematics achievement the negative impact is more salient in mathematics this is likely because during primary and lower secondary science curricula consist of basic notions and in mathematics the rational approach is introduced earlier considering the size of the effects the negative impact of religious faith on mathematics is comparable to the negative average impact that religious faith produces on the average clssas performance this implies that in countries that are strongly oriented toward religious faith performance in mathematics could be better in the absence of such value orientation discussion and implications for policy and future research this paper employed a macrolevel analysis to test how schooland pupilembeddedness in national culture influence the school achievement aggregate measures of childrearing values were used to assess the impact of values on school achievement at the aggregate level the empirical evidences support the three hypotheses first societallevel parental values have an impact on the clssas estimates of average student achievement second societys pricing responsibility as value that children should learn increases the chances that primary and lower secondary students will perform better on international tests religious faith when used as a driver for child rearing produces the opposite effect which has a stronger manifestation for mathematic achievement value orientations toward obedience have a small negative effect while independence as a 242 voicu achievements social values parental value produces a small increase in the probability that students will have higher achievements in science mathematics and reading all of these results hold true when controlling for various aspects of societal development educational policy and survey characteristics the findings contribute to two fields of social research that were rarely connected in the past research social values and studies of countrylevel school performance i argue that social values are part of the cultural environment in which schools evolve and that they influence school achievement to the best of my knowledge this approach is new when considering parental values and their consequence for student achievement in clssas therefore the paper joins current debates around the need to extend the contextualization of school outcomes by considering the consequences of cultural traits considering practical consequences in terms of education policy it may seem difficult for policymakers to manipulate factors like value orientations this makes it hard to detect the implications for education policy however the stability of values was often questioned in the past decades in the longterm exposure to certain institutional factors may lead to changes in social values is it possible for policy to affect such changes let start with the easier even if notsoeasy task analysis in this paper considered society as a whole but one may speculate on how to apply these findings when considering the values of the teaching staff teaching staff is a particular group which spends a lot of time in the relatively controlled environment of the schools here the influence of institutions on social values could be used as leverage for policy directions teachers are not necessarily a homogeneous group in any society some may share value orientations toward autonomy while others may value authority exposing teachers to training programs and explicit curriculum that reinforce values like responsibility and independence may influence their attitudes behaviors and even their value orientations as the findings shows out this may be beneficial for enhancing student achievement however in this sense the evidence is still indirect the results show that an average societal orientation towards autonomy values produces higher achievement in order to see whether the value orientation of individual teachers influences student achievement it is necessary to obtain data about the teachers orientations of value this might be a subject for future research as well as a potential proposal for the timss and pisa teams since the findings do not refer to individual teachers but to society as whole new questions may arise for societies to consider collectively for instance societies may consider through public debate what is more important to teach the next generation to stick to traditional values or to have more and better high achievers the question is not easy to answer and may not have one comprehensive answer having higher achieving students may result in higher productivity and economic competiveness dropping traditional values may involve changing cultural identity particularly in highly religious countries this may be an important issue nevertheless the findings add only a small brick to what should be a more sophisticated explanation of how cultural factors impact on student achievement to be investigated by future research considering just the impact of parental values fails to properly predict the success of asian education systems in clssas tests other measures of cultural values should be included in more sophisticated models in terms of future research directions the impact of social values particularly parental values could be considered in other several fields one of them is school performance for immigrant children and secondgeneration migrants if school achievement depends on cultural contexts it might be the case that the culture of origin and the one of the host society mix up in determining the achievements of these children beyond language barriers and the status of origin family particularizing the assumptions of the segmented assimilation theory for the case of educational achievements as measured through the clssas scores may be a topic for future research gustafsson points out the need to control for as many possible explanatory variables as possible when seeking to explain the crosscountry variation of student achievement in the clssas scores this may also be the case for further validating the findings of this study three different levels would be necessary to achieve this first more indicators for culture are necessary as this paper reduces them to childrearing values the second strategy is to add to the model curriculumrelated indicators the average workingtime of the students and teacher quality such indicators were not easily available or computable in a comparative analysis of the 67 societies included in this 244 voicu achievements social values study this paper focused on betweencountry differences the third strategy would be to extend it and explain differences within countries as well reynolds et al point out that regardless of the societal context many factors that determine education outcomes are similar acrosscountries but the detail of how school level concepts play out within countries is different between countries could social values be part of the contextual elements that change the impact of other factors in order to assess this would require controlling for individuallevel classroomlevel and schoollevel characteristics communitylevel variables including social values should also be considered since societies are not necessarily homogeneous such vast contextualization would allow verifying if the basic schooling rules change or not when context changes notes 1 using various other techniques of analysis on the evs 2008 dataset rabušic reported similar findings 2 data was retrieved from the arda dataset 3 albania algeria argentina armenia australia austria belgium brazil bulgaria canada chile colombia croatia cyprus czech republic denmark egypt el salvador estonia finland france germany ghana greece hong kong hungary iceland indonesia iran ireland israel italy japan jordan korea kyrgyzstan latvia lithuania luxembourg malaysia malta mexico morocco netherlands new zealand norway peru philippines poland portugal romania russian federation saudi arabia singapore slovak republic slovenia south africa spain sweden switzerland thailand trinidad and tobago turkey ukraine united kingdom united states uruguay in the cases of belgium and the uk the achievement indicators as well as the survey characteristics refer to flanders and wallonia and to scotland and england and wales respectively for all other indicators only nationwide figures were available therefore i have treated such countryrise international journal of sociology of education 2 245 survey pairs as nested in belgium respectively the uk when considering the country

this paper looks at countryaverage results in surveys of studentachievements like pisa pirls or timss as other recent papers do i advance the idea that the betweencountries differences are determined by cultural factors focusing on the macrolevel i discuss social values as part of the contextual determinants for student achievement values are defining features of the unwritten but powerful hidden curriculum and are likely to have strong impact on learning i combine macrodata computed from the values surveys evswvs 19902008 respectively pisa timss and pirls 19992009 crossclassified models assess the effect of dominant social values on student achievement the findings show that a society that places high value on autonomy in child rearing creates an environment for higher student achievement conversely promoting authoritarian values as a priority for younger generations has the opposite effect the effect is even stronger for achievements in mathematics

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introduction despite increasing access to antiretroviral therapy and declining new infections and aidsrelated mortality the number of hivaffected children in africa continues to rise as many people living with hiv lack access to care and treatment and continue to die from the disease there are now 178 million children under the age of 18 years who have lost one or both parents to aids the majority living in subsaharan africa orphaned children have a greater risk of living in households exacerbated by poverty due to lost earnings and increased medical costs of ill family members studies have also linked orphan status with increased vulnerability to hiv orphaned youth are at greater risk of early sexual debut sexual exploitation early pregnancy unprotected sex and transactional sex adolescent orphans also have higher rates of hiv and other sexually transmitted infections compared to nonorphans several factors contribute to orphans heightened risk to hiv these may include the psychological distress of a parents death inadequate caregiver support and lack of money housing and other economic resources particularly financial distress has been shown to motivate vulnerable groups to engage in highrisk survival strategies that increase vulnerability to hiv such as combat sexual violence and sex exchange studies also suggest that the psychological effects of poverty such as loss of hope from limited future aspirations can diminish motivations to avoid exposure to risks including hiv risk yet few programs targeting orphaned youth have addressed economic determinants of hiv vulnerability one approach to reducing hiv risk among orphaned youth is implementing assetbased interventions that economically empower adolescents and their families according to asset theory increasing productive assets of the poor can positively impact individual behaviors including health behaviors by motivating protective attitudes to avoid negative consequences in the future this could mean that enabling poor youth to accumulate economic assets such as savings may encourage more positive beliefs about the future and in turn motivate youth to engage in fewer risk behaviors including sexual risk behaviors to affirm those positive expectations however few studies have examined changes in savings assets and sexual risktaking intentions among orphaned youth who are engaged in economic empowerment interventions such information may inform best practices for reducing hiv risk for orphaned youth through integrated prevention and economic programs this paper examines the effect of the suubimaka project a savingsled economic empowerment intervention in uganda on orphaned adolescents attitudes toward hivpreventive practices including changes in adolescents cash savings and attitudes toward future savings over time to foster economic development and more positive health intentions for adolescents in aidsaffected families the suubimaka project provided matched child savings accounts along with mentoring and hiv prevention and financial education csas have received increasing attention as a mechanism to improve youth asset development and family economicstrengthening without the financial risks associated with loan debt however the impact of savingsled interventions through csas on adolescents perceptions toward sexually protective behaviors over time is less well known methods study design and setting the suubimaka study used a cluster randomized experimental design with three assessments at baseline 12 and 24 months postbaseline in the rakai and masaka districts the two districts are heavily affected by poverty and have high hiv prevalence rates of 85 and 10 respectively compared to the national average of 65 an estimated two in five children are orphaned to aids each year in the districts despite increasing coverage of art the majority of ugandan youth have limited access to formal financial services sample three hundred and fortysix orphaned adolescents and their primary caregivers were enrolled in the study adolescents were eligible to participate if they had lost one or both biological parents to aids were enrolled in the last two years of primary school and were living within a family not an institution eligible adolescents were selected from 10 geographically separate public primary schools with similar socioeconomic characteristics study group assignment detailed information on the design and implementation of the suubimaka randomized experiment is published elsewhere in summary participating schools were randomly assigned to one of two study groups intervention or control adolescents in the control group received usual services given to all orphaned children in the region these included counseling services school lunch and scholastic materials adolescents in the control group also received monthly mentoring sessions based on the study teams prior findings that mentorship offers orphaned youth opportunities to develop positive future trajectories adolescents in the intervention group received usual orphan care services plus monthly mentoring financial education and a matched csa held in the adolescent orphans name accumulated savings in the csas were matched at a ratio of 21 during the 12month intervention period with a match limit equivalent to us 10 a month kept separate from the adolescents own csa outcomes the primary outcomes of this analysis were adolescents cash savings attitudes toward savings and attitudes toward hivpreventive behaviors adolescents cash savings were measured according to csa cash deposits and other noncsa savings deposits into csas were calculated monthly from bankobtained financial statements and did not include the studymatch provided to adolescents in separate savings accounts the amount of other cash savings such as at a bank credit union or with a caregiverguardian was assessed during a 90minute survey administered by trained ugandan interviewers at each of studys three time periods baseline 12 months postbaseline and 24 months postbaseline which corresponded to a oneyear postintervention assessment adolescents were asked if they had money saved anywhere else and if so how much a combined savings amount was calculated based on the total csa deposits and reported other savings all values were recorded in ugandan shillings and converted to united states dollars using a timeappropriate standard exchange rate attitudes toward savings were measured in two ways importance of saving and confidence in ability to save in the future importance of saving was assessed for six goals relating to education family business vocational training familial assistance buying an animal for income generation or moving into ones own home adolescents were asked to state the importance of each savings goal and how confident they were in their ability to save for each goal affirmative responses of verysomewhat important and very somewhat confident were coded as 1 nonaffirming responses of not verynot important and not verynot confident were coded as 0 a total savings attitudinal score was then calculated based on the sum of affirmative responses for the 12 savings items higher composite scores indicated more positive attitudes toward savings hivprevention attitudes were assessed across five statements relating to adolescents perceived risk to hiv infection acceptability of condom use acceptability of sexual abstinence or delayed initiation of sex to avoid hiv infection condom use with main sexual partners and consistent condom use over time affirmative responses of strongly somewhat agree were coded as 1 and stronglysomewhat disagree were coded as 0 a total hivprevention attitudinal score was similarly calculated for the sum of affirmative responses to the five prevention items where higher composite scores indicated higher sexually protective attitudes all attitudinal items were adapted for ugandan adolescents using previously tested instruments including among youth in uganda and south africa analysis two sample tests of proportions ttests and chisquare statistics were used to examine baseline demographic characteristics by study group and withingroup differences in the distribution of accumulated savings and attitudinal items by time period and study group data were hierarchically structured as observations that were nested within individuals who were nested within schools requiring a multilevel approach mixedeffects linear and logistic regression models with an interaction term of study group and time were used to examine differences in accumulated savings and in attitudinal changes over time in the intervention group as compared to the control group random effects were incorporated to correct for unmeasured schooland individuallevel characteristics and fixed effects were included for measured demographic characteristics stata was used for all analyses with a p 05 level of statistical significance results savings and savings attitudes sample characteristics are summarized in table 1 in terms of adolescents savings there were no statistically significant differences in the mean baseline cash savings in the intervention versus control groups the mean total csa deposits significantly increased in the intervention group from baseline to 12 months and increased from 12 to 24 months although not statistically significant intervention adolescents also had significant increases in total other savings from baseline to 12 months and from 12 to 24 months prior to the intervention 20 and 18 of adolescents in the intervention and control groups respectively had any cash savings no adolescents in either group had savings in csas at baseline at 24 months 92 of intervention adolescents had accumulated savings compared to 43 in the control orphaned adolescents most commonly valued at baseline saving goals related to money for ones education helping ones family out and buying an animal for income generation confidence in ones ability to save money was the highest for education money to buy an animal and to help ones family the mean savings score at baseline was 105 for intervention adolescents and 109 for the control group the baseline proportion of adolescents with a maximum savings score of 12 was 469 and 569 in intervention and control groups respectively the mean savings attitudinal score significantly increased in the intervention group from baseline to 12 months but significantly dropped from 12 to 24 months resulting in a significant net increase of 05 points p 01 the largest changes over time in savings goals for intervention adolescents were the proportion of adolescents valuing saving for money to buy a home pursue vocational training and start a family business significant increases were also observed in the proportion of adolescents with a maximum savings score from baseline to 12 months in the intervention and control groups but were attenuated by significant declines from 12 to 24 months hivprevention attitudes hivprevention attitudinal scores at baseline were low to moderate in both the intervention and control groups the baseline proportion of adolescents with a maximum prevention score of 5 was 156 and 275 respectively the most frequently affirmed hivprevention attitudes at baseline were perceived risk of hiv sexual abstinence or delayed initiation and consistent condom use adolescents least affirmed using condoms with main sex partners the mean hivprevention attitudinal score significantly increased in the intervention group from baseline to 12 months and from 12 to 24 months resulting in a significant net increase of 10 point affirmations were most commonly toward perceived hiv risk sexual abstinence or postponement to avoid hiv and consistent condom use a smaller but significant net change was observed in the mean hivprevention scores in the control group as a result of a significant gain at 12 months which was attenuated by a decline at 24 months adjusted effect of suubimaka intervention in adjusted models intervention adolescents had an average significant increase of us1232 in csa deposits per time period and an average significant increase of us1500 in combined savings per time period adjusting for changes over time in the control group there were no differences in baseline csa deposits or combined savings by study group and no significant changes over time in the control group in csa deposits or combined savings mean savings attitudinal scores at baseline were significantly lower in the intervention group as compared to the control group however adolescents in the intervention group had an average relative increase of 0252 points per time period compared to adolescents in the control group where no significant time effect was observed intervention adolescents had 35 greater odds of having a maximum savings attitudinal score over time compared to the control group although this trend was only marginally significant mean adjusted scores for hivprevention attitudes were comparable between intervention and control at baseline with no significant group effect however significant time and group by time effects were observed there was an average significant relative increase of 0189 points in hivprevention scores per time period among intervention adolescents adjusting for significant changes over time in the control group adolescents in the intervention group also had 2017 significantly greater odds of having a maximum hivprevention score over time adjusting for significant changes over time in the control group discussion these findings suggest that in resourcepoor communities a savingsled economic empowerment intervention can expand orphaned adolescents financial resources and positively impact attitudes toward future economic goals and attitudes toward hivpreventive practices over the twoyear assessment period adolescents participating in the suubimaka project significantly increased their cash deposits in registered csas and also reported higher other savings compared to orphaned adolescents in the control group these financial gains were coupled with more positive attitudes toward saving for the future and more positive attitudes toward engaging in sexually protective behaviors to avoid hiv infection the largest improvements were observed during the interventions active phase adolescents cash savings and hivprotective attitudes also continued to increase in the year following the intervention although adolescents value placed on savings and confidence in their ability to save decreased after the interventions match incentives ceased one important implication is that these findings support the premise proposed by asset theory that increasing vulnerable youths assets or savings in this case would encourage more positive beliefs about the future which in turn would result in more healthful and selfprotective intentions our results suggest that the suubimaka project may have enabled orphaned adolescents to identify tangible goals toward creating a more positive future that included both improving their economic situation and avoiding further negative consequences of hiv and aids all enrolled youth had experienced the death of one or both parents due to aids however participation in the suubimaka project appeared to raise awareness on ways to avoid hiv infection and provide actual economic means to pursue opportunities shown to reduce hiv risk such as education such findings are consistent likewise with studies that have shown that youthled savings as a form of economic empowerment can decrease risky sexual attitudes and behaviors by alternating the economic contexts contributing to risk the second important implication relates to the observation that the largest changes in hivprevention attitudes were regarding recognition of hiv as a risk factor in adolescents communities and increased endorsement of safer sex practices such as consistent condom use these changes were coupled with the largest changes in savings goals for a family business vocational training and purchase of a home adolescents potentially perceived being able to financially support and shelter themselves and their families with the requisite skills to do so as the most essential economic capabilities reaching these goals may also have been associated with increased selfefficacy to avoid unprotected sex as a result of sexually exploitive housing or incomeearning arrangements other studies have demonstrated the importance of housing for hiv prevention there is also a growing body of literature on the efficacy of incomegenerating activities to minimize economic determinants of hiv among youth findings from the suubimaka project suggest that enabling adolescents to increase their financial assets through formal savings initiatives is an important step in youths broader pathway to overcome the economic shocks experienced by youth and families made vulnerable due to hiv in addition the continued growth of intervention adolescents cash savings and hivpreventive attitudinal scores implies that savingsled economic empowerment initiatives for orphaned youth may have lasting effects after the intervention activities are completed at the same time the decline in intervention adolescents confidence to save suggests that ongoing efforts are still needed to support continued economic growth in the absence of the interventions matched savings and educational workshops adolescents may have perceived a loss of support that influenced their perceptions toward saving in the future our analysis measured attitudes toward sexual risktaking rather than sexual behaviors since prior research with this population indicated low rates of sexual activity however the transitional period from adolescence to young adulthood is one of the riskiest periods for hiv acquisition motivating orphaned adolescents to avoid hiv through ongoing engagement both prior to and at the start of sexual activity will be crucial our suubimaka study found that even at relatively young ages adolescents at baseline had lower awareness of hiv risk and affirmed several highrisk sexual behaviors integrated economic and preventionfocused programs for orphaned youth are needed to provide longterm support to mitigate hiv vulnerabilities over time limitations the study was limited by inclusion only of adolescent orphans enrolled in school and is therefore not representative of poorer orphans who did not attend school the high agreement across some attitudinal items may have introduced a ceiling effect which limited the studys detection of further attitudinal shifts in addition attitudes toward risky sexual practices are important precursors to behavior but were not direct measures of behavior conclusion this study contributes to the body of knowledge regarding care and support for orphaned youth by demonstrating that in resourcepoor settings a savingsled economic empowerment intervention can increase orphaned adolescents financial resources and positively impact youths attitudes toward future economic goals and hivpreventive behaviors however to minimize hiv risk throughout the adolescent and young adult periods more effort is needed to develop longterm strategies that economically strengthen youth and their families csa deposits and other savings among orphaned adolescents at baseline 12 months and 24 months postbaseline by study group table 3 proportion of orphaned adolescents reporting affirmative attitudes toward savings and hivpreventive behaviors at baseline 12 months and 24 months postbaseline by study group table 4 changes in orphaned adolescent savings and attitudinal scores toward savings and hivpreventive behaviors with estimated effect of group time and group by time interactions using mixed linear and logistic regression models

improving economic resources of impoverished youth may alter intentions to engage in sexual risk behaviors by motivating positive future planning to avoid hiv risk and by altering economic contexts contributing to hiv risk yet few studies have examined the effect of economicstrengthening on economic and sexual behaviors of orphaned youth despite high poverty and high hiv infection in this population hierarchal longitudinal regressions were used to examine the effect of a savingsled economic empowerment intervention the suubimaka project on changes in orphaned adolescents cash savings and attitudes toward savings and hivpreventive practices over time we randomized 346 ugandan adolescents aged 1017 years to either the control group receiving usual orphan care plus mentoring n 167 or the intervention group receiving usual orphan care plus mentoring financial education and matched savings accounts n 179 assessments were conducted at baseline 12 and 24 months results indicated that intervention adolescents significantly increased their cash savings over time b us1232 ±112 p 001 compared to adolescents in the control group at 24 months postbaseline 92 of intervention adolescents had accumulated savings compared to 43 in the control group p 001 the largest changes in savings goals were the proportion of intervention adolescents valuing saving for money to buy a home δ t1t0 149 p 001 pursue vocational training δ t1t0 88 p 01 and start a business t1t0 67 p 01 intervention adolescents also had a significant relative increase over time in hivpreventive attitudinal scores b 019 ±009 p 05 most commonly toward perceived risk of hiv 958 n 159 sexual abstinence or postponement 916 n 152 and consistent condom use 934 n 144 in addition intervention adolescents had 2017 significantly greater odds of a maximum hivprevention score or 2017 95 ci 143284 to minimize hiv risk throughout the adolescent and young adult periods longterm strategies are needed to integrate youth economic development including savings and income generation with ageappropriate combination prevention interventions

19846_0

background unsafe abortion continues to be a leading cause of maternal mortality and morbidity particularly where abortion is legally restricted attributable to 47132 of maternal deaths globally each year 1 almost half of abortions worldwide are considered unsafe meaning the procedure was not conducted by a trained provider using recommended methods 2 unsafe abortions are especially high in lowresource settings in subsaharan africa about three quarters of abortions are unsafe contributing to an annual casefatality rate of 185 maternal deaths per 100000 abortions which is higher than any other region and at least tenfold higher than the rate in highresource settings 3 heterogeneity in casefatality rates is a result of differences in healthcare infrastructure and specifically the availability of safe abortion care 4 sac is an essential component of sexual and reproductive health services enabling women to safely terminate unwanted pregnancies and treat complications that may arise from unsafe abortion while most countries in ssa have highly or moderately restrictive abortion laws that either prohibit or only allow the procedure to save a womans life 2 all have pledged to provide quality postabortion care a component of sac to treat unsafe abortion complications as part of the 1994 international conference on population and development 5 pac services can address incomplete abortions treat lifethreatening complications and provide postabortion contraception to help prevent future unwanted pregnancies 36 in ssa pac services have expanded in many countries in recent years yet provision remains inadequate 7 8 9 10 11 and service quality greatly varies across settings 12 evaluating health systems ability to provide safe abortion and pac must go beyond an assessment of the service availability to include an evaluation of servicespecific readiness to deliver quality care the first efforts to measure servicespecific readiness were developed by the united nations via signal functions for emergency obstetric care a set of structural and process indicators intended to measure the ability to provide different levels of care to properly address obstetric complications 13 healy and colleagues first applied the signal functions framework to sac highlighting elements necessary for facilities to provide basic sac at the primary level and additional elements required for comprehensive sac at the referral level 14 basic sac consists of safe abortion and pac services for pregnancies less than 12 weeks gestation in addition to postabortion contraception and comprehensive sac consists of all basic sac functions for pregnancies more than 12 weeks gestation as well as provision of blood transfusions and major abdominal surgery this model has since been adopted to assess abortion and pac service readiness in a few subsaharan african countries with studies in general finding low levels of readiness across settings 7 9 10 11 15 a multicountry analysis by owolabi et al found that less than 10 of primary facilities were ready to provide basic pac in five out of seven ssa countries the proportion of referral facilities ready to provide comprehensive pac was slightly higher ranging from 23 to 58 10 in 2018 the democratic republic of congo decriminalized abortion by codifying their ratification of the african unions maputo protocol into law 4 abortion is now legal in cases where continuing the pregnancy endangers the mental and physical health of the woman the ministry of health approved the corresponding updated comprehensive abortion care guidelines in 2020 which included allowances for task shifting to midlevel providers at any facility with adequate equipment thus broadening the cadre of abortion providers and facilities that could offer sac services in 2020 the country also took a critical step in expanding access to medication that address supply chain challenges may improve facility readiness to provide abortion care services and further efforts are needed to narrow the gap in accessibility especially among poor women from rural settings abortion with the inclusion of mifepristone in the essential medicines list the world health organization recommends the use of mifepristone and misoprostol as a combined regimen or misoprostol alone for medical abortion 16 keywords abortion postabortion care democratic republic of congo facility data survey even before this reform abortions were common many of which were unsafe and resulted in complications requiring pac results from the 2016 kinshasa abortion study estimated 146700 pregnancy terminations in kinshasa alone in 2016 approximately 34 of which were likely to have involved complications requiring treatment at a health facility 17 in addition almost onefourth of women who had abortions did not receive care from a health provider while the quality of the pac the other 77 received was uncertain results from a recent study in the drc assessing national pac services suggest pac availability and readiness were low only 47 and 38 of facilities in kinshasa had all basic and all comprehensive pac signal functions respectively while nationally 37 and 14 of facilities met these standards and only 134 of facilities had misoprostol in stock 15 the authors were not able to evaluate the geographic accessibility of services which is important to determine the extent to which clients who may need services are able to reach them additionally availability has not been examined among facilities since the legal reform though estimates from 2021 suggest abortion incidence is high 105 per 1000 women aged 1549 in kinshasa and 44 per 1000 in the rural province of kongo central 18 approximately onethird and 43 of abortions in kinshasa and kongo central respectively involved a nonrecommended abortion method andor source signaling the continued need for efforts to improve availability of safe termination of pregnancy services and postabortion care for treatment of complications in this postdecriminalization era in the drc 18 examining accessibility in conjunction with the abortion and pac readiness of the nearby facilities can provide a more complete picture of the abortion landscape available to those experiencing an unintended pregnancy in a specific geography the current study seeks to address these gaps and provides a comprehensive examination of the status of abortion services and access in two provinces of the drc kinshasa the capitol and kongo central a rural area using healy et al s sac signal functions framework using multiple data sources we aimed to assess sac availability and facility readiness to provide sac in each province using a representative sample of facilities describe pac and medication abortion provision before and after decriminalization of abortion by facility characteristics and examine disparities in geographic accessibility of facilities providing pac and medication abortion across sociodemographic groups by linking facility data to representative samples of reproductiveaged women in kinshasa and kongo central methods demographic and health survey service provision assessment survey overview we used data from the drc demographic and health survey service provision assessment collected from october 2017 to april 2018 to describe facility readiness for our first aim and to describe pac and medication abortion service provision before the decriminalization of abortion in 2018 for our second aim the spafunded by the united states agency for international development the united states presidents malaria initiative and the global fundis designed to collect information regarding health service availability and delivery within countrywide health systems using five core components the inventory health worker interview newborn resuscitation simulation observation protocols and client exit interview questionnaires the questionnaires were modified for the drc context by the ministry of health 19 data for this analysis was taken from the inventory questionnaire only which asked about the availability of equipment commodities and staff in health facilities using a sampling frame of 12050 health facilities provided by the moh probability proportional to size sampling was used to select 1412 facilities for the spa the resulting sample covered all 26 provinces in the country with an average of 50 facilities in each a total of 1380 facilities participated in the survey the other 32 were in areas of armed conflict at the time of data collection and were therefore not reached we limited our analysis to facilities in kinshasa and kongo central the survey was administered in french to health providers or facility managers by medical professionals who underwent three weeks of interviewer training kinshasa school of public health led the data collection in collaboration with the moh with technical assistance from icf international facility readiness measures for our first aimto describe provincespecific facility readiness for sacwe examined three dimensions of abortion caretermination of pregnancy basic treatment of postabortion complications and comprehensive treatment of postabortion complicationsbased on signal function indicators using dhs spa data as defined by glover and colleagues which they adapted from healy et al s framework 1415 the three dimensions of abortion care and the signal functions used to define readiness for each are presented in table 1 because primary care facilities in the drc are expected to provide longacting reversible contraception if they have trained staff and at minimum sac requires at least one doctor degree nurse or degree midwife for each of the three domains we modified the signal functions framework by requiring the availability of at least one shortacting method and at least one larc for each domain additionally it is important to note that the who recommends the use of vacuum aspiration for surgical abortion or medication abortion for pregnancies up to 14 weeks and for treatment of postabortion complications it suggests that these methods replace dilation and curettage due to safety issues 16 however the spa inventory survey asks about a functioning vacuum aspiration kit or d c kit and these two methods could not be separated in the data hence we included the d c kit in our signal functions despite it no longer being a recommended termination or pac method each signal function indicator was operationalized as a binary variable to denote availability equipment needed to have been observed and recorded as functioning while commodities needed to be observed and with valid expiration date at the time of data collection for the signal function about contraceptive availability at least one shortacting method and at least one larc had to be available services were coded as available if they had been provided in the prior three months finally for staffing if at least one of the provider types needed for basic sac or comprehensive sac was employed or temporarily employed at the facility we considered them available service provision variables were not included in termination of pregnancy or basic pac readiness estimates as other included variables measured the same aspect of care service provision variables were included in the comprehensive pac readiness estimates however as those services are not captured in other variables facilities were considered ready to provide each dimension of abortion caretermination of pregnancy basic treatment of postabortion complications or comprehensive treatment of postabortion complicationsif all their corresponding signal functions were available these facilities categorized as having all signal functions had all four signal functions for termination of pregnancy all seven for basic treatment of postabortion complications and all ten for comprehensive treatment of postabortion complications given that this is an allornothing measure we also generated an additive index weighting each signal function equally for each dimension of abortion care this indexreferred to as a readiness scoreis an estimate that captures the average percent of signal functions for each dimension a facility has given its type managing authority and province this score provides a more nuanced measure of abortion care readiness by allowing us to evaluate how close facilities are to being 100 ready to provide the full range of signal functions comprehensive pac readiness was only assessed among referral facilities service provision measures to present provision of pac and medication abortion for our second aim facilities were considered to provide pac if they performed removal of retained products of conception in the three months prior to the survey and to provide misoprostol if misoprostol was in stock at the facility and observed with at least one unexpired misoprostol tablet performance monitoring for action service delivery point and female surveys survey overview we used data from the performance monitoring for action initiative to describe pac and medication abortion service provision postdecriminalization of abortion in 2018 for our second aim and to examine accessibility of services in kinshasa and kongo central for our third aim pma conducts female household and service delivery point surveys in the drc using resident female interviewers who collect information in their communities on reproductive health services and womens reproductive health history and practices using smartphones full details of the pma initiative including study and sampling design questionnaires and data are available online 20 we used crosssectional female and sdp data from the kinshasa and kongo central phase 3 surveys collected in december 2021april 2022 ksph implemented the survey with technical support and overall project direction from the bill melinda gates institute at the johns hopkins bloomberg school of public health the female survey used a stratified cluster design to generate representative samples at the provincial level samples of 58 and 52 census enumeration areas were drawn separately from master sampling frames for kinshasa and kongo central respectively using probabilities proportional to size all households within the selected ea were mapped and listed and a random selection of 33 households within each ea were invited to participate household heads completed the household interview and all resident women aged 1549 in the selected households were eligible to participate in the facetoface female survey interviews were conducted primarily in french and as needed local dialects using agreed upon oral translations out of 2475 and 1897 women who were eligible to participate in the survey in kinshasa and kongo central respectively 2326 and 1856 completed the female interviews for the sdp survey sampling aimed to include the public facilities that served each ea and up to three private facilities within the ea boundary the private facilities were selected from a list generated by interviewers through mapping and listing and public facilities were identified via a list obtained from local health authorities trained interviewers administered the survey to all identified sdps which included questions about reproductive health service provision commodity stock cost quality of services and other related topics survey respondents were management staff answering on behalf of the facility out of the 229 and 201 sdps selected for in kinshasa and kongo central respectively 197 and 191 completed the survey although pharmacies provide medication abortion pills they were excluded from the analysis as they were not asked about postabortion care or misoprostol and the combination therapy of misoprostol and mifepristone availability in the pma survey the resulting analytical sample included 273 facilities service provision measures to capture provision of services sdp survey respondents were asked which of the following services are provided at this facility facilities were considered to provide pac if they selected postabortion services from the answer options for misoprostol and the combipack respondents were asked is misokare available in the facility for management of postpartum hemorrhage or other gynecologic issues and is makare available in the facility respectively and responded yes or no if the medications were reported as available interviewers recorded whether they were instock and observed instock but not observed or out of stock a facility was considered to provide accessibility measures we linked the sdp and female samples using geospatial data to examine the percentage of women who have access to facilities providing abortion services global positioning system points were taken at the time of each sdp and female interview and each womans distance to any sampled facility and to a facility that provided pac misoprostol or the combipack was calculated in kilometers using euclidean distance a method applied in a similar study exploring accessibility of services 9 four access variables were developed assigning either 0 or 1 to each woman based on whether she had accessdefined as being within a three km distanceto any facility or a facility providing pac misoprostol or the combipack facility type was recorded differently between the two data sources to keep categories uniform across the two data sources the facilities were grouped into referral facilities which included tertiaryprovincial hospital general reference hospital hospitalclinic and reference health center categories in the spa and hospital health clinic and other in the sdp and primary facilities which include health center in the spa and health center and health post in the sdp facilities were also grouped by management authority public facilities included those managed by the government whereas private facilities were managed by nongovernmental organizations forprofitprivate organizations or faithbased organizations analysis our first aim was to describe abortion service readiness in representative samples of dhs spa facilities in kinshasa and kongo central we first examined distributions of facility characteristics in each province we estimated the percentage of facilities ready to provide each of the signal functions overall and by facility type in each province we then calculated the percentage of facilities ready to provide all the signal functions under each dimension and generated readiness scores for termination of pregnancy basic and comprehensive care separately by facility type and managing authority in each province while referral and primary facilities were included in the denominator for both readiness measures of the termination of pregnancy and basic pac domains only referral facilities were included in the calculations for comprehensive pac the descriptive analyses were weighted to account for the probability of selection and nonresponse our second aim was to examine pac and medication abortion provision before and after the decriminalization of abortion in the drc in 2018 we used the spa data to describe the proportion of facilities providing pac misoprostol and the combipack before decriminalization and the sdp data for after decriminalization we applied poststratification weights to the sdp data to reflect the representative distribution of facilities in the spa within each province provision of the combipack was only calculated using the sdp data because information about mifepristone was not collected in the spa proportions were presented by facility type and managing authority for each province our third aim was to examine accessibility in each province using the linked pma data we described the proportion of women living within three kilometers of facilities that provided pac misoprostol and the combipack by sociodemographic characteristics separately by province sociodemographic characteristics were selected to explore potential relationships with access to services we then ran two multivariable logistic regression models to assess sociodemographic characteristics associated with access to each service one model for kinshasa and another for kongo central in kinshasa due to the almost universal access to pac regression models were run for only misoprostol and combipack accessibility the analysis was weighted to account for the complex survey design and clustering in the female data the analyses were conducted in stata version 16 21 results signal functions and facility readiness to provide abortion services there were 73 facilities in kinshasa and 80 facilities in kongo central in the spa the majority of facilities were primary level in both kinshasa and kongo central most facilities in kinshasa were private while less than half were private in kongo central in both provinces the percent of facilities with all signal functions to provide pregnancy termination basic pac and comprehensive pac was low ranging from 49 to 190 in kinshasa 72 of facilities had all signal functions for pregnancy termination 49 for basic pac and 190 for comprehensive pac under pregnancy termination and basic pac a higher proportion of referral facilities had all signal function components compared to primary facilities in kongo central 72 had all signal functions for pregnancy termination 79 for basic pac and 170 for comprehensive pac like kinshasa referral facilities were more ready than primary facilities under pregnancy termination and basic pac interestingly basic pac was slightly higher in kongo central than kinshasa but the opposite was observed for comprehensive pac despite few facilities in both provinces having all signal function components for the different domains of abortion care many had several components as indicated by the readiness scores in kinshasa termination of pregnancy had the lowest readiness score at 610 of all facilities followed by basic pac the readiness score was highest for comprehensive pac though this was only calculated among referral facilities in kongo central we observed the same pattern 641 for termination of pregnancy 743 for basic pac and 831 for comprehensive pac readiness scores were thus higher across all three abortion care domains for kongo central compared to kinshasa in kongo central the same pattern was observed readiness scores were higher across all three abortion care domains in kongo central compared to kinshasa in both provinces slightly higher readiness scores were observed for public versus private facilities across all domains except for basic pac in kinshasa scores were also higher among referral facilities as compared to primary facilities in both provinces for termination of pregnancy and basic pac certain signal functions were consistently less available within each of the domains of abortion care overall in both kinshasa and kongo central misoprostol was the signal function most missing when assessing readiness to provide pregnancy termination the most missing signal functions for basic pac were injectable antibiotics in kinshasa and having at least one shortand one larc in stock in kongo central for comprehensive pac facilities in both provinces were often missing blood transfusion pac and medication abortion before and after abortion decriminalization differences in the provision of pac and misoprostol before and after abortion was decriminalized in 2018 were observed in both kinshasa and kongo central in kinshasa pac provision postdecriminalization was only slightly higher in referral facilities but lower by 9 in primary facilities compared to pre2018 by managing authority pac was higher by 20 in public facilities but lower by almost 13 in private facilities for misoprostol provision was lower in referral facilities by almost 20 but was double in primary facilities after 2018 misoprostol provision in private facilities was almost the same preand post2018 but in public facilities the proportion post2018was threetimes that of pre2018 in kongo central pac provision was higher by 1620 in both referral and primary facilities after 2018 provision was also more than double in public facilities but lower by about 7 in private facilities misoprostol provision was higher in all facility types and managing authorities by 328 postdecriminalization the combipack was provided by at least one out of four referral facilities in both provinces but in primary facilities only 218 provided it in kinshasa and 122 in kongo central in kinshasa more than double the public facilities were providing the combipack compared to private facilities whereas in kongo central slightly more private facilities provided it than public facilities access to abortion services the pma sdp sample included 37 referral and 110 primary facilities in kinshasa and 22 referral and 104 primary facilities in kongo central in kinshasa most of the facilities in the sample were private whereas in kongo central slightly over half were public access to facilities that provided pac misoprostol and the combipack was almost universal among women in kinshasa but more variable in kongo central across women of different sociodemographic characteristics in kinshasa all women lived within three kilometers of a facility that provided pac and over 89 had access to facilities that provided misoprostol overall nine out of ten women lived near a facility that provided the combipack in kongo central access was more variable with only two in three women living close to a facility providing pac half living near a facility providing misoprostol and one in three living near a facility providing the combipack pac access increased as education attainment and wealth increased similarly proportions of women who were in proximity to facilities that provided misoprostol and the combipack increased as education attainment and wealth increased results for the multivariate logistic regression models of pac misoprostol and combipack accessibility in kinshasa and kongo central are presented in table 7 there was no heterogeneity in pac access in kinshasa since all women lived within three kilometers of a facility providing the service thus we omitted those results for misoprostol age was associated with access in the capitol province women aged 2029 had lower odds 072 95 ci 052099 of living near a facility providing misoprostol than women aged 20 years education and wealth were not significantly associated with living near a facility providing misoprostol or the combipack in rural kongo central we observed more variability in access by sociodemographic groups for all three services although some confidence intervals were very wide age was only significantly associated with access to pac with women aged 2029 years having 067 lower adjusted odds of living near a facility providing pac compared to women who had never attended school women who had higher education had more than four times adjusted odds of living near a facility that provided misoprostol those with secondary and higher education had three to nine times odds of living near a facility that provided the combipack wealth was also associated with access to all three services with the wealthiest women having six to fourteen times greater odds of living near a facility providing pac misoprostol and combipack than the poorest women women in the middle wealth group had more than two times odds of living near a facility providing misoprostol compared to the poorest women discussion our findings show that before the legal reform for access to safe abortion in the drc in 2018 readiness to provide abortion services defined by having all the signal functions for each domain was low in both kinshasa and kongo central however most facilities had many of the signal functions as indicated by their readiness scores facilities mostly faced stock shortages of misoprostol injectable antibiotics and contraception these shortages were more pronounced among primary facilities compared to referral facilities in both provinces comparing spa data with more recent data from the pma initiative to examine differences in service provision after the abortion reform pac and misoprostol provision was higher across facility types and sectors in kongo central but only among public facilities in kinshasa finally while womens access to pac and medication abortion was almost universal in the capitol province after the reform disparities existed in rural areas with access decreasing as education attainment and wealth decreased the low levels of facility readiness for the three abortion service domains are consistent with national findings from glover and colleagues 15 like the results from the national study the limiting factor in achieving full facility readiness to provide safe abortion care in kinshasa and kongo central is primarily stockouts of commoditiesinjectable antibiotics misoprostol and contraception a study of contraceptive availability in kinshasa showed rampant stockouts that were relatively unchanged between 2014 and 2016 22 signaling a persistent challenge in the supply environment to minimize this limitation in the health system investments in solutions focusing on ensuring a wellfunctioning supply chain are needed the shortage of misoprostol stock may also be related to its relatively recent introduction to the countrys essential medicines list in 2012 only five years prior to the spa data collectioncombined with supply chain challenges recent introduction may also explain the low levels of combipack provision given that mifepristone was not registered in the drc until 2020 because both medications were only recently introduced and given the changes in abortion legality in the country health providers may not have had adequate training or be willing to provide these services 15 the low provision of medication abortion is especially pronounced in rural areas than the capitol province and our accessibility results pointed to a greater need among poor women and those of lower education attainment who were least likely to live near a facility offering these services improving accessibility to sac services for poor rural women is likely to improve reproductive health as evidence suggests these populations are most likely to suffer the negative sequelae associated with unsafe abortion and least likely to access treatment for unsafe abortion complications 23 expanding on previous studies describing abortion service availability and facility readiness in the drc this study is the first to present a comprehensive analysis of abortion service availability readiness and accessibility in kinshasa and kongo central including data collected before and after the liberalization of the abortion law 15 by using the dhs spa data we were able to assess facility readiness to provide abortion services using a representative sample of facilities in both provinces highlighting individual signal functions that are most often not available and required improvements in supply chains in addition the inclusion of two readiness measures enabled us to examine facility readiness to provide quality care in different ways whether facilities were fully ready versus how ready they were along a continuous spectrum the latter providing a more nuanced assessment of readiness furthermore using the representative sample of facilities in the dhs spa we were able to adjust the more recent sdp sample to reflect the distribution in the health care system and assess differences in the provision of services after the drc made policy changes for access to safe abortion demonstrating which facility type sector and province experienced improvements over time lastly by linking facility data to a representative sample of women we were able to evaluate disparities in abortion service access as defined by living in proximity to a facility providing pac and medication abortion among different sociodemographic groups however this study is not without limitations first not all signal function indicators were completely aligned with the data captured in the spa survey having a functioning vacuum aspirator for examplewhich is recommended by the who for surgical abortion of pregnancies up to 14 weeks and for treatment of postabortion complicationswas not measured on its own in the inventory survey instead it was combined with the d c kit which is no longer recommended by the who due to issues with safety 16 however results from the 2016 kinshasa abortion study health professionals survey found that contrary to best practices d c was performed by health professionals to terminate pregnancies and was the most common treatment for women receiving postabortion care 24 therefore if d c kits are still common in facilities our measure may be higher than if we captured vacuum aspirators alone additionally the spa inventory did not collect any information on mifepristone stock at facilities despite it being added to the who essential medicines list in 2005 after who guidelines recommended the use of the combination regimen for medication abortion 25 mifepristone was registered in the drc more than two years after the 20172018 dhs spa and so was not included in the survey therefore we were only able to look at the availability of misoprostol and not the combipack in the spa the spa survey also collected information on the number of health providers at different occupational levels yet did not include any data on specific abortion care training for these positions this restricted our ability to assess staff readiness based only on the presence of occupational categories at facilities and not on the capacity of staff to perform the necessary abortion procedures lastly the spa dataset only enabled us to examine signal functions and facility readiness right before the codification of the maputo protocol in 2018 ideally we would have used the pma data for a more recent status of these measures but the data were not collected in the sdp survey additional limitations were present in the pma data first our analysis did not include pharmacies because they were not asked abortionservicerelated questions we may have eliminated a major source of medication abortion with their exclusion as findings from the kinshasa abortion study confirmed that women who relied on medication abortion often obtained them from pharmacies 24 second we analyzed access to pac or medication abortion using proximity to a facility defined as less than or equal to three kilometers but our narrow definition of access excludes other factors that may influence womens access to services such as costs transportation availability and knowledge of services provided in addition women may not necessarily seek services at the nearest facility opting instead for farther facilities that offer better service quality studies evaluating womens facility choice found that they consider many factors when deciding where to go for healthcare including health provider competency and bias availability of supplies level of discretion afforded and cost of services 26 27 28 29 finally there are limitations with the selection of facilities for the sdp survey selection only included up to three private facilities in each ea and the public facilities that are assigned to serve that ea so we may have failed to include nearby facilities that either were outside of the ea boundary or did not serve that ea but may have been less than three kilometers from some women in the sample in addition selection was not based on a facility sampling frame instead facilities were selected if they served the nationally representative sample of women for the female questionnaire because women were selected using probability proportional to size sampling facilities that served larger population were more likely to be selected conclusion our findings highlight specific areas that can be targeted by interventions aiming to improve facility provision of and access to abortion services in the drc facilities have many of the components needed to provide safe abortion care services but shortages in commodities limit their ability to be fully ready to provide services supply chain evaluations should be considered to better understand the low levels of these commodities and offer solutions to improve their availability across all facility levels that are supposed to provide services while there was an overall improvement in the provision of services particularly in kongo central after the maputo protocol was codified into law our accessibility analysis showed disparities in access across sociodemographic groups efforts to improve delivery of abortion services should focus on narrowing the gap in access particularly trying to understand barriers among disadvantaged groups in rural areas data availability pma data and materials for this study will be posted publicly at pmadataorg once available online anyone can access after completing a brief request form at dhs data are available online at list of abbreviations competing interests the authors declare no competing interests

background the democratic republic of congo drc legalized abortion in 2018 to preserve health and pledged to provide quality postabortion care pac yet little is known about the availability of abortion care services and if facilities are prepared to provide them even less is known about the accessibility of these services using facility and populationbased data in kinshasa and kongo central this study examined the availability of abortion services readiness of facilities to provide them and inequities in access methods data on 153 facilities from the 20172018 drc demographic and health survey service provision assessment spa were used to examine signal functions and readiness of facilities to provide services across three abortion care domains termination of pregnancy basic treatment of abortion complications and comprehensive treatment of abortion complications to examine pac and medication abortion provision before and after abortion decriminalization we compared estimates from the 20172018 spa facilities to estimates from the performance monitoring for action pma data collected in 2021 n 388 lastly we assessed proximity to pac and medication abortion using pma by geospatially linking facilities to representative samples of 2326 and 1856 women in kinshasa and kongo central respectivelyfew facilities had all the signal functions under each abortion care domain but most facilities had many of the signal functions overall readiness scores were 60 for each domain in general readiness was higher among referral facilities compared to primary facilities the main barriers to facility readiness were stock shortages of misoprostol injectable antibiotics and contraception overall provision of services was higher postdecriminalization access to facilities providing pac and medication abortion was almost universal in urban kinshasa but patterns in rural kongo central showed a positive association with education attainment and wealthmost facilities had many of the necessary signal functions to provide abortion services but the majority experienced challenges with commodity availability inequities in accessibility of services also existed interventions

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introduction type 2 diabetes has drastically risen in the us over the last decade disproportionately affecting ethnic minority populations the mean prevalence among adult minority populations with diabetes is 217 in comparison to 113 among nonhispanic whites 1 although type 2 diabetes has historically been coined as adultonset diabetes it has increased by 305 in youth aged 1019 years between 2001 and 2009 2 among new cases of diabetes among youth the vast majority of subtypes in white youth represent type 1 in contrast among minority youth onehalf to threequarters of new cases represent type 2 3 there is an urgent need to engage atrisk youth in preventing an illness that poses substantial risks for disabling complications prevention efforts have primarily focused on individual behaviors and personal responsibility however encouraging youth to engage in healthy eating and physical activity is challenging a limitation of previous approaches is an overemphasis on longterm health outcomes as the primary source of motivation this focus on individual behavior change despite the importance of the social economic and environmental context in determining behaviors reinforces the notion of individual shame and blame and contributes to a lack of effectiveness in engaging youth creating messages that align with values held closely by adolescents are much more likely to resonate with them and effect change 4 although adolescents might not be motivated by their health in the distant future they are certainly not apathetic while they are often regarded as being vulnerable to hedonism they do have strong drives towards eudaimonism adolescents aspire to feel like socially conscious autonomous people worthy of approval by their peers and others whose opinions they respect 4 such values include social justice autonomy and defiance against authority for example the kinds of messages previously developed for the antitobacco truth campaignthose that vilify the tobacco industry and its corporate henchmen and call out the targeting of minority consumersrepresent attempts to tap into adolescent values of defiance against authority the expression of autonomy and social justice moving adolescents towards healthier behaviors such as not consuming soda or junk food can become a way to stick it to the man and rebel against industry executives authority in the bigger picture campaign minority youth poets have created content that enables youth to see the the bigger picture eg the social and environmental forces that create and perpetuate diabetes and motivates their peers to take a stand against injustice eliciting righteous anger and action for social change 56 a recent study of us media coverage related to type 2 diabetes revealed that only 12 mentioned social or environmental contributors the vast majority focus on individual choices unhealthy behaviors or genetics 7 the bigger picture differs from traditional diabetes prevention campaigns in that it is a countermarketing public health literacy campaign that harnesses minority youthcreated spokenword performance pieces produced as short films countermarketing campaigns use health communications strategies to reduce the demand for unhealthy products by exposing the motives of their producers and portraying their marketing activities as outside the boundaries of civilized corporate behavior tbp brings together the arts with public health to create authentic and compelling content that speaks to and resonates with youth values of defiance against authority and the struggle for social justice we have previously described the development and implementation of tbp 8 while tbp process is curated by spoken word poet mentors and health communication experts the creative work itself is generated by minority youth poets tbp encourages young viewers to take a step back and observe and reflect on the larger social structural and environmental forces that shape behavior and determine disease risk psas get disseminated via live high school assemblies and workshops and social media with the goal of increasing public health literacy and positively influencing behavioral norms 49 individual health literacy focuses solely on improving knowledge and capacity so the individual makes better health decisions 10 and consists of three dimensions functional interactive and critical public health literacy is the degree to which individuals and groups can obtain process understand evaluate and act upon information needed to make public health decisions that benefit the community 11 this construct consists of three dimensionsconceptual foundations critical skills and civic orientationand differs from the construct of individual health literacy public health literacy contextualizes individuals as parts of a whole in the social ecology engaging more stakeholders in advocating for communitylevel changes to address population health concerns in combination both individual and public health literacy provide a broader framework to promote health and reduce health disparities understanding the degree to which lowincome youth integrate tbp as conveying individual vs public health literacy messages will likely determine the effectiveness of the campaign in addition examining whether the context in which youth are exposed and respond to tbp messages has important implications as to how to best deliver refine and amplify tbp messages to achieve the campaigns goals materials and methods research design since the focus of tbp is to shift discourse around type 2 diabetes in youth away from individual fault or deficits toward a more systemic socioecological framework we performed a nonexperimental qualitative study to examine whether and how tbp campaign psas advances health literacy among a sample of lowincome minority youth sample we recruited a convenience sample from youth radio identifying youth at the beginning of their health internship program youth radio is a nonprofit media production organization in oakland ca that engages and trains lowincome and minority youth in media literacy in late 2014 the program coordinator asked her 13 health interns to participate in an interactive project on type 2 diabetes the ucsf study team offered these youth a 10 gift certificate to partake in a 1h viewing of tbp psas followed by a postviewing questionnaire and a focus group discussion the study was approved by the ucsf institutional review board we enrolled 10 of 13 potentially eligible youth aged 1520 they included 6 females and 4 males who were currently in high school or had completed high school education within the last 2 years six participants selfidentified as african american 2 as white 1 as mixed race and 1 as middle eastern intervention we first delivered a 30min nonfacilitated presentation that included 9 representative tbp psas genres of psas ranged from comedic parody to suspense each psa conveyed a central public health literacy message related to type 2 diabetes table 1 trying to be healthy in an environment not conducive to healthy living feels like living in a nightmare suspense 29 key quote our addiction to fast food is real so much so its odd when we wanna be healthy one participant did not respond 19 key quote how its hard to escape diabetes but possible 19 key quote about unhealthy eating habits 59 key quote that theres good and bad people 9 the corner inaccessibility of healthy food options in lowincome neighborhoods makes choice an illusion testimonial 38 key quote corner store convenience boost risks of diabetes two participants did not respond to questions pertaining to this video 18 key quote the dilemma between junk food and healthy food 28 key quote all that unhealthy food is leading to diabetes 28 key quote it was about a dude at a grocery store a all films can be found at participant responses to tbp messages immediately after watching each psa participants completed a questionnaire with openended questions that asked participants for each psa to reflect on what they felt the psa was about what the biggest lesson of the psa was what they liked or did not like about the psa whether the psa changed how they felt about type 2 diabetes and what changes they would make to the psa if any because these questions were posed after each of the 9 videos respondents were provided with up to 30 min of nonviewing time to complete the questionnaire the youth radio coordinator a masterslevel experience facilitator then conducted a 1h focus group that largely mirrored the survey questions eliciting participant reflections with respect to specific and general opinions of the psas understandings about type 2 diabetes and intentions to change behavior including barriers to and facilitators of change moderatorguided facilitation provided a safe and confidential forum for participants to openly discuss their personal experiences and perspectives maximizing opportunities to share a wide range of positive and negative opinions during the focus group brief video clips of all 9 psas were shown to participants as reminders to trigger conversation the focus group was audiorecorded and transcribed analysis with respect to individual responses to each tbp psa we evaluated the degree to which participants integrated public health messages based on their responses to the questions what was the video about and what was the biggest lesson responses were grouped into one of four categories participants fully integrated the psas intended message discussed a theme related but not central to the psas intended message expressed an unrelated message or did not perceive a message we also mapped responses into the broader constructs of individual health literacy and public health literacy identifying salient themes within the relevant dimensions of each form of health literacy because we were interested in gaining insights into minority youth responses to the content of the psas from this public health communication campaign the qualitative approach that we applied to the questionnaire and focus group data was exploratory and formative insofar as we did not have a specific hypothesis we employed content analysis to identify emergent themes 1213 in a subsequent analytic phase based on the overarching objective of the communication campaign and the patterns of youth responses that emerged we mapped these themes onto distinct domains derived from the health literacy construct members of the research team one a predoctoral student in medicine and the other a masterslevel communication expertindependently coded the openended questionnaire responses and the transcripts to identify recurring themes iterative discussions amongst the study investigators including the principal investigator a health communication scientist and public health physician then led to a final set of overarching predominant public health and sociological themes finally based on the conceptual frameworks of nutbeam 10 and freedman 11 relevant coded statements were independently assigned by jt and sf into one of three dimensions of individual health literacy or three dimensions of public health literacy respectively any disagreements as to the assignment of these statements were adjudicated by ds who was blinded as to the source of the statements we first coded the questionnaires and the focus group transcript linebyline categorizing responses by themes of the lowest complexity we then organized the preliminary set of themes under overarching themes to be considered an overarching theme it needed to have at least 3 associated responses since the focus group discussion was often characterized by dualistic and competing perspectives on lived experiences as they relate to type 2 diabetes we also coded responses that reflected these tensions again we mapped responses into the broader constructs of individual and public health literacy identifying salient themes within health literacy dimensions finally as psas can be viewed in vivo by individuals alone or in a facilitated group setting we assessed differences in patterns of response across settings to compare the individual vs group setting responses we organized coded statements pertaining to particular constructs and dimensions of health literacy in order of frequency determined by counts of coded statements and calculated as a percentage of total coded statements results participants integration of central messages of psas from postviewing questionnaires the percentage of participants who fully recognized a psas intended public health message ranged from 222 to 70 with the psa entitled quantum field being the least and the psa entitled sole mate being the most understood on average more participants postpsa questionnaire responses exhibited a complete understanding of the public health message a minority of participants expressed a theme related but not central to the public health message or described an unrelated public health message or no message prominent public health themes four prominent themes related to factors associated with diabetes risk emerged from the initial coding framework of both individual and focus group responses individual behaviors built environment financial barriers and institutional factors below we describe these themes illustrative participant quotes can be found in table 2 individual behaviors proponents of this notion described how individuals have the choice to be healthyto eat healthy and exerciseoften assuming that they are in full control of their own health and wellbeing built environment some participants expressed understanding that type 2 diabetes is not simply a result of individual behaviors and choices but can also result from structural forces in the built environment 14 structural determinants included poor access to healthy food and drink options eg the dearth of grocery stores and farmers markets vs excess of corner stores and fast food establishments unsafe neighborhoods and insufficient recreational space for physical activity financial barriers and competing demands in the context of poverty and food insecurity individuals eating habits and choices are limited adults in lowincome families are also often pressed for time making cooking challenging therefore some participants reported how youth often resort to highcaloric nutrientdeficient food and beverages from the corner store for a fast hunger fix at a fraction of the price of healthier options institutional factors deceptive marketing barriers at the institutional level involve deceptive marketing by profithungry food and beverage industries and lack of government regulation participants reported an understanding of how the food and beverage industry employs false advertising to sell unhealthy products to youth i want us to leave out of here with help and whatever we can powerlessness vs empowerment its much bigger than our own so we cant andi hate to say itthat we cant really do anything we write as many letters to the government as we want but theyre not going to take these liquor stores that have been here since i was a child im sure somebody complained about them theyre still here im going to go tell somebody because it seems likei didnt used to know why the life expectancy of african american people was shorter that white people but now that look at all the factors it starting to make sense to me so if you tell somebody else maybe they want to eat healthier or something like that or maybe they have a better idea than me start a garden in your community we have fresh produce in our garden i mean we have in our garden fresh produce id say thats what i can think of like communitywise cultural determinism vs cultural relativism theres a lot of cultures that have things that americans will look at and be like ugh why would you eat that but thats their culture regardless if its healthy or not so its kind of for black people thats our culture so for you to say its unhealthy its so offensive i dont like that for the same reason it was kind of tedious too and its like okay we know black people know that its not usually the healthiest thing to eat but thats culture underlying sociological themes in addition to these surfacelevel themes we identified three additional themes that reflected the underlying sociopolitical tensions faced by these youth when responding to the psas these were more complex themes that likely reflected their lived experience below we describe these themes illustrative participant quotes can be found in table 2 entrapment vs liberation some participants reported they felt confined by the structural barriers in their surroundings conditioning them to lead unhealthy lives in contrast other participants aspired toward liberation from these entrapments through increased health literacy and social activation powerlessness vs empowerment while there was an appreciation for the need to address diabetes as a social justice issue some participants reported a sense of futility and frustration they believed that social action instigates change but not always generates positive outcomes these individuals felt that the epidemic has no fixable solution the same corner stores will still be there and healthy food will not get cheaper anytime soon on the other hand other participants wanted to channel knowledge into action either through intended personal or communitylevel change cultural determinism vs cultural relativism some responses demonstrated a conflict between cultural determinism and cultural relativism as such some rejected psa messages articulating a rebellion against the dominant culture differential impact of setting on participant responses figure 1 demonstrates the relative frequency of individual and public health literacy constructs emerging from questionnaire and group discussions while there were more responses elicited in the individual setting than in the focus group setting we observed a dramatic shift in content focus and emphasis between the two settings from an individual health literacy construct towards a public health literacy construct a total of 175 statements were coded from participants individual questionnaire responses seventynine of those statements were classified under individual health literacy 29 out of 79 pertained to functional 3 interactive and 47 critical health literacy the remaining 96 statements were classified under public health literacy 56 conceptual foundations 30 critical skills and 10 civic orientation a total of 56 statements were coded from the focus group responses 14 statements related to individual health literacy with 3 statements related to functional 3 interactive and 8 critical health literacy fortytwo responses were categorized under public health literacy with 15 statements related to conceptual foundations 15 critical skills and 12 civic orientation table 3 demonstrates the dimensions of health literacy within the two constructs of heath literacy as articulated by respondents in the individual and focus group settings a total of 175 statements were coded from participants individual questionnaire responses seventynine of those statements were classified under individual health literacy 29 out of 79 pertained to functional 3 interactive and 47 critical health literacy the remaining 96 statements were classified under public health literacy 56 conceptual foundations 30 critical skills and 10 civic orientation a total of 56 statements were coded from the focus group responses 14 statements related to individual health literacy with 3 statements related to functional 3 interactive and 8 critical health literacy fortytwo responses were categorized under public health literacy with 15 statements related to conceptual foundations 15 critical skills and 12 civic orientation table 3 demonstrates the dimensions of health literacy within the two constructs of heath literacy as articulated by respondents in the individual and focus group settings interactive health literacy theme empowerment • should come together to change the way we eat theme liberation • how its hard to escape diabetes but possible critical skills theme institutional factors deceptive marketing • be careful on what you buy because the things they say is in there is really not theme liberation • do more research on the government and nutritions theme institutional factors deceptive marketing • from a young age sugar is shown as good and how fast it gets addictive civic orientation theme empowerment • we need to remove junk food places and put in more markets that sell cheaper healthier food theme financial barriers and competing demands • low income neighborhoods are at higher risk for diabetes due to the lack of resources conceptual foundations theme built environment • they can go to a corner store for a 099 cent bag of chips its convenient but its not good but they put it there theme institutional factors deceptive marketing • you got to think about like a cartoon commercial i feel like it was a parody and then thats how they were trying to market it to the kids but its a company functional health literacy theme individual behaviors theme built environment • for me living where i live the closest healthy store is trader joes but thats across the bridge that means i have to spend money to get there i have to spend money when i get there so its hard to just be healthy its not that easy theme entrapment • even if people wanted to be healthy they dont have the opportunity to go about it like financially or physically because they have nowhere to go theme entrapment • after watching the videos i think that to an extent its a social justice issue for the reasons that anonymous number two was saying that the restaurants are strategically put together like for example hagen burger the shopping center by walmart theres wing stop in and out candy express chipotle allinone and none of those are healthy at all yes and then like jamba juice theyre all together like theres not one place there and then theres a mcdonalds in walmart civic orientation theme empowerment • start a garden in your community the center we have we have fresh produce in our garden i mean we have in our garden fresh produce id say thats what i can think of like communitywise theme financial barriers and competing demands • so its like all these places put in one place and that area is not a place where rich people live so its like its kind of scandalous in a way discussion in clinical settings limited health literacy contributes to health disparities especially among older adults immigrants racialethnic minorities and lowincome individuals 15 improving individual health literacy therefore is a promising strategy to improve population health particularly in the management of type 2 diabetes 16 however encouraging atrisk youth to prevent diabetes through traditional health education is often ineffective furthermore such individuallevel interventions do not support broader health promotion and health policy efforts to achieve public health goals the bigger picture is an innovative communication campaign that both features atrisk youth as creators and performers of novel public health content as well as targets atrisk youth this model is relevant for conditions such as type 2 diabetes where exposures are determined by behavioral patterns solidified during adolescence tbp model is unique in how it nurtures and supports the talent authenticity and creativity of new health messengers youth whose lived experience can be expressed in powerful ways never aiming to solely improve individual health literacy or direct individuals to change health behaviors tbp attempts to harness core values of social justice and defiance against authority to improve youth public health literacy and foment action around social environmental and policy change while we are not aware of any research to shed light on the question as to whether defiance and social justice are more compelling for certain adolescent subgroups tbp campaign has yielded promising results in shifting lowincome adolescent social norms 8 we carried out this study to explore whether scaling up this model holds promise for low income and minority youth determine whether the socioecological perspective a complex and multilevel construct can be integrated by youth exposed to tbp messages and determine the extent to which facilitated discussions and reflective learning are needed to improve youth public health literacy our research found that tbp psas elicited responses that aligned with the broad constructs of both individual health literacy and public health literacy and their respective dimensions individual responses after viewing psas revealed a fairly even distribution of statements representing individual and public health literacy immediately after viewing the psas in the context of an openended questionnaire some participants perceived tbp messages as conveying diabetes primarily as an individual concern these participants reflected on intended personal changes such as eating less sugar or processed foods and exercising more other participants articulated a greater understanding of the broader social and environmental forces that shape individual behavior and can determine type 2 diabetes risk such as the lack of affordable food healthy food in poverty communities and how advertise the food behind the scenes of the product these participants moreover proposed changes in their community through education and health promotion that suggest increases in public health literacy in contrast responses derived from the facilitated group discussions more heavily emphasized the roles of social structural and environmental determinants articulating a need to address diabetes through communal and civic engagement demonstrating a more consistent paradigm shift toward public health literacy in the setting of a group discussion the psas served as vehicles for more extensive critical thinking reflecting a more comprehensive public health literacy framework with a greater focus on socioecological constructs this shift suggests that not only can a group setting amplify the messages to improve public health literacy in atrisk youth but also supports the notion that tbp psas can align with youth values to motivate social action and influence social norms the most striking themes that emerged in response to psas involved the tensions that these minority and lowincome youth experience expressed as sociopolitical themes such as entrapment vs liberation this speaks both to the structural barriers and behavioral complexities inherent to reducing diabetes risk in vulnerable communities as well as the unique ability of the spoken word medium to make these challenges visible naming and reflecting on such tensions represent critical skills that raise communal consciousness and can promote civic engagement fundamental dimensions of public health literacy our study has a number of limitations first the sample was based on the number of individuals involved in the youth radio internship due to limited funding and the size of the youth group that our partner youth radio had enrolled in its program we were unable to carry out additional focus groups as we now have created 27 videopoems we are attempting to obtain funding for more youth focus groups however we are currently carrying out a randomized trial on facebook to determine which framing messages most engage youth to view the video psas second while ethnically diverse and of low income the sample was likely not fully representative as participants had selfselected to enroll in a media literacy program however we carried out this work at the beginning of their internship making it less likely that exposure to the internship influenced their responses third we cannot determine whether our comparisons of the impact of tbp messages across different communication settings were a result of the setting and format or the order in which we elicited responses there certainly could be bias introduced by virtue of the order in which the videos were presented and the two ways in which the videos were discussed the first wave was after individuals viewed each one and responded as individuals and the second wave was in the context of discussing them in a focus group recall bias may favor the initial viewing the focus group reflections reflect the aggregate impact of all videos relatedly we cannot determine whether the shift to a more socioecologically oriented conceptualization in the group setting was a result of communication dynamics or a result of participants integrating aggregate metamessages across all nine psas fourth participants viewed only 9 of the 27 current tbp psas so we were not able to comprehensively evaluate all campaign messages however we selected the nine videos based on thematic artistic and genrerelated representativeness finally no qualitative report can fully capture participants perspectives for example some participants revealed that they did not realize that tbp youth performers and their messages reflected authentic first person narratives assuming some were performed by youth actors reading from a script written by adults had our psas consistently made clear that low income and minority youth were delivering their own artistic interpretations of their lived experience it is likely that psas impacts would have been even more robust this report suggests that tbp provides a promising artistic platform to communicate important factual and sociopolitical content related to the diabetes epidemic to low income and minority youth one that appears to foster both individual and public health literacy for some the psas encouraged viewers to plan personal behavior changes and feel empowered to engage in community initiatives to prevent type 2 diabetes for others the psas also revealed the structural and social barriers they face when trying to prevent diabetesa revelation that was frustrating for some but activating for others our findings support the need for tbpa campaign that focuses on the multilevel causes of diabetesto be accompanied by interactive and actionoriented pedagogy if it is to achieve optimal impact this interactive reflection could be facilitated via digital platforms or live group settings and augmented by advocacy and action toolkits we have recently expanded tbps digital reach modernized the website and are curating a new tbp facebook group that will allow for more interactivity in addition we have received seed funding to institute tbp programming in a more longitudinal fashion in public high schools potentially enhancing public health literacy enabling culture changes with respect to social norms and promoting civic engagement tbp process and content have also been harnessed by the local county health department to support public health actionspecifically the installation of fresh water stations in lowincome neighborhoods that have the highest rates of consumption of sugarsweetened beverages in the county finally several community pediatric practices have reported using tbp content to motivate adolescents and families enrolled in their obesity or prediabetes clinics these activities suggest that the model may have broad implications for public health specifically related to an important social determinant of health health literacy conclusions tbp represents an innovative health communication and countermarketing campaign that harnesses the talent and lived experience of minority youth poets who serve as messengers of novel and authentic first person content whose intent is to catalyze social action and influence social norms by aligning with adolescent values of defiance and social justice 5 the key messages contained within tbp psas appear to often hit home frequently generating activating responses from youth for whom the messages are intended both at an individual and communal level tbp holds particular potential to promote diabetesrelated public health literacy thus building capacity among youth to both change behavioral norms as well as confront the social economic and structural factors that largely determine these behaviors it is likely that the tbp model is generalizable to other health conditions and may appeal to youth stakeholders not only to youth 6 author contributions dean schillinger directed all of the functions jessica tran contributed to analysis and writing for this proposal sarah fine contributed to conceiving and designing the qualitative study performing the experiment as well as analysis and writing

as type 2 diabetes spikes among minority and lowincome youth there is an urgent need to tackle the drivers of this preventable disease the bigger picture tbp is a countermarketing campaign using youthcreated spokenword public service announcements psas to reframe the epidemic as a socioenvironmental phenomenon requiring communal action civic engagement and norm change methods we examined whether and how tbp psas advance health literacy among lowincome minority youth we showed nine psas asking individuals openended questions via questionnaire then facilitating a focus group to reflect upon the psas results questionnaire responses revealed a balance between individual vs public health literacy some focused on individual responsibility and behaviors while others described socioenvironmental forces underlying risk the focus group generated a preponderance of public health literacy responses emphasizing future action striking sociopolitical themes emerged reflecting tensions minority and lowincome youth experience such as entrapment vs liberation conclusion our findings speak to the structural barriers and complexities underlying diabetes risk and the ability of spoken word medium to make these challenges visible and motivate action practice implications delivering tbp content to promote interactive reflection has potential to change behavioral norms and build capacity to confront the social economic and structural factors that influence behaviors

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introduction loneliness across time loneliness across space linking macrolevel factors to loneliness implications for policy summary and future directions faculty of psychology ruhr university bochum bochum germany email review article change that influence social networks and psychosocial factors such as loneliness 44 macrolevel factors can also moderate the associations between individual predictors and outcomes macrolevel factors influence peoples standards for their social relationships which in turn moderate the extent to which other factors such as the level of social integration are related to loneliness 42 for example when macrolevel factors restrict peoples opportunities for social interactions the frequency of daily social contact might be less strongly related to loneliness than when macrolevel factors do not influence peoples opportunities for social interactions in this review we summarize the current evidence on whether and why loneliness varies across time and space because historical changes and geographical differences in loneliness have largely been investigated separately we review these topics in separate sections for each topic we first examine whether differences in loneliness across time and space exist in the first place next we discuss macrolevel factors that might account for these differences to that end we draw on the historical changes in developmental contexts framework 39 that organizes macrolevel factors into four categories values and norms family and social lives technology and mobility and individual resources and living conditions although this taxonomy was developed to explain historical changes in adult development the included macrolevel factors can in principle also vary across geographical regions hideco therefore provides a useful framework to organize our review of macrolevel factors related to loneliness finally we discuss policy implications and provide specific recommendations on directions for future research introduction people experience loneliness when they feel that their social relationships are deficient in terms of quantity or quality and perceive a gap between their actual and desired relationships 1 around the world people describe loneliness as a painful sometimes agonizing experience 2 loneliness is conceptually distinct from being alone solitude 3 and social isolation 135 through its adverse effects on sleep immune functioning and health behaviours loneliness can lead to longterm health issues such as an increased risk for cardiovascular diseases and reduced longevity 169 the healthrelated consequences of loneliness are detrimental for individual wellbeing and come with substantial economic costs for society 1011 loneliness has therefore been recognized as a public health issue that needs to be addressed by public policy 1213 indeed loneliness is on political agendas in the united kingdom 14 germany 15 japan 16 and the european union 17 thus loneliness has important societal implications and there is a need for evidencebased recommendations for public policy despite these societal implications loneliness is a deeply subjective experience and almost all empirically established predictors of loneliness refer to characteristics of the person loneliness is more common among individuals with low socioeconomic status 1819 and poor health 1920 two individual factors that limit peoples opportunities to participate in everyday social activities because poor health is particularly common among the elderly old age is sometimes considered a critical risk factor for loneliness however although studies conducted before the covid19 pandemic found that average loneliness was highest in the oldest age group 18 21 22 23 increased loneliness has also been reported in younger age groups 1824 and a metaanalysis of longitudinal studies found no significant relationship between age and loneliness 25 identifying with a group that is marginalized within a society is associated with higher average levels of loneliness presumably because these groups are more likely to experience stressors such as discrimination or rejection which increase the risk of loneliness 29 30 31 32 33 loneliness is also correlated with personality traits individuals high in extraversion and emotional stability are less prone to loneliness than individuals low on these traits 34 finally the characteristics of ones social relationships are among the most proximal predictors of loneliness having a romantic partner a large social network frequent social interactions and highquality relationships decrease the risk of loneliness 19203536 however how people think feel and behave is also shaped by the greater context 37 including the sociohistorical context 3839 and the geographical and cultural context 4041 macrolevel factors can influence the distribution of individuallevel predictors of loneliness at a given time or in a given location for example cultural norms and values societal welfare and demographic composition explain geographical differences in loneliness through their effects on individuallevel predictors such as the quality of living conditions and social integration 42 such indirect pathways are also proposed in theories that focus on lonelinessrelated outcomes for example context factors influence peoples social opportunities their available time and energy and their capacity and motivations all of which influence the extent to which people form and maintain friendships in older age 43 moreover health outcomes are partly determined by a causal cascade of macrolevel factors such as culture socioeconomic factors and social review article time existent crosstemporal metaanalyses on loneliness have been restricted to specific age groups countries measurement instruments andor time periods for young adults a metaanalysis focusing on the usa reported decreases in average loneliness 52 a metaanalysis focusing on china reported increases in average loneliness 53 and a metaanalysis including samples from all over the world found a weak increase in average loneliness that was more pronounced in north american samples and not significantly personality traits extraversion and emotional stability are linked to a lower risk for loneliness extraverted people are more likely than introverted people to seek out social interactions and to make friends emotionally stable people are less likely than emotionally unstable people to experience being alone as adverse buecker et al 34 metaanalysis of relations between loneliness and big five personality traits gender empirical findings on gender effects are inconsistent across single studies metaanalytic evidence shows that gender differences are small to negligible nationally representative study of older adults in the usa using data from romantic couples review article different from zero in nonnorth american samples 54 a fourth crosstemporal metaanalysis found increasing loneliness levels among older adults in china 55 notably both metaanalyses that focused on chinese samples found increases in loneliness over time 5355 however this trend was not replicated in the worldwide metaanalysis examining young adults 54 so these findings do not allow any inferences about potential systematic national differences in loneliness trends crosstemporal metaanalyses are often the only way to examine changes in a construct over several decades but they have several limitations first existing metaanalyses focus on specific populations and measurement instruments so it is unclear whether the findings generalize to other age groups and measurement instruments second most of the original studies relied on convenience samples convenience samples are generated using nonprobability sampling techniques and are usually not representative of the population of interest specific subgroups might be overrepresented or underrepresented owing to sampling biases survey research indicates that response rates have generally been declining over the past five decades 56 raising additional concerns that the nature of these sampling biases might change over time if sampling bias is systematically related to loneliness estimates of changes in loneliness over time might be biased as well thus crosstemporal metaanalyses allow conclusions to be drawn only about how loneliness changed among people who participated in these kinds of study third crosstemporal metaanalyses cannot establish the extent to which the observed meanlevel trends might be influenced by historical changes in how people respond to questions about loneliness for example people might be more likely to admit to feeling lonely frequently in times when loneliness is socially accepted rather than stigmatized 5457 empirical tests of longitudinal measurement invariance of loneliness scales are rare and typically cover only short time lags 58 59 60 and therefore do not allow inferences about historical changes in response styles nevertheless the impact of longitudinal measurement invariance on the meanlevel trends observed in crosstemporal metaanalyses is generally assumed to be small 54 finally crosstemporal metaanalyses do not allow conclusions about whether the observed changes are due to the specific historical context or due to generational differences to disentangle period and cohort effects it is necessary to track loneliness in multiple generations across long periods of time even then possible causes of these effects often remain unclear only a few studies have systematically examined generational differences in loneliness with again inconsistent findings studies from germany 61 and the netherlands 62 reported lower levels of loneliness in laterborn cohorts of adults aged 55 years and older however most other studies focusing on older european adults did not find any cohortlinked differences in loneliness levels 63 64 65 66 the findings are similarly diverse in studies of noneuropean or younger populations in general observable differences in loneliness across time can be due to different effects which can only be inferred in specific research designs 6768 thus when studies report cohort or period effects it must be critically examined whether the research design was appropriate to examine these kinds of effect despite these limitations crosstemporal metaanalyses currently represent the best available estimates of changes in loneliness over historical time however their findings are inconsistent and therefore do not support sweeping claims of a global loneliness epidemic more methodologically robust research on historical changes in loneliness in diverse populations is needed review article relevant macrolevel factors one reason the popular narrative that loneliness is on the rise persists despite a lack of clear empirical evidence might be that many societies have been experiencing major changes in macrolevel factors that influence how people form and maintain social relationships 48 it is plausible that these changes inform peoples intuitions about whether loneliness is becoming more common values and norms cultural values are constantly changing 39 for example individualism is on the rise across the world 69 and is associated with an increased focus on selfdevelopment and a devaluation of traditional family ties 70 on the surface the devaluation of family relationships might pose a risk for increased loneliness because the quantity and quality of family relationships might suffer when people are less invested in them however individualism does not devalue social relationships in general but rather is defined by a shift in the importance of different types of relationship 69 for example relationships with friends are gaining importance relative to relationships with biological family members 69 and the concept of family is becoming more inclusive and less bound to biological relationships 71 thus it is not clear that rising individualism increases the risk for loneliness in a population review article another cultural value with potential implications for loneliness is materialism materialism refers to the importance people place on money and materialistic possessions and acquisitions 72 materialism is correlated with negative outcomes such as poor wellbeing 73 and increased loneliness 72 a populationwide increase in materialistic values might therefore lead to an increase in loneliness such an increase has been found in the usa 7475 but a study using representative data from the netherlands found the opposite pattern 72 thus increasing materialism might contribute to rising loneliness levels in some countries historical periods are also characterized by the political values and attitudes that are dominant at the time one way in which the contemporary political climate might contribute to loneliness on a societal level is through its implications for marginalized groups who might be less likely to experience personal and institutional discrimination in more progressive periods than in more conservative political periods 7677 family and social lives many societies have experienced shifts in social norms related to family relationships and household structures people get married less frequently and at an older average age and are more likely to get divorced and to live alone or in nontraditional family constellations 3971 living with others and being married is generally associated with a lower risk of loneliness 2035 so an increase in the number of people who live alone or are unmarried might increase loneliness in a population however this effect might be counteracted by the changing social norms themselves such that living alone or being unmarried might matter less in generations or historical periods in which marital norms are less strict supporting this view a study conducted among german adults found that partnership status was less strongly associated with loneliness among younger birth cohorts than among older birth cohorts 78 similarly a study among dutch adults found that loneliness levels among divorcées decreased from 1992 to 2012 presumably because divorces became more common and therefore more accepted over this timeframe 79 technology and mobility the wide distribution of smartphones and the rise of social media have substantially changed how people interact in daily life 80 the impact of digitalization on loneliness and other indicators of wellbeing is a highly active research area and the results are complex 81 82 83 84 overall the link between the digitalization of social interactions and loneliness seems weak 8186 moreover the causal direction of the association is unclear whereas some studies suggest that using smartphones and social media lead to higher levels of loneliness others suggest that loneliness leads to more frequent smartphone use 81 many countries have also experienced increased residential mobility both within countries 87 and between countries 88 climate change is an additional cause of global residential mobility that will become more important in the coming decades 89 residential mobility has disruptive effects on peoples social networks 9091 in the face of a residential transition people often anticipate 92 and experience loneliness 93 94 95 but they might also be motivated to expand their social networks 96 the extent to which residential mobility contributes to loneliness and social isolation therefore depends on how successful people are at forming new and maintaining old social networks 97 individual resources and living conditions macroeconomic indicators such as poverty rates or unemployment rates reflect the distribution of low income and unemployment in a population two factors that increase the risk for loneliness 1819 hence changes in these kinds of macrolevel factor might be correlated with changes in loneliness levels in a population because the macrolevel factors mirror the prevalence of individuallevel risk factors the authors of the hideco framework assume that individual resources are generally more widely available today than in the past 39 however this does not imply that loneliness is less prevalent today than in the past for example medical advances have improved disease prevention and treatment leading to an increase in life expectancy in most countries 9899 however in the usa the prevalence of diseases has also increased indicating that medical advances have not led to a healthier population in the usa overall 98 on the individual level this means that all else being equal an individual person suffering from a serious disease in the usa today is more likely to survive to experience a higher quality of life and hence less likely to be lonely than in the past but this positive effect on the individual level does not necessarily translate to a reduction in loneliness prevalence on the population level because the relative proportion of people with health issues in the total population has increased this complex association between changes in macrolevel factors and loneliness can also be found for the link between historical changes in the demographic composition of a population and loneliness in most countries the combined effects of higher longevity and lower fertility rates increase the proportion of older adults in the total population 100 many studies have identified older adults as a central risk group for loneliness presumably because of a higher prevalence of risk factors such as widowhood and functional limitations in this age group 1821101 a growing proportion of older adults in a population can therefore be associated with increased average loneliness levels but this effect could be counteracted by older adults having more opportunities for social interactions with peers 42101 in sum there are a number of macrolevel factors for which links to loneliness are theoretically plausible however these links are complex and mediated through multiple pathways thus they are not always evident when examining simple correlations between changes in macrolevel factors and changes in loneliness across time in addition correlations among time trends are often spurious 102 making it methodologically challenging to establish true causal links between historical changes loneliness across space the potential relevance of macrolevel factors for loneliness can also be gauged by examining how and why loneliness varies across geographical space both between and within countries crossnational differences similar to studies on longterm historical trends studies examining crossnational differences in loneliness should be based on large nationally representative samples from multiple countries that all use the same loneliness measure most comparative studies that fulfill these criteria focus on european countries these studies consistently find that loneliness levels are lowest in northern and western european countries and substantially higher in southern and eastern european and other former soviet countries 103 104 105 106 107 although there is also substantial variation within these regions 108 for example in one study examining a representative sample of adults aged 65 years and review article review article older in 11 western european countries the proportion of respondents who reported feeling lonely most of the time was more than four times as high in italy and greece than in denmark and switzerland 104 similar patterns were found in a metaanalysis that examined loneliness across 113 countries 107 overall these studies indicate that loneliness can and does vary across countries it is possible that these crossnational differences are at least partly driven by methodological factors for example survey response rates vary across countries 109 differences in response rates are particularly problematic if survey nonresponse is associated with loneliness such a nonresponse bias would directly bias national prevalence estimates furthermore the observed crossnational differences might stem from a different understanding of the concept of loneliness itself most crossnational studies use single items such as how often do you feel lonely if the term lonely is interpreted differently across nations or languages the data collected with this measure are not comparable indeed some research suggests that there are cultural differences regarding the meaning of loneliness 110 higher loneliness is associated with being partnerless and childless and other nonnormative transitions there are crossnational differences in the strength of these associations childlessness has a stronger effect on loneliness in more traditionalist countries table 4 summary of empirical studies investigating crossnational differences in loneliness review article to which loneliness is about romantic experiences versus broader social approval 111 however qualitative studies examining the meaning of loneliness in different cultures and languages 2 and quantitative studies examining the structure and measurement invariance of loneliness measures across cultures 112 113 114 115 indicate that loneliness is a universal experience that can be measured reliably and validly across cultures beyond these methodological issues crossnational differences in loneliness can also be due to national differences in macrolevel factors most research has focused on cultural values particularly individualismcollectivism as a macrolevel factor that might account for crossnational differences in loneliness individualistic cultures value autonomy and selfreliance whereas collectivistic cultures value being part of and contributing to the ingroup 70116 hence individualism collectivism reflects the value of social relationships and might therefore be particularly relevant for loneliness but in complex ways 111117118 on the one hand loneliness might be more prevalent in individualistic cultures because social ties are looser and people might invest less in their social relationships than in collectivistic cultures on the other hand loneliness might be more prevalent in collectivistic cultures because social ties are more important and social relationships might be more likely to be perceived as insufficient moreover people in collectivistic cultures are more likely to perceive the social stigma of loneliness than people in individualistic countries 119 the social stigma of loneliness is characterized by the belief that disclosure of being lonely will engender negative responses from others 120121 because the perceived risk associated with disclosing loneliness is stronger in collectivistic than in individualistic cultures people in collectivistic countries might be less likely to disclose their feelings of loneliness in surveys or interviews in addition tight social relationships are not necessarily indicative of good social relationships but can be characterized by ingroup vigilance and withingroup competition which are more common in collectivistic than in individualistic cultures 122 crossnational studies suggest that the latter effects trump the former at least in europe loneliness levels are higher in more collectivistic than in more individualistic nations 117123 cultural values might also moderate the effect of individuallevel predictors on loneliness by influencing peoples social expectations such that people in collectivistic countries might be more likely to take having close friends and living with others for granted than people in individualistic countries 42124 consistent with this perspective the protective effect of having a confidant was stronger in individualistic than in collectivistic countries 117 whereas the harmful effect of living alone was weaker in individualistic than in collectivistic countries 125 it must be noted that the individualismcollectivism distinction has been criticized as being vaguely defined and lacking explanatory power for many crosscultural differences 126 it is therefore important to consider more precisely defined cultural values as well 126 for example cultural norms related to family and social relationships might contribute to population levels of loneliness via their effects on family and social lives according to the cultureloneliness framework 127 people in cultures with more restrictive norms about social relationships might experience more loneliness because despite being less physically isolated they are more likely to experience a discrepancy between their actual and desired social relationships this notion is consistent with the work on individualismcollectivism discussed above and with research showing that stronger filial norms in eastern compared to western european countries might contribute to the higher loneliness levels among older adults in eastern european countries compared to those in western europe 42123 beyond cultural values national differences in loneliness can also partly be explained by macrolevel factors reflecting the sociodemographic composition of a population for family and social network structures studies comparing older adults across multiple european countries have found that loneliness levels are higher in countries with higher proportions of older adults living alone and nevermarried older adults 103123 with respect to individual resources and living conditions two studies found that loneliness levels were lower in countries with higher average wealth and better average health 103123 differences in technology and mobility have not yet been systematically examined as correlates of national differences in loneliness but it has been proposed that higher rates of mobility and migration might be linked to higher national loneliness levels 103107 and there is some evidence that the effect of social media use on psychological outcomes might differ across cultures 128 overall these studies show that loneliness varies across nations and that macrolevel factors such as values or sociodemographic characteristics account in part for this variability however most studies focused on european countries and only a few macrolevel factors have been examined systematically withincountry differences geographical variation in loneliness can also be found within countries 129 130 131 132 133 134 in a study using a representative german sample there was a difference greater than two standard deviations between the regions with the highest and lowest loneliness levels 131 in another study examining a representative sample of young people in the uk geographical region accounted for 58 of the total variance in loneliness 132 explanations for withincountry differences in loneliness include sociodemographic physical and perceived neighbourhood characteristics under the hideco taxonomy physical and demographic characteristics can best be categorized as individual resource and living conditions factors whereas perceived neighbourhood characteristics describe the cultural and social aspects of neighborhoods similar to crossnational research regional differences in loneliness are often explained by differences in the sociodemographic composition of the population empirical studies directly examining this link on a withincountry level provide mixed results some studies find that loneliness levels are elevated in areas with a greater percentage of older lowincome adults 134 and in socioeconomically deprived areas 135 but these associations do not hold up in other studies 131136 suggesting that the effect of the sociodemographic composition of the population on loneliness might depend on other factors to be identified in future research a group of macrolevel factors unique to withincountry studies comprises physical characteristics of places such as the distinction between urban and rural areas multiple studies find no significant differences in average loneliness levels between urban and rural areas after controlling for covariates such as income or age 129 130 131 134 135 136 furthermore related characteristics such as population density are also not associated with loneliness 131136 however one study found that loneliness levels were higher in areas that were more remote from local centres 131 physical characteristics also encompass neighbourhood characteristics such as general walkability 137 and walkable distance to public parks 131 which are associated with lower loneliness overall concrete and tangible physical characteristics of places appear to be more review article relevant to explain differences in loneliness than broad categorizations such as urban versus rural perceived neighbourhood characteristics such as perceived neighbourhood quality or neighbourhood social capital tend to be negatively correlated with loneliness 129132133138 however this effect seems to be limited to selfreports of neighbourhood characteristics 136 and does not replicate in all studies 139 in sum regional and neighbourhood characteristics potentially account for some of the withincountry variation in loneliness but these findings do not always replicate across studies there are several possible reasons for the lack of replicability first the studies have been conducted in different countries and it is possible that neighbourhood characteristics vary in their importance across different countries second some studies focused on specific age groups whereas others included the entire adult age range 131 it is possible that some neighbourhood characteristics are more important for certain age groups than for others more generally it is unclear to what extent the association between individuallevel predictors of loneliness is moderated by macrolevel factors describing regional differences linking macrolevel factors to loneliness overall there are many plausible reasons why macrolevel factors such as values family and social network structures technology and living conditions might affect population levels of loneliness across time and space however for both historical changes and geographical differences it is often hard to find robust associations between macrolevel factors and loneliness there are multiple possible explanations for this observation first most macrolevel factors influence social relationships through multiple indirect pathways some positive and some negative these positive and negative pathways might counteract each other such that the net effect of specific macrolevel factors on loneliness is close to zero for example social media can lead to more frequent social contact and decrease peoples sense of social isolation but also displace offline interactions and increase online mobbing and cyber bullying thus when combined the populationlevel effect of social media on loneliness might be weak 8186 second the strength and even the direction of the effect of a macrolevel factor on loneliness might differ among different subgroups in populationlevel studies these subgroups are collapsed so strong effects that exist in only some subgroups might be overlooked for example social media use appears to be more beneficial for older adults than for adolescents and young adults 81 some leading to an increase and some leading to a decrease in factors that in turn either increase or decrease loneliness the direction of the total effect of an indirect pathway is defined by the product of the two direct effects for example the indirect pathway involving offline interactions involves two negative effects that together result in a total positive effect if positive and negative pathways are approximately counterbalanced the overall effect of a macrolevel factor is close to zero even though specific causal effects might exist b macrolevel factors might have differential effects on different subgroups within a population these differential effects might differ in strength and direction such that they lead to increased levels in loneliness in some subgroups and to decreased levels of loneliness in other subgroups c most sociocultural changes occur gradually over time but sudden changes are possible for example in the context of historical events changes in loneliness might be similarly slow and they might be delayed such that loneliness changes lag behind changes in macrolevel factors whether these changes can be linked empirically depends on the time window examined for example the yellow time window would reveal no association between changes in the macrolevel factor and changes in loneliness levels by contrast the purple time window would reveal a strong association between changes in the macrolevel factor and changes in loneliness levels review article but this differential association would not be detected if these groups were analysed together third the effects of most macrolevel factors might unfold over long timescales 39 so effects on loneliness might be weak slow and delayed the exact temporal course of these effects is unclear but it is possible that many macrolevel factors require decades to affect population levels of loneliness in an observable way because their effects are weak initially but accumulate over time 140 implications for policy a better understanding of how macrolevel factors influence loneliness across historical time and geographic space is necessary to develop evidencebased recommendations for public policy measures against loneliness for researchers this is an invitation to study these factors more systematically in future research but loneliness has also become a public policy issue in the past 5 years and policymakers cannot wait for science to reach some consensus for those who require guidance now we offer some tentative policy implications first the impact of macrolevel factors should not be overestimated even on the individual level the causes of loneliness are complex and idiosyncratic this is probably even more true for the effects of macrolevel factors on population levels of loneliness attempts to pin some perceived uptick in loneliness to highly specific macrolevel factors such as the introduction of smartphones 141 are likely to overestimate the relevance of a single factor at the peril of drawing attention away from other factors that are at least as important instead public policy is probably most effective if it targets individual risk factors such as poverty and unemployment and provides funding for the development and dissemination of individuallevel evidencebased interventions against loneliness several reviews provide overviews of effective interventions for different target populations 142 143 144 at the same time the importance of macrolevel factors should not be underestimated shifts in macrolevel factors such as demographic changes or changes in norms and values can influence the risk of loneliness in a population albeit through complex and still poorly understood pathways geographical differences in the distribution of these macrolevel factors can help to identify regions that might be particularly at risk and could serve as model regions for testing specific policies macrolevel trends can therefore provide some tentative information on whether loneliness might become a greater concern in the future finally macrolevel factors might moderate the effects of individuallevel predictors on loneliness 42 for example the protective effect of being married might depend on the social norms related to marriage at a particular time period or in a particular geographical region 78 thus the efficacy of policies aiming at reducing loneliness by strengthening marriages will vary across historical time and geographical space this also means that both individuallevel and macrolevel measures against loneliness have to fit into the greater context policies that are applied in different historical or geographical contexts are not necessarily as effective as in the original setting and therefore need to be reevaluated and if necessary adapted summary and future directions systematic effects of macrolevel factors on loneliness are theoretically plausible but difficult to detect macrolevel factors tend to have weak effects on individuallevel psychological phenomena particularly if their effects are directly contrasted against individuallevel predictors 140 however this does not mean that macrolevel factors should be dismissed the effects of macrolevel factors often accumulate over time 140 influence individuallevel constructs through multiple indirect pathways and might have divergent effects on different subgroups to achieve a more nuanced and complete picture of the association between macrolevel factors and loneliness it is necessary to broaden the available database representative samples are key to drawing valid conclusions about differences in population levels of loneliness across time or space representativeness can be restricted unintentionally through methodological factors and intentionally for example many panel studies deliberately exclude residents of care homes yet this group faces substantial risk for loneliness 145 future research must include individuals from groups regions and countries that have been underrepresented or completely excluded from previous studies to study macrolevel factors systematically researchers must routinely collect multilevel data on the social network neighbourhood and region in which their participants are embedded many individuallevel predictors can be aggregated at higher levels for example the availability of individual resources can be studied at the individual level as well as at the local regional and national level in addition future theoretical and empirical work needs to consider genuine macrolevel factors that is factors that can only be conceptualized and measured at the macro level collecting data repeatedly at regular intervals over multiple years or even decades would allow systematic investigations into the causal dynamics through which macrolevel factors are linked to loneliness although most theories and empirical studies treat macrolevel factors as predictors of loneliness the association between macrolevel factors and individuallevel loneliness is most probably bidirectional the effects of loneliness on individual economic physical and psychological wellbeing can translate into populationwide outcomes such as reduced life expectancy 6 increased healthcare costs 1011 or reduced political participation 146 moreover trends in macrolevel factors might be more relevant than their absolute levels for example changes in the demographic composition of a population due to high residential mobility might be more predictive of population loneliness than the demographic composition itself 131 owing to a cascade of indirect effects across multiple levels such a crosslevel process takes time to unfold and can only be detected with longitudinal data in which factors at all levels are measured repeatedly over long periods of time a better understanding of the causal relationships between macrolevel factors and loneliness is also necessary to identify causal factors that can be targeted by public policy measures to reduce loneliness 147 examples of research designs that would allow such causal inferences include randomized control trials on communitylevel or regionallevel interventions in addition and contrary to conventional wisdom among psychologists nonexperimental studies can under specific circumstances and with specific assumptions be used for causal inference 148149 for example natural experiments and prospective studies conducted in the context of major historical events 147 including wars 150 natural disasters 151 pandemics 151152 or economic crises 153 indeed since 2020 researchers have used the covid19 pandemic review article to study the impact of sudden changes in macrolevel factors on loneliness 152 154 155 156 finally a broad database fulfilling these criteria would enable integrative investigations of loneliness across both time and space the association between a macrolevel factor and loneliness always has to be understood in its specific geographic and historical context simultaneously and as geographic space or historical time change so might the relevance of a macrolevel factor for changes in loneliness across space and time in addition the relationships and interactions among different macrolevel factors might also vary across time and space for example on the individual level social class is correlated with the size and function of social networks such that individuals of higher socioeconomic classes tend to view themselves as more independent allowing them to form more diverse and loose social networks 157 it is possible that similar relationships can be found on the macro level for example economic growth could lead to changes in cultural values related to social relationships although there is some overlap between macrolevel factors explaining longterm trends in loneliness across historical time and macrolevel factors explaining geographical variation in loneliness few attempts have been made to conceptually or empirically integrate these different perspectives a recent exception is a spatiotemporal metaanalysis in which historical changes in loneliness among young adults were related to different regionallevel characteristics 54 in general spatiotemporal metaanalyses expand classic metaanalytic techniques by using spatial and temporal information to explain heterogeneity in effect sizes 158 although no significant spatiotemporal associations were found in that particular metaanalysis 54 this methodological approach might serve as a template for future research examining macrolevel factors across time and space simultaneously in sum longitudinal multilevel data from representative samples from multiple countries are necessary to gain a deeper understanding for why loneliness varies across time and space collecting such comprehensive data is not feasible for any single laboratory but with shared resources it is not an impossible goal in fact largescale studies that cover multiple countries across multiple years already exist but loneliness is not yet routinely measured in these studies we therefore call on researchers and funders of largescale crossnational panel studies to include standardized measures of loneliness in addition we call on researchers around the world to routinely measure loneliness in their studies and thereby contribute to growing the collective database of loneliness across time and space published online 7 november 2022 factors at all higher levels might influence individuals loneliness at the same time individuals influence higherlevel factors directly and indirectly b bidirectional associations between macrolevel factors and loneliness might be explained by a cascade of crosslevel indirect effects that unfold over time in this example an increase in residential mobility on the country level is assumed to lead to less contact with friends which in turn increases individuallevel loneliness this individuallevel increase might lead to increased loneliness in their social network and contribute to increased loneliness at the community regional and country level competing interests the authors declare no competing interests

people feel lonely when their social needs are not met by the quantity and quality of their social relationships most research has focused on individuallevel predictors of loneliness however macrolevel factors related to historical time and geographic space might influence loneliness through their effects on individuallevel predictors in this review we summarize empirical findings on differences in the prevalence of loneliness across historical time and geographical space and discuss four groups of macrolevel factors that might account for these differences values and norms family and social lives technology and digitalization and living conditions and availability of individual resources regarding historical time media reports convey that loneliness is on the rise but the empirical evidence is mixed at least before the covid19 pandemic regarding geographical space national differences in loneliness are linked to differences in cultural values such as individualism but might also be due to differences in the sociodemographic composition of the population research on withincountry differences in loneliness is scarce but suggests an influence of neighbourhood characteristics we conclude that a more nuanced understanding of the effects of macrolevel factors on loneliness is necessary because of their relevance for public policy and propose specific directions for future researchheadlines and titles such as the loneliness epidemic or the lonely century 45 convey that loneliness is more common today than ever before but although it is true that variables related to objective social isolation such as living alone 46 and time spent alone 47 have increased in the past halfcentury 383948 it is less clear whether loneliness is on the rise as wellthe ideal way to examine longterm trends in loneliness across historical time would be to track large representative samples across multi ple years or even decades for example according to the general social survey 21 average loneliness levels declined from 2014 to 2018 except among young adults who experienced an increase in loneliness over these 4 years 21 unfortunately existing longrunning panel studies started incorporating standardized loneliness measures only within the past 15 years since 2008 in the dutch longitudinal internet studies for the social sciences panel 49 since 2013 in the german socioeconomic panel 18 and since 2014 in the general social survey 21 thus these data cover only short time periods and cannot be used to track longerterm changes in average loneliness levels data on loneliness from representative samples from the past century are almost nonexistent an alternative way to identify longterm trends in loneliness is to examine how average loneliness levels reported in empirical studies change over time crosstemporal metaanalyses statistically aggregate mean scale scores of a construct from single studies using samples that are approximately the same age 5051 by examining the correlation between the mean scale scores and the year of data collection this method enables changes in a construct to be estimated over historicalcorrespondence should be addressed to maike luhmann peer review information nature reviews psychology thanks johannes beller katherine fiori and the other anonymous reviewers for their contribution to the peer review of this work reprints and permissions information is available at publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations springer nature or its licensor eg a society or other partner holds exclusive rights to this article under a publishing agreement with the author s or other rightsholder s author selfarchiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law

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the diet and physical activity aspects of the regimen pose particular challenges for socially disadvantaged individuals due to financial and environmental constraints access to healthful foods varies greatly it is relatively more expensive and difficult to obtain whole grain foods and fresh vegetables in minoritysegregated and low income communities horowitz and colleagues found that diabetesrecommended foods were largely absent from stores in disadvantaged neighborhoods in addition lower income populations perceive fewer options for safe and affordable exercise options the challenges for socially disadvantaged populations in adhering to the diet and exercise aspects of the regimen could partially explain socioeconomic differences in health outcomes however further research is needed to examine the challenges from a participants perspective we are interested in going beyond the practitioner model of regimen adherence and instead want to understand challenges from a patient perspective in the present article we analyze whether or not there are differences in diabetes among women based on subjective social status the experience of diabetes diagnosis is a crucial period for adaptation to the illness until the event of diagnosis patients often are not willing to make adjustments to their lifestyles this is due to the disruptive nature of rapidly imposed lifestyle changes research focusing on the patients perspective has identified the diagnosis of a chronic illness to be a traumatic process although in certain situations identification of the disease can provide relief through reducing uncertainties other studies that examine diagnosis from the patients perspective frame it as a transformative process of adaptation to illness a separate body of research considers how diagnosis timing relates to longterm chronic illness outcomes this research also addresses how timing and outcomes vary with socioeconomic position a qualitative study by richards and colleagues investigated socioeconomic variations in responses to chest pain they found that residents of relatively deprived areas were more likely to normalize initial symptoms of chest pains and less likely to seek care due to selfblame and concerns of stigma for worse selfcare practices several quantitative studies have examined socioeconomic differences in chronic disease among women including the influence of socioeconomic factors on breast cancer diagnosis such studies found that lower ses groups were diagnosed later and had more advanced stages of breast cancer at diagnosis which might explain the higher rates of preventable breast cancer deaths in low ses women the socioeconomic variations in stage of diagnosis were consistent with other forms of cancer such as colorectal lung cervical and prostate cancers prior research has addressed the patients experience of chronic illness diagnosis and the social disparities in timing of chronic illness diagnosis however to our knowledge no studies have examined socioeconomic differences in diagnosis experiences from a patients perspective from their own circumstances and words our goal in the present study is to examine whether or not socioeconomic factors shape the experiences of people finding out they are diabetic more specifically we hope to examine threads that intersect diagnosis experiences and socioeconomic experiences if they do at all this analysis can inform research on social disparities in health and disease further this research has practical implications in clinical settings as well as for policymakers who design and implement health promotion and disease management programs method interpretive phenomenological analysis is the approach used in this qualitative study the ipa approach is situated to understand peoples social and personal experiences such as life transformation or traumatic events we selected ipa to examine diagnosis because discovery of chronic illnessincluding diabetescan be a transformative experience because disease naming and framing is socially constructed there is great value in interpreting participants evaluations of their experiences recruitment as part of the parent study 20 women were selected and were sent a letter of introduction describing the studys objectives and procedures the letter specified that they would be contacted in 2 to 4 weeks directly by phone to answer questions about the study a script was followed during the call that provided additional information about the study a maximum of three followup calls were attempted for recruitment of the 20 women recruited two were institutionalized two members of the recruited sample were unwilling to participate the resulting sample size was 18 women the sample lived within 60 miles of detroit in cities and towns of diverse population densities and sociodemographic compositions participants ranged from 51 to 92 years of age varying greatly in physical functional ability data collection took place from may to july 2008 the majority of interviews were conducted in respondents homes to enhance participant comfort and confidentiality all participants signed a letter of consent and completed the interview in full the parent study was approved by the university of michigan institutional review board the motivation or analysis for the present research study was not influenced by other substudies from the parent study data collection orallyadministered surveys collected information on regimen adherence health and illness status and sociodemographic characteristics the audiorecorded semistructured interview followed the survey in interviews respondents were consistently asked the following questions • could you tell me about when you learned you had diabetes • if you could put yourself back in that instant what were your initial thoughts • how did you feel about making the changes your doctor said you should make • are there things that help you stick to a diet what kind of things get in the way • can you think of anything that might help you to manage your regimen better each transcript was independently coded by two researchers general themes were developed by the research team which consisted of the principal investigator and five research assistants following the interpretive coding process the final coded passages were entered into nvivo software for retrieval the coding strategy is described by bradley and colleagues as a process by which coding is first conducted independently then teams meet to reach consensus one approach to applying the finalized code structure to the data is to have two to three members of the research team rereview all the data applying independently the codes from the finalized code structure then the team meets in a group to review discrepancies resolving differences by indepth discussion and negotiated consensus the decision to use more than one coder was made to enhance the credibility of the coding process our rationale was to increase code credibility reliability and to reduce coder fatigue coders met to resolve discrepancies and reach consensus which enhanced confirmability research assistants were undergraduate sociology majors with training in statistics and research methods procedure to characterize participant socioeconomic status socioeconomic status was determined according to participant selfassessment following the objective in ipa to better understand the experiences from the perspective of the participants lifeworld participants were asked how would you describe your financial situation welltodo comfortable a little tight or a struggle among the 18 participants none considered themselves welltodo twelve participants responded comfortable while the remaining six responded a little tight or a struggle the 12 participants who identified as comfortable were categorized in the relatively higher sss group while the six participants who identified a little tight or a struggle were categorized in the relatively lower sss group incomes in the higher sss group ranged from 1000 5000 per month incomes in the lower sss group ranged from 1000 4000 per month the groups were both raciallyethnically diverse findings theme 1 situations of diabetes discovery during the interviews participants were encouraged to reflect on when they first learned of their diabetic condition probes were provided to solicit information on who delivered the news and what recommendations were made at the time of diagnosis respondents were categorized as either discovering they were diabetic at a routine appointment or through symptomssuspicions that prompted the visit most participants were diagnosed with diabetes during a routine appointment and were not aware of symptoms beforehand the remaining participants who experienced symptoms prior to diagnosis overwhelmingly identified as lower sss before being diagnosed rita had already experienced diabetesrelated symptoms rita before being diagnosed i remember waiting for the bus and my feet were just so painful cold rita made an appointment with a physician due to foot pain and tingling sensations in retrospect rita could not recall if she was unaware or in denial of the symptoms being diabetesrelated at the time of her diagnosis rita recalled feeling angry with herself for waiting to go to the doctor despite having symptoms until her diabetes had worsened rita was angry at herself for waiting even though she did not know she had diabetes disease discovery can occur during inopportune times as the result of progressive symptoms developing particularly among the socially vulnerable rita did not have routine medical checkups and did not have a regular source of medical care routine or preventive health care appointments were sometimes considered luxuries prolonged symptoms delayed diagnosis and selfanger contributed to an overall negative experience selfblame of her lifestyle choices prior to diagnosis continued for decades rita emphasized mistakes of the past over how she has since adapted her lifestyle rita remarked that the financial burdens resulting from becoming diabetic continue to be a strain although the majority of financially secure participants became aware that they were diabetic during routine screenings several suspected they had diabetes prior to diagnosis this can be a way to take control over the circumstances of diagnosis such an example is provided by margaret an elderly participant with a comfortable financial situation and an advanced educational degree she stated my sister the doctor had always said we were going to get diabetes because we were overweight i had a pretty good constitution so i put going to the doctor off despite having taken control over the timing of the situation of disease discovery margaret still blamed herself at the time of diagnosis and when the doctor told me i had diabetes i was really mad and angry at myself because i knew what could happen margarets approach seemed paradoxical like socioeconomically disadvantaged participants margaret postponed seeking care unlike socioeconomically disadvantaged participants however she sought care when she felt emotionally prepared to be labeled as diabeticshe was already aware she had diabetes she also did not postpone seeking care due to financial concerns although margaret asserted control over the timing of the diagnosis situation she nevertheless experienced selfanger margaret experienced selfanger during diagnosis because of lifestyle choices even though she knew better while lowersss respondents such as rita experienced selfanger for postponing care for financial reasons or normalizing diabetesrelated symptoms the proportionately high financial consequences are a nagging reminder however like the majority of other high sss respondents margaret mentioned she was able to change her lifestyle following diagnosis but i decided i was going to follow through and i have therefore unlike rita margaret emphasizes the changes she has made in her life since diagnosis to keep her diabetes under control this emphasis of managing versus being managed provides a framework through which illness experiences differed according to participant sss we discuss how negative discovery experiences branch into negative or positive illness experiences theme 2 managing versus being managed regardless of social position most participants reported feeling some fear anger and anxiety when they found out they were diabetic however these feelings tended to dissipate or disappear among socially advantaged participants the prospect of making drastic and longterm changes in ones life was particularly traumatic for socially disadvantaged respondents here sandy recalls that she had resigned herself to being sick interviewer so initially when you found out you had diabetes how did you feel about making those changes sandy neglected or deprived like i was making a sacrifice … sandy then said she has since given up fighting back due to her age i dont want to get into a war that i cant win this demonstrates two related emotional reactions to the event of diagnosis rita experienced feelings of selfblame while sandy experienced feelings of deprivationturnedsurrender to the illness both emotional reactions are characteristic of diabetes managing them rather than the participants managing diabetes in comparison study participants who were socially advantaged tended to recall feelings of manageability optimism and determination one welltodo participant described her initial disease discovery at a routine appointment with ease and a sense of normalization interviewer when your primary care physician told you that you had diabetes how did you respond katherine i thought no surprise there i really felt thatno surpriseand ive seen enough people having to manage diabetesshe said its type ii and it could stay like that for a long time so we will treat it with exercise and diet linda who considers herself financially comfortable also recalls diagnosis as an event wrought with emotions like sandy linda felt deprived or victimized upon diagnosis unlike sandy and rita however linda described diagnosis as the motivation to successfully manage her diabetes linda you just step up to the plate and do what you have to do interviewer anything else that you would like to comment on regarding when you first found out you had diabetes and your feelings then l well it was kind of depressing you feel why me you know thats about it our interview respondents across the socioeconomic spectrum suggested that fear depression and even denial are typical emotions that emerged during the initial discovery of diabetes most of the participants who responded with neutral feelings or normalization of the illness at the time of disease discovery described their financial situations as favorable thus socially advantaged respondents were more likely to perceive the diagnosis of diabetes as a manageable process the analysis of transcripts revealed a pattern of comments from socially advantaged respondents such as so what no big deal i can handle it and something to work with differences in perceived manageability could explain much of the socioeconomic differences in subsequent adherence to a regimen theme 3 diabetesrelated knowledge what participants knew about diabetes and the regimen prior to diagnosis also influenced the discovery experience generally we found that socioeconomically disadvantaged participants had more extensive experience with diabetes in contrast participants who were socioeconomically advantaged had relatively less experience with diabetes but held more knowledge about diabetes and its regimen rita knew type 2 diabetes could lead to severe outcomes several of her immediate and extended family members had suffered extreme complications associated with the illness she was unaware she had diabetes despite diabetesrelated symptoms and personal experiences with diabetes rita described her financial situation to be a struggle and recalled the lifestyle that could have exacerbated her diabetes prior to diagnosis came with the territory of her job after having the symptoms i drank a whole lot of water i was also still working in advertising so i was drinking cocktails and eating a lot of food and doing the things you shouldnt be doing with diabetes despite her personal experience with diabetes she lacked knowledge to recognize that the symptoms she was experiencing were actually diabetesrelated complications further she was not aware at the time that her workrelated lifestyle was further aggravating her symptoms through analysis of the interview data it became apparent that having previous knowledge about diabetes and the regimen as well as having previous experiences viewing complications unfold among loved ones shaped the experience of diagnosis and attitudes toward diabetes previous knowledge prepared participants to modify lifestyles while having known others who experienced diabetes provoked fear of extreme outcomes among participants socioeconomically advantaged participants had greater access to information about diabetes prior to diagnosis while disadvantaged participants had witnessed more extreme diabetes cases particularly among friends and family milly knew little about diabetes prior to diagnosis she had barely enough to get by during adulthood and at the time of diagnosis millys familiarity diabetes was limited she had an acquaintance with diabetesrelated complications when milly was diagnosed her main concern was the possibility of developing devastating complications if she did not make dramatic changes in her lifestyle interviewer and how did you feel about making those changes milly i didnt like it but you knew you had to my husband had a friend that he was in the navy with that had diabetes and didnt believe his doctor and he wouldnt take his medicine or anything lost his toe lost his foot and then lost his leg and then he died it was fear that motivated milly to adhere to her diabetes regimen this is in contrast to lindas initial reaction who considered herself to be in a more financially comfortable situation interviewer what were your initial thoughts upon finding that you were diabetic linda well youre afraid that youre going to have to go on shots and i have been hypoglycemic a few times so you have to watch that real closely thats the low in a concurring example margaret illustrated how her knowledge of diabetes prior to diagnosis partly due to her social connections prepared her for the realities of the life changes that come with a diagnosis of diabetes interviewer what did you know about diabetes before you found out you had it margaret i probably knew everything about diabetes before i found out my sister the doctor had always said we were going to get it because we were overweight as suggested in theme 1 above she was ready to take action to modify her lifestyle at the time of diagnosis despite originally feeling angry with herself for becoming diabetic margaret did not carry with her the implicit concern of experiencing extreme diabetesrelated complications rather she focused on lifestyle changes the diabetesrelated information she received from her sister reduced many barriers others face in making changes quickly further she had access to financial resources and did not face the cost barriers less advantaged participants confront behavior and emotions were influenced by exposure to friends or family who suffered from extreme complications associated with type 2 diabetes participants shared feelings of aversion stating that they did not want to end up like their mother similarly the subjects who were interviewed reflected on their family members experiences and discussed initial worries about having to go on insulin or fear of losing a limb while higher sss participants also were frequently exposed to friends and family members with type 2 diabetes this tended to be later in the life course further these participants did not tend to mention severe outcomes such as amputations or death for disadvantaged participants such as milly negative feelings are often targeted around a worst case scenario the concerns shared at the time of diagnosis were primarily about potential complications and not with the process or lifestyle changes that would have to be made theme 4 opportunities to gain knowledge overwhelmingly socioeconomically disadvantaged participants did not want to attend diabetes classes classes were described as less accessible or not culturally appropriate betsy is a participant who described her financial situation as always a struggle betsy recalled her experience attending a diabetes education class as negative and coerced i didnt get it in response to her physicians request that she attend further classes she explained i didnt want to do it period thats how i feel about it in contrast higher sss participants reflected positively upon their diabetes classes katherine who is welltodo and had a relatively favorable disease discovery experience reflected on diabetes classes as an opportunity to learn more about successful diabetes management interviewer so your initial feelings when she told you that you had diabetes you felt you could handle it so what did you think about the changes she wanted you to make katherine i didnt know what a diabetes diet is she said they have a very good education program at local hospital and you need a prescription referral and i did go there and i was really intriguedi thought it was great3 different sessions for 2 to 3 hours at a time people with different experiences there but i learned a lot more about nutrition and particularly carbs i was very diligent when i first started from katherines discussion of the diabetes program she attended we can observe that although the program itself was free there were additional accessibility concerns first it required a large time commitment which might not be possible for those balancing multiple jobs and obligations second classes followed a classroom instruction style which would likely be more familiar be less intimidating and more engaging for patients who have completed higher levels of education classes also required appropriate medical referrals finally classes assumed access to transportation and the ability to buy and obtain ingredients and supplies required for adhering to the regimen as described these interviews suggest that such opportunities to learn about diabetes and its regimen might be more accessible to more affluent patients in most cases participants who were at greatest need for these resources often did not find them appropriate or accessible discussion the theory of constrained choices could be used to examine how socioeconomic experiences relate to health and illness experiences among women with diabetes bird and rieker use constrained choice theory to analyze gendered disparities in health over the life course we draw on the theory as envisioned by bird and reiker except we suggest that diagnosis experiences provide insight into the processes by which health disparities are exacerbated over the life span further we find that diagnosis experiences should operate as a critical intervention period social systems generate inequalities which is exacerbated over the life span through developmental and demographic processes while individuals are a part of these social forces human agency is constrained by the opportunities structured by social institutions and culture thus opportunities for individuals to exercise agency in health behaviors such as regimen adherence could be constrained by economic realities these constraints could be activated in multiple realms such as constraints of information finances culture priorities and access for example external forces such as the cost of diabetesfriendly foods could make it disproportionately more difficult for disadvantaged groups to adhere such constraints could lead to different initial experiences and timing of diagnosis as well as subsequent health behaviors compounding into divergent health outcomes the findings are consistent with the theory of constrained choices socioeconomic constraints were demonstrated through different situations of diabetes discovery the degree to which one feels diabetes is manageable the extent of diabetesrelated knowledge before diagnosis and opportunities to gain knowledge shortly thereafter due to these constraints women reporting lower sss had particularly adverse disease discovery experiences the qualitative findings provide examples of mechanisms that illustrate how diabetes experiences are influenced by socioeconomic factors this overall finding is fundamental because ones perspective at initial disease discovery influences the patients world view level of engagement in services and the point of departure from which selfmanagement begins women reporting relatively lower sss presented to physicians after diabetesrelated complications became apparent learning that one has diabetes through a routine or annual examination is a favorable method of disease discovery because it allows for earlier detection more effective treatment options and preventive therapies from the onset of diagnosis less favorable methods included discovering diabetes in the later stages once symptoms such as excessive thirst foot pain or blurred vision have developed into a complication prompting a medical visit previous research has shown that a later diagnosis of diabetes is associated with a higher risk of mortality or morbidity our findings are consistent with previous qualitative research that focused on other chronic diseases suggesting that socioeconomic variations in diagnosis timing partially explain socioeconomic differentials in chronic illness outcomes negative emotions at disease discovery relate to micro and macro social conditions differences can be seen at the individual level or at community levels it is valuable to realize the sources of strain and culturalenvironmental contexts to best serve disadvantaged populations the findings suggest a later and more traumatic diagnosis for less privileged respondents relatively lower sss women tended to report concerns regarding potential outcomes while relatively higher sss women concentrated on lifestyle change during the disease discovery process the diagnosis of chronic disease has been identified as traumatic from a patients perspective while our results show that initial concern at disease discovery appears over the socioeconomic spectrum the way these emotions are activated do vary the analysis shows differences in emotional states at the time of diagnosis by sss which can provide relevant information for practitioners who provide diagnoses while some individuals view the potential for negative consequences as a motivating force to manage diabetes ensure longevity and maintain good health for others fear can be debilitatingleading to avoidant behaviors and reduced adherence levels our study suggests that among socioeconomically disadvantaged adults with diabetes fear of negative outcomes is not a motivating factor for adherence over time negative feelings of selfblame and frustration can reduce selfefficacy particularly with diet exercise and patient education this is a significant finding since it provides evidence of the mindbody connection which has been supported throughout the literature to link emotional issues to body functioning particularly for women further it emphasizes the illness discovery stage to be an important stage for adapted identity formation diagnosis could be an ideal time for healthpromoting interventions particularly for socially disadvantaged patients conclusions this research provides unique insight into the perspectives and perceptions of type 2 diabetics during the disease discovery process and beyond the findings are innovative in the identification of how constrained choices leads to less favorable circumstances of diabetes diagnosis the differential diagnosis by sss is a process by which health disparities are exacerbated in the experiences and outcomes of diabetes our findings emphasize the importance of the disease discovery process as an opportunity for health promotion interventions ideally physicians nurses social workers nutritionists and other health practitioners should follow through with supportive phone calls or educational literature to emphasize the importance of regimen adherence the women in our study specifically stated that their doctors did not answer all of their questions but a sizeable body of research has similarly shown timely and integrated postdiagnosis care to be highly effective among diabetics additionally patient recommendations should be individually tailored to specific learning preferences health literacy levels and socioeconomic resources individuals without adequate transportation or work schedule availability may not consider a diabetes lecture a priority further research should investigate the openness and cultural competency of diabetes classes to different socioeconomic groups emphasizing the opportunity to create a space for processing the information and gaining social support from other diabetics in other studies preferences in health education courses have been found to differ by the degree of formal education to which one has obtained and has a hidden advantage for patients with greater resources and economic security formal classes are often tailored to those who are educated at universities while patients with less education might benefit from a lateral learning or peerbased approach at the time of or shortly following diagnosis patients should be provided with superior medical counseling a practical education a realistic plan of adherence as well as connection to longterm support systems the findings are based on selfreported data and are based on current evaluations of subjective social status despite efforts to assist participants with recall recall and interpretations of events can be subject to bias over time further evaluations of sss could have changed from the time of diagnosis to the interview period despite these limitations this article offers a unique contribution to the understanding of processes of how socioeconomic disparities in diabetes outcomes and adherence particularly relating to the experience of disease discovery and diagnosis implications for health workers these research findings have strong implications for community health workers who hold a significant role in connecting both the individual patient to services as well as partnering with the larger medical systems to make institutional based changes for those suffering from chronic illness the expertise of social workers and nurses can provide vital health education as well as assistance linking patients to natural social supports and community resources that are available based on the findings it would be valuable to connect patients to one another at initial disease discovery to help set realistic regimen adherence goals that fit with the individuals life experiences health literacy level and cultural background this would be of particular importance to members of socially disadvantaged groups who may require more assistance processing what it means to be diabetic how to access care and utilize medical services

the purpose of this article is to examine whether or not subjective social status sss contributes to diabetes diagnosis and disease discovery experiences eighteen diabetic women participated in semistructured interviews interview transcripts were reviewed and coded using interpretative phenomenological analysis several general themes emerged from the data analysis sss shaped different experiences through a situations of diabetes discovery including the circumstances and stage of diabetes at the time of diagnosis b the degree to which participants considered diabetes to be manageable c the extent of diabetesrelated knowledge and experience before diagnosis and d opportunities to gain knowledge shortly thereafter due to these constraints lower sss individuals had particularly adverse disease discovery experiences the findings are consistent with the theory of constrained choices implications for practitioners and for future research are discussed

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background most smokers have tried to quit and many try repeatedly without success providing alternatives in the form of nicotine replacement therapy has been shown to facilitate longterm cessation 1 smokers should be properly informed about ways they can reduce their risks of harm 2 as far as we know there are no serious health effects of use of nrt to quit as a result nrt is increasingly available over the counter outside of pharmacies the limited available evidence also shows that use of nicotine replacement products for up to at least 5 years is safe 3 evidence from use of the lowest toxin forms of smokeless tobacco suggests that even longer use can be done with much lower risks compared to smoking 4 the available evidence shows that nicotine is not a carcinogen 5 although it may be a cofactor in the cause of cancer 6 tobacco products are on the whole more harmful than pure nicotine as they contain other toxins and in the case of smoked products are taken into the lungs which is more sensitive tissue than the stomach typically smokeless forms of tobacco are less harmful than smoked forms and there exist low toxin forms that produce few of the adverse effects of other tobacco products 7 while many existing smokeless products are very harmful low nitrosamine versions like swedish snus have been estimated to be 90 95 less harmful than cigarettes when used longterm 4 and others contend it is even less harmful 9 there is no doubt that the toxicity of slt can be systematically reduced without it unduly reducing user acceptability something that has not been achieved for smoked tobacco in sweden more exsmokers report having quit using slt than nrt including some who continue to use it as a longterm substitute 1011 and recent studies in norway report similar findings 1213 slt is not available in some western countries being banned in australia and new zealand and all european union countries other than sweden it has remained available in the us and canada despite this most smokers are misinformed about the safety and efficacy of both nrt and slt for example one study 14 found that a majority of us smokers erroneously believed that nicotine is a cause of cancer while another found a large minority in four countries held the same misbelief in 2002 with it more prevalent among low socioeconomic status smokers 15 the misinformation may be a barrier to use of it as an aid to quit smoking or for premature discontinuation oconnor and colleagues 16 reported that less than 20 of smokers in canada the us the uk and australia believe that any smokeless products are less harmful than cigarettes though this analysis appears to have underestimated knowledge particularly in the uk and australia even in sweden where slt use is higher than smoked tobacco among males 17 a recent study has shown that swedish cigarette smokers are misinformed about the relative safety of slt 18 the facts about relative harms and smokers lack of knowledge on this has gained some public exposure eg 1920 so it is of interest to see whether there has been any improvement in smokers knowledge the country where improvements in knowledge might be most likely is the uk the royal college of physicians published two high profile reports one on nicotine addiction and smoking in 2000 21 and the other in 2007 9 focusing on nicotine addiction and harm reduction both reports received public coverage about the role of nicotine in smoking and the second report in particular explored the role that different forms of nicotine delivery including nicotine replacement therapies and low nitrosamine slt products could play in a harm reduction strategy based in part on this knowledge base the uk smoking cessation strategy has involved training a national cadre of stop smoking advisors and specialists from a variety of health professional backgrounds to give advice and support to smokers wishing to quit 22 typically it has involved increasing knowledge about nicotine dependence and relative harms of nrt compared with smoking stop smoking advisors and specialists are also trained to interact with primary care professionals to enhance their knowledge and increase referrals to stop smoking services the uk also changed its licensing requirements for nicotine replacement medications permitting them to be given to pregnant women and labelled for used as a substitute for smoking 23 so the message about stopsmoking medication not being harmful to health is one that is likely to be widely promulgated to uk smokers there have also been a lot of mass media campaigns around nrt from pharmaceutical companies and some governmental campaigns that may also have helped to profile these messages the aim of this paper is to assess any trends in beliefs about the harmfulness of nicotine itself stopsmoking medication including nrt and slt over the last 4 to 7 years in canada the us the uk and australia this paper also examines the extent to which the beliefs vary by sociodemographic group and how beliefs about nicotine related to use of nrt and slt products method data collection and sample the itc4 is an annual survey conducted via computerassisted telephone interview in canada uk usa and australia respondents are selected via randomdigit dialling to ensure a broadly representative sample all respondents are smokers at the time of recruitment but are retained at followup surveys if they quit smoking at each wave approximately 30 of the sample is replenished from the original sampling frame a detailed description of the itc projects conceptual framework 24 and methodology 25 can be found elsewhere for this study we selected respondents who were current smokers at the time of each of the seven itc4 waves table 1 shows the number of eligible respondents at each baseline survey and the distribution by demographic characteristics demographic trends remained fairly stable across the survey waves although the sample was significantly older and of higher socioeconomic status at wave 7 compared to wave 1 measures main outcome measures beliefs about the safety of nicotine and alternatives to smoked tobacco to assess knowledge of the relative harm of slt respondents were asked are you aware of any smokeless tobacco products such as snuff or chewing tobacco which are not burned or smoked but instead are usually put in the mouth those who said yes were asked as far as you know are any smokeless tobacco products less harmful than ordinary cigarettes those who answered yes were asked whether they are a lot less harmful or less harmful respondents who answered no were asked whether they are more harmful or the same two measures were created with 1 less harmful vs all other responses and 2 a lot less harmful vs all other responses because there is a wide range of slt forms and we did not explore precisely what product respondents were considering in giving their answer we considered both less harmful and a lot less harmful to be correct answers due to an error in the survey a substantial number of respondents were not asked this question at wave 4 and as such we do not report data for the wave 4 survey to assess knowledge of the harmfulness of nrt compared to smoked tobacco respondents were asked as far as you know are nicotine replacement medications less harmful than smoking cigarettes those who said yes were asked whether they are a lot less harmful or less harmful respondents who said no were asked whether they are more harmful or the same a dichotomous measure was created with the correct belief lot less harmful vs little less harmfulsamemore harmful dont know the correct answer is a lot less harmful at each wave beliefs about the harmfulness of stopsmoking medication were assessed by asking respondents to indicate on a fivepoint scale whether they 1 strongly agree through to 5 strongly disagree with the statement stopsmoking medications might harm your health a dichotomous measure was created with agreeneither agree nor disagreedont know vs disagree with the latter treated as the appropriate answer at each wave knowledge about the cancer risk posed by nicotine was assessed by asking respondents whether the statement the nicotine in cigarettes is the chemical that causes most of the cancer was true or false the correct answer is false recent use of any stopsmoking medication and nrt at waves 1 and 2 respondents were asked whether they had used any stopsmoking medications in the previous 6 months from wave 3 onwards they were asked about this in reference to the last survey to assess use of nrt specifically respondents were then asked the last time you used medications to quit smoking which product or combination of products did you use respondents were read a list of current products available including nrt and nonnrt prescription medication and asked to indicate which ones applied a dichotomous measure was created with used nrt vs other medication or none at all recent use of smokeless tobacco at waves 1 and 2 respondents who were aware of slt products were asked whether they had used any slt in the previous 6 months from wave 3 onwards they were asked about this in reference to the last survey demographics demographic variables included age sex country and socioeconomic status ses was derived from separate tobacco dependence dependence was assessed using the heaviness of smoking index 26 the hsi was created as the sum of two categorical measures number of cigarettes smoked per day 1 1120 cpd 2 2130 cpd 3 31 cpd and time to first cigarette the hsi was then recoded into three categories of dependence low 0 to 1 moderate 2 to 3 and high 4 to 6 analysis bivariate correlations were performed to explore associations between different belief measures chisquare tests were used to examine country differences in reported past year use of slt and stopsmoking medications at each wave a separate multivariate analysis was run for each of the four beliefs to determine whether there were overall differences by country and each of the other covariates in order to control for the correlations between responses from respondents who had data on multiple wavetowave transitions the multivariate models were tested using a generalised estimating equation 27 with binomial variations logit link function and an unstructured correlation structure to explore whether there was a systematic longitudinal trend in each belief survey wave was included all variables were entered as a categorical variable except survey wave which was treated as a continuous variable we subsequently tested interactions between survey wave and country and between country and the sociodemographic variables only significant interactions will be discussed in the results all reported frequencies and analyses are based on weighted data to control for sampling and attrition biases due to age sex and geographic region statistical significance is set to p 05 all analyses were performed using stata v10 results table 2 shows the usage of stopsmoking medications and slt in the four countries at each wave use of nrt declined after wave 5 in canada the uk and australia and after wave 6 in the us use of any ssms increased up to wave 5 but then may have stabilised indicating an increased use of prescriptiononly medications in the last two waves nrt use remains the strongest in the uk slt use was most common in the usa and there were no trends over time overall there were low correlations all in the expected direction between each of the beliefs suggesting some inconsistency in respondents knowledge about the safety of slt or nicotine alternatives the strongest association was the belief that nrt is a lot less harmful than smoked tobacco being positively associated with disagreeing that stopsmoking medication might be harmful to health we looked for any notable change in the strength of these associations across waves but found none nor was there any systematic difference in these correlations between countries belief that nicotine is not the chemical that causes most of the cancer whilst respondents in the uk were least likely to report that nicotine is not the chemical that causes most of the cancer between waves 1 and 4 from wave 5 the difference between countries was not significant the interaction between survey wave and country was significant correctly reporting that nicotine is not the chemical that causes most of the cancer significantly declined in canada and the us whilst significantly increasing in the uk and australia overall males those of higher ses younger respondents those higher on the hsi and those who had used any ssm or had used slt in the past year were more likely to hold this belief beliefs about the safety of stopsmoking medications compared to respondents in canada the us and australia respondents in the uk were more likely to report that nrt is a lot less harmful than smoked tobacco at each wave overall males those of higher ses and those who had used nrt in the past year were more likely to hold this belief the interaction between survey wave and country was significant this belief increased significantly in canada the us and the uk but not australia the interaction between country and gender was also significant males were significantly more likely than females to hold this belief in canada and australia but not in the us or the uk at each wave respondents in the uk were the most likely to disagree that stopsmoking medications might be harmful to health the interaction between survey wave and country was significant the proportion of respondents disagreeing that stopsmoking medications might harm health significantly increased in canada the uk and australia whilst significantly decreasing amongst us respondents overall males those of moderate to high ses and hsi and those who had used nrt in the past year were more likely to hold this belief significant interactions were also found between country and age group ses and gender there was no significant age effect in canada or australia in the us those aged 40 to 54 were significantly more likely to hold this belief than 18 to 24 year olds in the uk those aged over 55 were significantly less likely than 18 to 24 year olds to hold this belief compared to low ses high ses smokers were more likely to hold this belief in canada and the us whilst moderate ses smokers were more likely in the uk there was no ses effect in australia a significant gender effect was found only in canada where men were significantly more likely to hold this belief than women belief about the safety of smokeless tobacco reported awareness of slt products was highest in the us at each wave and lowest in the uk the mean proportion of smokers aware of slt in canada and australia was 729 and 611 respectively being aware of slt was associated with being male high ses and aged 39 or under among those aware of slt reporting that there are forms of slt less harmful than smoked tobacco was highest in the uk at each wave although not significantly different from australia between waves 1 and 5 between wave 5 and 7 the proportion in the uk increased from 283 to 401 compared to only 273 to 297 in australia the interaction between survey wave and country was significant the proportion in canada and the us did not significantly change whilst it significantly increased in the uk and australia overall males younger respondents those of higher ses and those who had used slt in the past year were more likely to hold this belief the interaction between country and gender was significant males were significantly more likely than females to hold this belief in canada and the us but not in the uk or australia the interaction between country and age group was also significant respondents aged 18 to 24 years old were significantly most likely to hold this belief in the uk and australia only the age variable was not a significant predictor in canada or the us despite an improvement in this belief among smokers who were aware of slt among all smokers this knowledge showed no significant linear improvement in any of the four countries in the uk there was a significant increase between wave 6 and 7 this was primarily due to increased awareness of slt in the uk between waves 6 and 7 from wave 3 smokers who were aware of slt and reported that it was less harmful than smoked tobacco were asked whether it was a little or a lot less harmful as a proportion of smokers aware of slt there was no significant improvement in the knowledge that some forms of slt are a lot less harmful than smoked tobacco in any of the four countries overall uk smokers were significantly more likely to report that slt is a lot less harmful than smokers in canada the us and australia table 4 presents the results of the gee analyses for each of the four beliefs showing the main effects for country and sociodemographic factors overall respondents who were better informed about the safety of nrt and slt relative to smoked tobacco were more likely to be aged 18 to 24 male and of high ses the same demographic profile was found for respondents who agreed that nicotine is not the chemical that causes most of the cancer respondents who disagreed that canada us uk au figure 1 the proportion of respondents who correctly reported that nicotine is not the chemical in cigarettes that causes most of the cancer by country stopsmoking medications might be harmful to health were more likely to be of moderate to high ses and there were varying associations with age across the four countries we found no evidence to suggest that the uks overall better knowledge about the safety of alternatives to smoked tobacco was confined to any particular sociodemographic group discussion knowledge about the relative harmfulness of tobacco products and nicotine remains low and the situation is worse among those of low ses and in most cases female smokers in late 2008 only about a half of smokers correctly reported that nicotine is not the chemical in cigarettes that causes cancer and the proportion having this correct belief had only increased in recent years in the uk and australia however in australia this was not matched by an increase in the belief that nrt is a lot less harmful than cigarettes which increased in the three other countries in canada and the us where slt is legally available only around one in six smokers believed that some slt products could be less harmful than cigarettes no noticeable change over the seven years of study suggests that this perception is entrenched in the minds of most smokers it is somewhat intriguing that smokers in the uk and australia countries where most slt products are banned appeared to be better informed about the the proportion of respondents who disagree that that stopsmoking medications might be harmful to health by country the only country in our study where there was consistent evidence of improving knowledge about the relative health dangers of smoking to alternative forms of nicotine delivery was in the uk where significant efforts have been made over the past decade to promote the use of nrt as a substitute for cigarettes the main strength of this study is the broadly representative nature of the sample of smokers in each country coupled with the capacity to weight the data to improve the accuracy of estimates the main weakness is that this study only recruited cigarette smokers so users of other tobacco products are not represented unless they also smoke cigarettes thus this study has nothing to say about the views of other tobacco product users in general the finding that each of the four beliefs we studied although logically related given the evidence were largely independent of one another suggests there is a low level of real understanding among smokers even among those who know some of the correct answers this is an important gap in knowledge with potential adverse public health implications if it leads to underuse of nrt and other medications or if it leads to continued use of cigarettes instead of seeking out harmreducing alternatives further research is required to explore whether misinformation is a deterrent to using alternatives to smoked tobacco the entrenched incorrect beliefs in north american smokers suggest that mere availability of the products with the attendant commercial activity encouraging their use is insufficient to produce adequate consumer knowledge regardless governments have a responsibility to ensure that something is done we suspect that part of the problem is that smokers are generalising from their knowledge of cigarettes to assume all tobacco products indeed anything to do with tobacco is seen as bad manufacturers of these products have clearly failed to educate consumers about the relative health benefits of using alternative forms of tobacco compared to cigarettes whether we should expect them to improve their consumer education or have government take over this role is unclear and may vary by jurisdiction with the advent of fda regulation of tobacco products in the usa including a mechanism for approval to market products as modifiedrisk and evidence for growth of the slt category the opportunity may present itself in the near future to provide the kind of public education that is so clearly needed other countries will need to develop comparable mechanisms in conclusion smokers remain misinformed about the relative safety of nicotine and tobacco products though some hopeful signs for improvement are evident in the uk where there have been concerted efforts to educate health professionals and through them the public about stop smoking medications authors contributions rb conceived of the study drafted parts of the original draft and supervised all aspects jc conducted the statistical analysis and drafted sections of the manuscript rb am roc and kmc participated in the design of the study and the interpretation of the results all authors participated in revising the manuscript and read and approved the final manuscript competing interests the authors declare that they have no competing interests liang

background evidence shows that smokers are generally misinformed about the relative harmfulness of nicotine and smokeless forms of nicotine delivery in relation to smoked tobacco this study explores changing trends in the beliefs about the harmfulness and use of stop smoking medications and smokeless tobacco in adult smokers in four countries where public education and access to alternative forms of nicotine is varied canada the us the uk and australia methods data are from seven waves of the itc4 country study conducted between 2002 and 2009 with adult smokers from canada the us the uk and australia for the purposes of this study data were collected from 21207 current smokers using generalised estimating equations to control for multiple response sets multivariate models were tested to look for main effects of country and trends across time controlling for demographic variables results knowledge remained low in all countries although uk smokers tended to be better informed there was a small but significant improvement across time in the uk but mixed effects in the other three countries at the final wave between 375 us and 614 uk reported that nrt is a lot less harmful than cigarettes in canada and the us where smokeless tobacco is marketed only around one in six believed some smokeless tobacco products could be less harmful than cigarettes conclusions many smokers continue to be misinformed about the relative safety of nicotine and alternatives to smoked tobacco especially in the us and canada concerted efforts to educate uk smokers have probably improved their knowledge further research is required to assess whether misinformation deters smokers from appropriate use of alternative forms of nicotine

19851_0

background in the united states the south is the region hardest hit by the hiv epidemic although the region contains only 36 of the us population it accounts for more than half of persons living with hiv and 40 of new infections racial disparities in hiv rates are striking although african americans represent 19 of the regional population more than half hivaids cases in the south occur among african americans the disparate burden of hiv among african americans in the us is not due solely to individuallevel behaviors social context contributes to the spread of hiv and may be particularly important in african american communities which tend to be socially segregated and characterized by higher rates of poverty unemployment and incarceration than other communities these social and economic disparities act synergistically to increase the likelihood of high risk behaviors and overlap between individuals in low and higher risk sexual networks the impact of these disparities can be magnified for african americans in rural communities where longstanding social and economic segregation are often present although early hiv research and prevention interventions focused on changing individual risk behaviors most recent efforts attempt to address multiple contributing factors simultaneously these multilevel interventions are complex employing various intervention approaches simultaneously making implementation evaluation and dissemination of these interventions difficult however few multilevel hiv prevention interventions have been developed tailored or tested in rural communities for african americans or other racial groups developing effective hiv prevention interventions that have broader sustainable effects that extend beyond individual behavioral change remains an ongoing challenge for the field accomplishing these efforts in rural communities where the number of service providers and the hiv advocacy communities are often small where populations tend to be spread out and in the context of more conservative values and hiv related stigma can make engaging community members more challenging in this paper we describe the approach we used to develop a multilevel hiv prevention intervention in two rural counties in north carolina researchers at the university of north carolina with others who had worked in these two counties for several years on a variety of public health initiatives responded to community concerns about the hiv epidemics disparate impact on african american communities and worked collaboratively to establish an academiccommunity partnership to address these concerns to ensure that our intervention addressed critical factors influencing hiv risk in these communities and to maximize sustainability and community engagement we integrated communitybased participatory research methods with intervention mapping a structured approach to intervention design intervention mapping has been used to develop health promotion programs and produces a framework that links health behavior theory and performance objectives with specific methods and strategies im is not a partnership we chose im as our method of intervention development process using a structured approach that moves from theory to practice our academiccommunity partnership chose im as our method of intervention development because consistent with cbpr principles im allows maximal participation of all partners in the planning process acknowledges the role of behavioral and environmental factors in health outcomes and explicitly draws on health behavior theory as the basis for program development although a number of papers in the published literature describe the use of im for public health intervention development including hiv prevention interventions we could find none that described the use of im within a cbpr framework in this manuscript we describe how we integrated im methodology with cbpr principles to develop a multigenerational hiv prevention intervention for two rural african american communities this paper will focus mainly on the process of integrating these two methodologies rather than on describing the resulting intervention in detail method community setting north carolina reports some of the highest rates of hiv in the southern us with almost twothirds of these cases occurring among african americans our communityacademic partnership project grace serves nash and edgecombe counties two predominantly rural counties in eastern north carolina both counties are experiencing some of the highest rates of hivaids in the state and the most significant hivsti disparities nash county ranked 16 th and edgecombe county 3 rd among north carolinas 100 counties in the threeyear average rate of new hiv cases for 20052007 in nash county 82 of people with hivaids in 2006 were african american although only 34 of the countys population was african american in edgecombe county 86 of hivaids cases were african american where african americans make up 58 of the county population communityacademic partnership structure project grace was formed in 2005 in response to community members concerns about the growing hiv problem in the two counties preexisting ties between the academic partners and community stakeholders in these counties facilitated the development of this partnership in prior formative work hiv disparities had been described as one of three major health concerns among community based organizations and lay community members in addition several stakeholders and community leaders from nash and edgecombe counties expressed a desire to collaborate with an academic center in their focus on the hiv epidemic in their counties in recognition of this health crisis the decision was made to create a communityacademic partnership with the explicit mission of addressing health disparities in the two counties with hiv as the initial focus the process for developing the project grace partnership the challenges in doing so and lessons learned have been described in detail elsewhere in brief to create our academiccommunity partnership we used the staged approach to partnership development described by florin mitchell and stevenson they describe four early stages of partnership development initial mobilization establishment of organizational structure capacity building for action and planning for action these initial stages focus on the cbpr principles of engaging community partners broadening the base of community support identifying the strengths and capacity of community representatives delineating roles for academic and community partners ensuring shared decision making developing organizational infrastructure capacitybuilding to support subsequent action steps and planning for action in our approach activities at each stage occurred in parallel with the intended result of reinforcing and strengthening the collaboration through a cyclical and iterative process of partnership development the key tasks and activities we engaged in associated with the first steps in florins model are shown in table 1 during the initial mobilization university investigators and community partners from each county reached out to community members through a series of open meetings to discuss the local hiv epidemic assess the interest of other established community based organizations to address the problem and discuss available funding mechanisms after funding was obtained a locally recruited community outreach specialist engaged a broad array of additional partners including general and key members of the target communities leaders of local cbos public health agencies and multidisciplinary researchers from university campuses we established an organizational structure involving a consortium and steering committee the consortium includes broad community representation from the two counties to ensure communitylevel oversight of partnership activities the 26 member steering committee is charged with the management and conduct of all projectrelated activities and is comprised of representatives from all subcontracting community partner organizations and community leaders in each county the consortium and steering committee provide a system of checks and balances on one anothers decisions and activities separate working subcommittees report to the steering committee and function to conduct the business of project grace six subcommittees tackle logistical aspects of project activities with subcommittee members representing our broader membership and reporting back to the steering committee as one of our early partnership activities we conducted formative research to identify community needs and assets as they related to hiv risk in the target community this comprehensive approach gave us collective confidence that the interventions we developed would be based on a thorough understanding of the needs of the target population and would build on existing community capacity to ensure sustainability in the sections that follow we detail the process by which we integrated our cbpr approach with im to develop our intervention intervention mapping intervention mapping is carried out in a series of steps from review of relevant data through evaluation we focus here on the first 4 steps related to intervention development step 1 involves assessing needs and assets step 2 includes developing matrices of change objectives and consists of the following tasks defining health promoting behaviors specifying performance objectives for health promoting behaviors deriving behavioral determinants of performance objectives from theory literature and practice and specifying and creating a matrix of learning objectives to link performance objectives with specific determinants step 3 involves specifying intervention methods and translating methods into practical strategies step 4 includes producing program components step 1 formative research on needs and assetswe conducted 11 focus groups during the spring and summer of 2006 with community youth ages 16 to 24 adults ages 2545 and formerly incarcerated adults we also conducted 37 key informant interviews in the fall and winter of 2006 the full methods have been described elsewhere we recruited through local cbos using flyers print and radio advertising and snowball sampling in keeping with our desire to involve community members throughout the research process we recruited hired and trained moderators note takers and interviewers from the local communities all were trained by a professional african american owned qualitative research firm to conduct the focus group and individual interviews the moderator and individual interview guides were developed jointly by community and academic members of the research and design subcommittee one of the six subcommittees of the steering committee the design and implementation of the coding strategy and all analyses were conducted with teams of analysts comprised of academic and community members to ensure validity of the findings through this intensive review and analysis of our assessment we decided to focus on hivsti prevention in youth step 2 developing matrices of learning objectives preparing for intervention mapping colearning on applying health behavior theory after collecting the formative data we conducted im with the entire steering committee and laymembers of the community in an intensive series of allday workshops small group conference calls and inperson meetings of subgroups where all partners were involved in each step of the process during may 2007 through january 2008 as one aspect of capacity building and colearning to ensure that all partners understood the im methods and had a working knowledge of health behavior theory we conducted a half day primer for community partners investigators and research staff that introduced the theoretical framework for several behavioral theories that could be relevant to our work and underscored the role of health behavior theory in development of effective interventions we used written simplified summaries of a number of major theories supplemented with didactic and small group discussion this provided an opportunity for collective discussion regarding the importance of theoretically grounding interventions reviewing the relevance of constructs from different theoretical models as well as answering questions about and clarifying the im process intervention mapping workshop the primer session on health behavior theory was followed by an intensive twoday workshop that initiated step 2 of the intervention development process the first half day of the workshop included an overview of im methods as well as a recap of the findings from the formative research training was conducted by a project staff person with prior training and experience using im methods and by steering committee members who facilitated the small group sessions and the recap of research findings the subsequent halfday session was a working group session in which small groups comprised of both academic and community partners brainstormed lists of intervention goals to target in order to address the high hiv rate in the target communities the second day of the workshop we reconvened as a large group to refine and determine the initial set of behavioral outcomes and to specify the associated performance objectives via consensus postworkshop intervention mapping activities in small groups comprised of academic and community partners we worked on the remaining tasks of step 2 over the next 4 months these tasks included refining performance objectives identifying behavioral determinants and creating matrices we accomplished these tasks through an iterative process in which groups of community and academic partners further refined the proximal behavioral and performance objectives as they defined the behavioral determinants as the intervention matrices developed each was reviewed by other subgroups and presented to the larger group of collaborators until we reached consensus on completeness consistent with our cbpr principles of colearning and disseminating early products of our work periodic presentations were made to the larger community at consortium meetings this allowed community members and leaders to remain aware of the projects activities and provided an opportunity for them to provide structured feedback final matrices factors that may influence the desired outcomes are referred to as behavioral determinants of the outcome behavioral determinants answer the question why do people engage in the behavior of interest and draws on behavioral theory to suggest the answer matrices are a grid of performance objectives and behavioral determinants for each behavioral outcome in each matrix cell the learning objectives are specified in response to the question what needs to be learned related to this determinant to achieve the performance objective for example what skills are needed to negotiate sexual abstinence the matrices display the answers to these questions for determinants of each performance objective step 3 select theorybased methods and strategiesthe goal of step 3 is to match intervention methods to the learning objectives listed in step 2 by answering the question how can we influence people to meet the learning objectives intervention methods are based on behavioral and social science theories and directly address the determinants of behavior in any given intervention methods are techniques for influencing change in those determinants strategies on the other hand are practical techniques for applying the appropriate methods for the target population and specific planned intervention we again used subgroups of academic and community partners to match intervention methods to the learning objectives step 4 produce program components and materialsthis step in im involves organizing strategies into a deliverable program and results in the actual design of the program including producing the intervention training manuals and workbooks as part of this task we had to determine the program structure theme channels for delivery and program materials continuing with our cbpr framework for im we had a working group of community and academic partners develop the curriculum lessons and conducted a community wide pretest event results step 1 needs and asset assessment focus group and key informant interviews detailed results from our assessment have been described elsewhere participants described behavioral social and environmental factors thought to mediate the high hiv rates in their communities they also made recommendations for what hiv prevention interventions for this community should look like in our focus group and indepth interviews there was a clear message to focus on youth behavior all respondents articulated the need to place those behaviors in the context of the family and community and noted individual and social factors that influence the sexual risk behaviors in youth in our target population in order to reduce the rates of stis and hiv all collaborators agreed that a familybased intervention involving youth and their parents or primary caregivers was needed moreover in order to promote sustainability beyond the duration of the program and to change social norms we chose to use a lha model in which individuals across generations share hiv prevention messages with members of their community although there are a number of hiv prevention programs that involve both caregivers and youth most target only mothers or fathers or they seek to improve sexual health outcomes only in one gender few are culturallytailored for african american parents and those that are focus on lowincome or urban families we also wanted to address the issue of sustainability and building on community strengths for this reason we chose an intervention approach of youthcaregiver dyads serving as lay health advisors we chose to use a lay health advisor model as an intervention framework because this model is adaptable targets change at multiple levels and builds on strong networks in rural african american communities the lha model has proven to be effective in developing both trust and the capacity of community members while building on various sociocultural strengths of african american culture thus enhancing opportunities for sustainability lha hiv prevention programs have decreased risky sexual behaviors decreased illicit drug use increased health knowledge regarding hivaids and led to more realistic perception of personal risk importantly lha interventions provide continuous opportunities for training and capacity building among community members a critical component of success of lha interventions has been the use of cbpr methods during needs assessment and planning of interventions all partners felt that the lha intervention model was in keeping with our overall partnership approach step 2 matrices of learning objectives we established separate intervention goals for youth and their caregivers the intervention goals for youth were to delay sexual initiation and improve engagement in responsible sexual behaviors for those who chose to be sexually active the specific behavioral outcomes identified as necessary to achieve these goals were the following abstinence from sex condom use among sexually active youth and healthy dating and relationship behaviors the intervention goals for caregivers were to improve parenting and communication skills the specific behavioral outcomes identified as necessary to achieve these goals included parental monitoring of adolescents socialdating activities and parental communication about sex and healthy dating relationships we chose to focus on these parenting practices because they have been most consistently shown in prior research to be associated with improved reproductive health outcomes for youth for each behavioral outcome for caregivers and youth we specified an observable subset of behaviors performance objectives that would be necessary to achieve the target outcomes for both youth and caregivers in considering our goals for the program we collectively decided to employ the theory of planned behavior to address individuallevel factors and a teaching model grounded in social cognitive theory to address the influences of the social environment that contribute to risky sexual behaviors among african american adolescents the tpb an extension of the theory of reasoned action suggested that behavioral intention the most proximal determinant of behavior is determined conceptually by attitudes subjective norms and perceived behavioral controls subjective norms are determined by normative beliefs and the motivation to meet those expectations selfefficacy is the belief in ones ability to engage in the behavior which can influence behavior directly or through behavioral intention sct integrates both determinants of personal behavior and methods of behavior change sct proposes that behaviors are performed due to complex interactions between environmental personal and behavioral factors personal factors include behavioral capability self efficacy and outcome expectation environmental factors include social support and social networks our behavioral determinants reflect constructs from these theoretical models excerpts of sample matrices for caregivers and youth that resulted from these steps are shown in table 4 step 3 theoreticalbasis methods and strategies the intervention has two primary components a curriculum for youth that focuses on abstinence condom use and healthy dating relationships and a curriculum for caregivers that focuses on parental monitoring communication about sexual health and healthy dating both curricula include social learning and cognitive behavioral methods in the education of caregivers and youth including modeling of desired behaviors guided practice and elements that improve self efficacy in attaining goals and skills both curricula provide practice opportunities to apply new skills in anticipated and difficult situations and opportunities for guided reflection the sessions emphasize active learning using a variety of instructional strategies step 4 program components and materials description of the teach one reach one interventionafter collectively examining epidemiologic data existing literature health behavior theory and the collected data on the needs and strengths of our communities we designed an intervention that addresses multiple contributors to hivsti risk in african american youth this multigenerational intervention addresses the individual social network and community levels of the social ecological framework by integrating community input throughout the development process and building on the strengths of our community the intervention was designed with particular attention to cultural appropriateness longterm sustainability within the community and potential for dissemination to other communities and organizations because our study design was innovative we drew explicitly from programs that have been demonstrated to be successful emphasizing those that were tested in african americans or rural populations curricular components were drawn from successful evidencebased programs on hivsti prevention focus on kids safer choices becoming a responsible teen making proud choices draw the line and real aids prevention program in our review of existing tested programs there were substantially more interventions that focused on youth than caregivers to address the behavioral objectives for caregivers we had to develop certain components or activities de novo or adapt activities using the theory based strategies and methods as a guide the training sessions are sequential with later sessions building on concepts of earlier ones integrated in each session are skills that lhas will need to reach out to youth and adults around these issues we pretested the curricular components in a 1 day communitywide event we pretested four youth and four caregiver sessions focusing on those that were developed de novo or that were thought to be controversial steering committee members and the community outreach specialist recruited 52 participants to take part in the pretest for each session two steering committee members were trained and served as facilitators to teach the caregiver and youth lessons respectively two other steering committee members served as impartial observers during each session to record time participant reactions to activities successes and challenges in the sessions at the conclusion of each session facilitators led a structured debriefing with participants to elicit their feedback about the session content the overall program objectives and the methods and activities used this allowed us to also pretest the process evaluation methods to ensure the cultural relevance of debriefing questions and to pretest the logistics of conducting all data collection activities the subgroups working on the training sessions were given the written feedback to guide subsequent program revisions discussion intervention mapping has been used successfully for planning health intervention programs including several hiv interventions it has been used to provide a systematic process to develop new interventions as well as to adapt existing interventions to new populations in culturally appropriate ways most of the literature on im include the methods and process but none have described integrating the im process into a cbpr framework we chose im because it could be used within the cbpr framework by including all partners in the process we believed that a participatory approach to im would enable us to better address the issues of hiv that are unique to rural african americans to design a more comprehensive program that fully involves caregivers in the reduction of adolescent sexual risk behaviors and to develop a program that would address change beyond the individual level we found the im process to be feasible to implement within our cbpr framework both community and academic partners were able to participate in every aspect of the process from the design conduct and analysis of the needs assessment to developing the intervention matrices applying the theories and strategies and designing and pretesting a deliverable program this participatory approach resulted in the adoption of an lha model for the intervention which has been shown to be effective when working with african american and rural communities for example the decision to involve caregivers was a direct result of the participatory needs assessment analysis the im process especially steps 2 and 3 enabled us to find acceptable ways to fully involve caregivers in ways that had not been done in prior programs and finally the process resulted in a program that addresses multiple levels of social change several challenges encountered are important to acknowledge first academic and community partners spoke different languages and came to the program development with different perspectives university researchers were more grounded in health behavior theory as well as research and program planning methods we had to find a way for community partners to feel comfortable with this new language we developed the half day workshop to address this challenge by introducing the theoretical framework and behavioral theories and allowing the intervention development process to commence with both academic and community partners at the same table and with a similar knowledge foundation this was a time intensive but necessary process which we would recommend to anyone wanting to use im in a participatory framework the second challenge was that community partners were far more versed than university researchers in what was feasible and culturally acceptable in our communities of interest community partners understood communities collective capacity resources informal relationships and which strategies would be most successful for effecting change university partners had to learn about these social relationships and how to effectively integrate this reality with the research design for the program to be successful this was addressed throughout the entire im process through community input and involvement at every step this cbpr approach to im led to the design of a program that was acceptable to all of the partners and culturally sensitive to the communities served finally one challenge faced by anyone planning to do communitybased work is recognizing and planning for the relatively high turnover of staff at local cbos in this instance staff turnover presented important challenges because new staff will inevitably lack knowledge about the academiccommunity partnership and will have missed participating in both the trustbuilding phase and workshops orienting them to research and program planning methods this lack of familiarity can result in conflicts that challenge both programmatic and partnership success we have addressed this by having multiple opportunities for continued involvement for individuals who are no longer employed by one of the partner organizations for example through committee membership ex officio positions on the steering committee and continued membership in the consortium we have also tried to incorporate into our academic partnership ways to preemptively address this for example having leadership of organizations who tend to experience less turn over sit on the steering committee to ensure their investment in the process and commitment to helping to orient and train new staff conclusion intervention mapping provides a structured approach for hiv prevention program development the inherent structure can be adapted to incorporate the principles of community based participatory research including colearning on a topic of interest sharing of the process and products of research collective decision making appreciation of unique expertise of all partners and research with the intended goal of social change • discuss with your partner alternative activities to sex • avoid situations where you could have sex • refuse to have sex • make the decision to use condoms • buy or obtain a free condom • carry condoms • communicate with partner your intentions to use a condom every time you have sex or you will not have sex • use a condom correctly • maintain condom use with every partner every time you have sex • decide to have healthy dating behaviors • communicate personal limits regarding dating behaviors • choose appropriate dating partners • avoidend unhealthy dating behaviors caregiver • to improve parenting and communication skills • parental monitoring of social and dating relationships • decide to monitor their childs social time and dating activities • communicate to their youth that they will be monitoring their whereabouts • establish rules regarding how youth spends hisher time permissible activities and dating relationships • determine the appropriateness of your youths extracurricular activities • decide to communicate with their youth about sex dating and relationships • createidentify situations that are conducive to talking about dhrsb with youth • discuss intimatehealthy dating behaviors with youth • discuss avoidancerefusal skills with youth • discuss abstinence with youth • discuss condom use with youth • putting knowledge into practice problematic for multiple reasons • condom use rates were reportedly low because of beliefs that they interfere with pleasure are too expensive that condoms provided by the health department are too small and easily broken • safe sex negotiation perceived to be difficult • participants understood links between drug and alcohol use poor judgment and risky sexual behaviors • due to a general lack of economic and recreational opportunities high substance use rates were perceived difficult to address • youth wanted opportunities to communicate with others about sexual health issues • youth wanted to learn from elders • participants wanted youth to practice abstinence but generally agreed youth should receive comprehensive sex education early and throughout their secondary schooling social • youth and adults describe lack of communication by caregivers about sex or hiv prevention discomfort with these discussions ineffective communication styles delayed discussions until adolescents experience adverse sexual outcomes insufficient knowledge to discuss sexual health issues • peer norms reinforce engagement in sexual behaviors or encourage youth to create the appearance that one is sexually active • having multiple partners is a socially sanctioned norm youth learn from watching adults • participants noted a need for positive mentorship within the family and in the community • youth noted families need education about hivaids • youth noted families need community support for any intervention • participants noted the need for improved communication about sex and relationships • participants stressed the need for a more comprehensive sex education environmental • social institutions contributed to sti risk among youth by ignoring the problem or ineffective policies • politicians thought to be aware of contributing factors to the high hiv rates but uninterested in addressing the problem • health department issues including long delays for appointments lack of confidentiality services tailored for females only • church silent or not engaged in addressing hivstis • lack of recreational activities for youth coupled with idle andor unsupervised time increases engagement in risk behaviors including sexual behaviors • schools need to offer comprehensive sex education • health facilities should provide reproductive health counseling and services for younger teens • politicians need to take steps to put the hiv epidemic among african american community members particularly youth on their agenda and take visible steps to address the problem • safe recreational activities both indoor and outdoor targeting preteens and adolescents aged 1021 are needed

southeastern states are among the hardest hit by the hiv epidemic in this country and racial disparities in hiv rates are high in this region this is particularly true in our communities of interest in rural eastern north carolina although most recent efforts to prevent hiv attempt to address multiple contributing factors we have found few multilevel hiv interventions that have been developed tailored or tested in rural communities for african americans we describe how project grace integrated intervention mapping im methodology with community based participatory research cbpr principles to develop a multilevel multigenerational hiv prevention intervention im was carried out in a series of steps from review of relevant data through producing program components through the im process all collaborators agreed that we needed a familybased intervention involving youth and their caregivers we found that the structured approach of im can be adapted to incorporate the principles of cbpr

19852_0

introduction globally populations are aging a trend that is taking place even more rapidly in urban areas 1 in the central communities of guangzhou china for example the percentage of elderly residents has reached 225 2 and this number is growing swiftly urban aging has emerged as a new direction in the fields of social and health sciences intersecting with multiple disciplines such as environmental science psychology medicine and urban geography older individuals as a valuable societal resource should be provided with an urban environment designed with agefriendly spaces and services 3 a series of initiatives and policies have been established to provide a more agefriendly physical and social environment for the elderly to live healthily in communities 4 research on agefriendly cities and communities is continually being advanced addressing aspects such as housing transportation outdoor environments and technology 5 agingfriendly community outdoor environment the outdoor environment has a significant influence on the independence and quality of life of the elderly affecting their ability to age in place 5 6 7 outdoor spaces serve as meeting places and support social contacts 89 studies show that as individuals age their outdoor activity radius tends to shrink due to decreased mobility leading to more limited activity spaces this often results in smaller social networks 10 community outdoor spaces can potentially serve as the primary venue for leisure activities for the elderly they typically prefer to relax socialize and converse with neighbors and friends in familiar settings researchers van melik and pijpers 11 examined how older residents use and experience public spaces as spaces of encounter in six urban aging environments moreover watching passersby in the outdoor space is also a meaningful form of social contact 12 particularly for the elderly who lack other forms of social engagement therefore the planning and design of outdoor space for the elderly to provide a comfortable leisure communication environment is particularly important the planning and design of community outdoor space in terms of the planning and layout of outdoor spaces the world health organization advocates for the widespread and even distribution of small quiet green spaces within agefriendly cities as opposed to a small number of larger busier parks 1013 such a distribution structure is conducive to improving space accessibility field research has found that the distribution of outdoor spaces in communities where the elderly gather also has similar characteristics as it may be challenging for older individuals to walk for extended periods without rest 14 as a result in contrast to spaces designed for mobility such as walking the demand for seating areas in outdoor spaces is more pronounced among the elderly seating areas are considered a crucial design element which includes factors such as the distribution of seating areas within the community the quantity and material of seats as well as the presence of greenery and lighting 15 suitable planning and design of the outdoor environment may support social interactions and strengthen communities for the aging group 16 influenced by a variety of social and physical environmental factors the principles of outdoor design vary by areas and communities therefore the purpose of this study is to better understand the preferences of the elderly in hot and humid regions for the use of outdoor leisure spaces through actual case analysis it aims to identify the primary environmental factors influencing the elderlys use of outdoor spaces to guide the planning and design of community outdoor spaces theoretical frameworks environmental factors influencing behavioral preferences historically physical environmental factors have been recognized as influencing individual behavior mental and physical health and quality of life especially in old age 17 some research has focused on the influence of the environmental parameters of outdoor spaces on human behavioral patterns for instance the effects of a hot environment on walking behavior and how urban design features stimulate individual and collective walking behavior have been studied 141819 both traditional and big data methodologies have been used to assess walking behavior 2021 however fewer studies have addressed the correlation between lingering behavior and the environment even though lingering behavior much like walking behavior is a weatherexposed activity influenced by climatic conditions environmental comfort and vitality 1822 occupants behaviors in outdoor spaces are profoundly influenced by climatic conditions this includes elements of the thermal environment 23 24 25 26 such as air temperature sunlight 27 wind and humidity 2528 identifying the relationship between space usage and human thermal perception can assist in the creation of more comfortable outdoor environments 29 for example people in hot areas are willing to stay under the tree shadows in outdoor spaces even during the hottest days 30 the acoustic environment is also a significant factor affecting outdoor environmental comfort with varying preferences across different age groups 3132 findings also suggest that outdoor spaces differ in terms of spatial form attributes such as area openspace ratio and green plot ratio 33 views and physical access to the green outdoor environments help enhance health and reduce stress 28 healthy geography provides evidence of how open spaces contribute to improving the health and wellbeing of the elderly 34 35 36 to efficiently determine why the elderly choose some specific outdoor spaces the aforementioned spatial characteristics should be considered as crucial influencing factors some researchers regard walkability as a measure of the vibrancy and sociability of an environment this metric also forms the basis for pedestrians to linger in outdoor spaces and engage in interactions and conversations 3738 enhancing walkability can effectively improve urban vitality and social activity the pedestrian volume is often used as a measure of walkability 3940 elderly residentss subjective preferences for outdoor environments according to research most elderly individuals choose to age in their own homes rather than in institutions 41 communities and neighborhoods significantly impact the capacity for aging in place with the community environments positively correlating with residence longevity 42 as noted by rowles as people age they become increasingly aware of and sensitive to their social and physical environments 43 furthermore the older individuals tend to prefer recreational activities within their communities over traveling to more distant city parks 3 medical research suggests that the best method to prevent dementia is promoting social interaction among the elderly 44 relevant studies show that the elderly are the primary occupants of community outdoor spaces 31 aging communities need to provide ample outdoor spaces to promote active aging current studies mainly focus on elderly individuals behavior in outdoor spaces which represent passive use and do not entirely reflect the real needs of the elderly for these spaces in some densely populated urban centers the elderly spontaneously repurpose smallscale outdoor spaces within their communities for temporary use 4546 typically these communities have a high proportion of aging residents decayed environments crowded living spaces and insufficient and unsatisfactory outdoor recreational spaces in terms of both quantity and quality through selfbuilt spaces the elderly naturally express their outdoor environment needs compared to the passive space usage these selfbuilt outdoor spaces more directly reflect the social needs and usage preferences of the elderly in their living environments 15 however this issue has received little attention and there is no relevant research discussing the elderlys preferences for outdoor space use in relation to this issue therefore this study selected a typical aging community in the yuexiu district of guangzhou china to investigate several selfbuilt outdoor spaces and discuss the elderlys usage preferences of the outdoor environment during the hottest days combining the elements discussed in section 21 the environmental factors influencing the elderly residents usage preferences include air temperature wind humidity and noise levels which are the most relevant variables for them to decide to stay in these places 21 regarding the form attributes of outdoor spaces the number of seats is more significant for elderly occupants than the areas sky visibility calculated by the proportion of the sky in spatial elevation is used to represent the openspace ratio 47 after considering the correlation and measurement method of each element pedestrian flow the number of seats sky visibility green visibility temperature relative humidity wind speed and noise were selected as the eight elements representing the environmental characteristics of outdoor spaces we analyzed the correlation between each element and the elderlys use of outdoor spaces 48 exploring the key elements affecting the elderlys usage preferences for community outdoor spaces association between behavioral preferences and the environment existing studies have not adequately characterized the behavioral impact of the outdoor environment by activity types age and gender for instance the older adults have a lower sensitivity to hot environments and their outdoor activities are primarily static 49 specialized research in this area can aid in designing specific outdoor spaces another issue is the weak causal evidence between outdoor environments and behavioral outcomes 25 existing studies primarily relied on traditional observational methods or questionnaires the former lack longterm records and the latter are influenced by the subjectivity of the interviewees both can impact the accuracy of the research 25 to address these shortcomings researchers can observe the elderly residents with several fixed video cameras recording their activities and the duration of their stay in the outdoor spaces this method efficiently observes them without disturbing their behavior while the highquality video data ensure continuity and consistent record keeping 475051 simultaneously it becomes possible to classify the community outdoor space according to the elderlys activity types from the recordings this then facilitates a discussion on the relationship between the activities of the elderly and environmental parameters by the types of outdoor spaces in terms of the data analysis methods in 1990 rotton and others first used a simple linear regression model to establish the association between a hot environment and pedestrian rhythm 52 other research has used polynomial models to establish the relationship between weather and human travel behavior 1853 given that the elements influencing human behavior are complex and variable and their mathematical relationship is nonlinear the advancement of machine learning algorithms has attracted widespread attention for establishing the association model between human behavior and the environment 54 55 56 however the strengths and weaknesses of various machine learning algorithms in the correlation model of human behavior and the environment have not yet been assessed furthermore the discussion on the application of the model in specific scenarios is not indepth enough aim of this study taking into account these knowledge gaps this study aims to explore the linkages between the behaviors of elderly individuals in the community and outdoor environmental conditions the specific objectives are as follows to gather and analyze outdoor environmental parameters that are associated with the activity behaviors of the elderly in outdoor spaces to collect and analyze data pertaining to the comfort of the outdoor environment and space form attributes in hot and humid climates to examine the quantitative relationships between outdoor environmental parameters and the preferences of the elderly and to analyze these correlations to evaluate and predict the number of elderly occupants in community outdoor spaces through the environmental parameters that influence them this survey is primarily characterized by objective measurements of the outdoor environment in the case community methodology methodology overview this research strategically selected a community environment comprising 15 outdoor spaces during the summer season in guangzhou in situ surveys were deployed to collect pertinent climatic and spatial parameters onsite interviews were conducted with a number of elderly participants to understand their environmental perceptions and the factors influencing their space selection video recordings were utilized to tally the occupancy of the elderly and the pedestrian flows surrounding the outdoor spaces based on the collected data relationships between the outdoor environmental parameters and the space vitality of the elderly were quantitatively analyzed the results are expected to contribute to a more nuanced understanding of the impacts of community outdoor environments on the choices and behaviors of the elderly across different outdoor spaces such information should prove invaluable for improving the community environment particularly in hot and humid areas the technical approach of this study is divided into four steps identifying and categorizing outdoor spaces within the case community and filtering key spatial elements field research and data collection drafting floor plans of each public space within the community and measuring space capacity monitoring the number of occupants staying in each space the physical environmental parameters sky visibility and green visibility as well as the pedestrian flow on nearby roads calculating the correlation between the number of elderly participants staying in the space and the environmental factors and arranging key spatial elements influencing public space use behavior in order of correlation strength establishing a quantitative model between the number of residents staying in outdoor spaces and the environmental elements with higher correlation to be used for optimizing design please see figure 1 for the research process study area the zhuguang community which was surveyed in this study is located in the yuexiu district of guangzhou the total area of guangzhou is 743440 square kilometers with a permanent population of 18734100 of which yuexiu district covers an area of 338 square kilometers and has a registered population of 1174500 in 2021 5758 this area is typically a highdensity area with a population density of 34748 per square kilometer which is much higher than the average density of guangzhou however this district contains a large proportion of elderly individuals with a low per capita green area of 569 m 2 which is much lower than the whole city 5758 detailed data are shown in table 1 the choice of the zhuguang community as the subject of this study is informed by several reasons first the community experiences severe aging the proportion of elderly residents in yuexiu district is 2225 and 1588 2 interview statistics reveal that in the outdoor spaces of the zhuguang community 8042 of the users are over 60 years old while 5714 are over 65 years old this demonstrates that the primary users of these outdoor spaces are the elderly because the accessibility of the open space around the zhuguang community is relatively low that is the closest distance from the neighborhood to the surrounding parks and green spaces is 15 km which takes about 30 min to reach at an elderly walking pace as it shows in figure 2 secondly the study selected 15 outdoor spaces in the zhuguang community for investigation these spaces are frequently used by a high concentration of elderly residents reflecting their preference for outdoor environmental usage in this community effectively lastly out of the 15 outdoor spaces surveyed 11 spaces were built spontaneously by the elderly using discarded furniture indicating an active and positive reflection of their usage preferences for outdoor spaces figures 3 and4 display the locations and site plans of the 15 surveyed outdoor spaces according to the survey the outdoor activities of the elderly in the zhuguang community are mainly chatting relaxing enjoying the cool strolling and waiting for their children from school due to the limitation of the outdoor space area few elderly residents participate in sports activities some elderly with good physical strength would walk to the pearl riverbank or nearby parks for individual or group sports activities such as sword training taijiquan or square dancing data collection onsite measurements of the number of residents staying pedestrian flow on surrounding roads seat numbers and physical environmental parameters were conducted for the aforementioned 15 outdoor spaces the survey was conducted on 713 september 2022 from 800 am to 700 pm the hottest times in guangzhou and the data of the two hottest days were selected for analysis on 1213 september 2022 the air temperature ranged from 232 to 352 • c the humidity ranged from 37 to 94 and the maximum daytime wind speed was 39 ms which were observed by the weather station with the longitude 1132688 and the latitude 2312897 in yuexiu district the number of residents staying in the 15 public spaces was recorded at different time intervals a stay duration of no less than 5 min was counted as valid data videos were shot using a multifunction highdefinition camera with a resolution of 3840 × 2106 the pedestrian flow on the road nearest to the community outdoor spaces was recorded using the same highdefinition camera mentioned above the number of seats in the outdoor spaces was counted air temperature relative humidity wind speed and acoustic environment are considered in this study all data are transformed with a resolution of 20 min the measuring tools and corresponding models are shown in table 2 figure 5 shows photos of the in situ measurement 4 physical environmental parameters tathe average temperature • c calculated by the following ta ∑ n i ta i n n1 60 n2 20 minute ta i the average temperature per minute measured by the instrument rhamean relative humidity calculated by the following rha ∑ n i rha i n n1 60 n2 20 minute rha i the mean relative humidity per minute measured by the instrument vamean wind speed ms calculated by the following va ∑ n i va i n n1 60 n2 20 minute va i the wind speed every minute measured by the instrument leqequivalent continuous sound level db calculated by the following leq 10 log 1001la dt ttime of duration t1 3600 t2 1200 s la is the instantaneous sound level at time t temperature and humidity were measured using a selfrecording hygrothermograph while wind speed and noise were measured using a multifunctional meteorological anemometer and noise was further recorded using a sound level meter the hygrothermograph and the weather station were installed 15 m above the ground level with the data logging interval set to one minute data analysis image recognition technology this study collected photographs of the public spaces in the case study at fixed time intervals using video recording then processed these images using fcn image recognition technology this provided access to data within the images such as the number of residents the sky visibility index and green looking ratio fcn was born based on the development of cnn which belongs to the deep neural network the network structure of cnn can automatically learn various highlevel and abstract features in the image it is usually constructed by an input layer a group of hidden layers in the middle and an output layer among which the hidden layer includes a convolutional layer a pooling layer a fully connected layer and other types of structures fcn can predict and detect the semantic labels of each pixel in the image and classify each pixel by processing the image features in that it has the structural characteristics of image semantic segmentation the advantages of fcn over cnn include the concept of convolution and upsampling technology the combination of multiple convolutional layers is used to improve the actual segmentation definition and effect therefore the recognition accuracy of fcn is higher and it can accept input images of any size figure 6 shows the principle of fcn image operation in deep learning the yolov5 model was used for object detection on video images which identified and counted the number of target objects within a specific time period this information was used to obtain pedestrian flow data for specific sections of road the reldpcb model was utilized to achieve pedestrian reidentification and frame image capture thereby obtaining the dwell time of residents in selected public spaces only those residents who stayed for no less than 5 min within the statistical period were counted correlation analysis after conducting research statistics in the case study community the number of residents staying in each public space was designated as variable x the corresponding pedestrian flow spatial capacity physical environment parameters sky view index and green view index were designated as variable y the pearson correlation coefficient was then used to calculate the correlation between x and y allowing the quantification of the coupling relationship between the number of residents in a space and the spatial elements the is r ∑ n i1 x i x y i y ∑ n i1 2 ∑ n i1 2 model building random forest regression model is a combination of multiple binary classification and regression tree and training random forest regression model is to train multiple binary decision trees in binary decision tree training an exhaustive approach is employed to select the splitting variables and points by traversing all features and their respective values to identify the optimal splitting variable and point the mean square error was used to measure the quality of nodes after segmentation the calculation is as follows g 1 n s 2 ∑ y i ∈x right 2 where x is segmentation variables v is the value of the segmentation variables x left x right are the training sample set of left and right child nodes n s is the number of all training samples of the current node y le f t and y right represent the average value of the output data of left and right child nodes figure 7 shows the structure of a random forest after passing the x dataset into the model the input training set is repeatedly sampled n times with replacement to obtain a bootstrap set then based on the size of the input parameters a subsample set is obtained and input into different tree structures after performing calculations on each tree structure the mean of each trees result is taken to obtain the models output y figure 8 shows the training process of a tree structure after inputting the training set decision tree nodes are constructed and it is determined whether the node is a leaf node if it is the average of all y values for the current node is taken and used as the output value for that tree structure otherwise the number of features in the training set and the size of the training set are calculated it is then determined whether the number of features is greater than 0 if it is the mse error at the splitting point is calculated and compared with the minimum mse error at the current node if it is smaller than the latter then that splitting point is stored if there are no more features left then the training set is divided into two sets left and right child nodes are constructed and it is determined again whether they are leaf nodes this process continues until all nodes are leaf nodes to further demonstrate the superiority of this method there are four baseline models for comparison knearest neighbor is a nonparametric algorithm that predicts the value of a target variable by considering the nearest neighbors in the feature space 59 support vector regression is a regression algorithm that uses support vector machines to find the best hyperplane in a highdimensional space minimizing the error within a certain margin 60 ridge regression is a linear regression algorithm that adds a penalty term to the loss function allowing for better control of overfitting and improved generalization 61 classification and regression trees is a supervised learning algorithm that creates a treelike model by splitting the data based on different feature conditions to make predictions or classifications 62 evaluation indicators and datasets in order to evaluate the performance of the model the following three evaluation indexes are adopted root mean squared error as shown in rmse 1 n n ∑ i1 y t ŷt 2 mean absolute error as shown in mae 1 n ∑ n i1 y t ŷt coefficient of determination as shown in r 2 1 ∑ i1 y t ŷt 2 ∑ i1 y t y t 2 specifically rmse and mae are used to measure the error where smaller values indicate better prediction performance r 2 is used to calculate the correlation coefficient which measures the ability of the prediction results to represent the actual data the larger the value of r 2 the better the prediction performance there are four characteristics in the dataset of the experiment which are temperature humidity the pedestrian volume of the people and noise these four features predict the number of residents staying in the outdoor spaces there were 110 groups of experimental data and the training set and test set were randomly divided according to the ratio of 82 the data in the dataset are used to train the model and the test set is used to demonstrate the predictive performance of the model the data for training were normalized by the method below as shown in x ij x ij min max min 10 where x ij represents the ith row and the jth column x min x j represents the smallest x in the jth column and max x j on behalf of the largest x in the jth column results measurement results the figure 9 shows the data of the environmental parameters measured in the 15 outdoor spaces in the zhuguang community shows the pedestrian volume in the main periods for residents to go outdoors compares the number of seats with the number of outdoor space occupants compares the number of residents in 15 outdoor spaces at different times show the air temperature relative humidity wind speed and noiseleq of the outdoor spaces with the minimum maximum and average values show the values of the sky visibility index and green looking ratio in the 15 outdoor spaces correlation analysis results behavioral and spatial element data of elderly individuals were extracted from 15 outdoor spaces in the zhuguang community these included the number of residents staying in highfrequency spaces pedestrian flow on paths spatial capacity physical environmental parameters sky view index and green view index data were extracted every hour for the highfrequency activity periods of the elderly obtaining a total of 90 datasets in 2 days from the 15 outdoor spaces the data includes 268 residents who stayed in the communitys outdoor space and 12216 people who walked through nearby roads in the three periods on september 12 and 13 the number of individuals staying in the outdoor spaces was separately analyzed for correlations with the eight corresponding environmental elements the results are shown in table 3 environmental elements with a high correlation with the number of individuals staying in the communitys outdoor spaces included temperature relative humidity pedestrian flow and noise of these temperature had a negative correlation while the remaining three factors were positively correlated model building data statistics indicate that three space spots 6 10 and 15 in the the zhuguang community are the sites with high frequency of use and a large number of residents staying all of which are spontaneously constructed by residents these can serve as typical spaces for building models at the same time the environmental factors highly correlated with the number of residents staying in the outdoor spaces are temperature relative humidity pedestrian flow and noise by taking 20 min intervals we extracted the number of residents staying temperature relative humidity pedestrian flow and noise from these three typical outdoor spaces from 800 to 1900 this resulted in a total of 110 sets of valid data which were used to build the machine learning model as described in section 343 the data includes 758 residents who stayed in the communitys outdoor space and 28865 people who walked through nearby roads from 800 to 1900 on september 12 and 13 in this experiment the settings of the hyperparameter of rf are as follows the number of decision trees is 50 the maximum depth allowed for each decision tree is 500 the minimum number of samples required to split an internal node is 8 and the minimum number of samples required to be at a leaf node is 1 to further demonstrate the superiority of this method there are four benchmark models for comparison knearest neighbor algorithm model support vector regression algorithm model ridge regression algorithm model and decision tree algorithm model from figure 10 it can be observed that initially all models predicted values exhibit a relatively small error compared to the real values however at the third sample the decision tree model fails resulting in a significant deviation between its predicted values and the real values in contrast the random forest model maintains a relatively small error within a certain range between the fourth and eleventh samples the rf model consistently demonstrates smaller prediction errors compared to the ground truth values and in multiple instances the predicted values align closely with the real values at the 12th sample there is a drastic change in the real value leading to poor predictions from almost all models however at the 13th sample when the ground truth value quickly returns to its previous level the rf model promptly captures this change and maintains a small error in subsequent samples the data in figure 11 confirm the superiority of the rf model as it exhibits the smallest rmse and mae values while achieving the highest r 2 value in its predictions discussion agefriendly renovation in community outdoor spaces typically priority is given to addressing the physical and safety needs of the elderly in outdoor space planning and design 63 while their social needs and preferences are often overlooked however compared to the subjective experience of planners and designers the actual needs of elderly users should receive more attention 64 65 66 the views and preferences of the elderly are important factors to consider in the codesign of agefriendly communities hence the necessity to focus on the role of outdoor spaces in promoting active aging 67 furthermore the perspectives of the elderly are seen as key to understanding agefriendly environments plouffe and kalache pointed out that the elderly have valuable insights into creating agefriendly urban environments 68 the experiences of the elderly in using community outdoor spaces and their emotional attachment to the community can provide guidance to planners and designers 69 in the renovation of outdoor spaces in old communities the elderly as the primary residential group should be taken into full consideration adopting different standards from the outdoor space design in new communities therefore this study focuses on the preferences of the elderly in the planning and design of outdoor spaces under the context of community renewal this paper aims to study the environmental preferences of the elderly when they actively participate in activities in community outdoor spaces by observing the spaces they autonomously select and modestly modify we analyze the key environmental elements influencing their choices the elderlys active participation in space construction reflects a sense of place and belonging particularly for those living in urban areas the selfbuilt outdoor space stimulates their autonomy and increases their motivation for community participation 70 compared to traditional studies where the elderly passively use spaces this research focuses on the environmental characteristics of community outdoor spaces that the elderly spontaneously gather in and autonomously build from a selfbuilt perspective this study focuses on the subjective spatial environmental preferences of the elderly this study emphasizes that the renovation of outdoor spaces in older urban neighborhoods should cater to the unique needs of the relatively concentrated elderly population 66 firstly they need to maintain interaction among themselves to avoid feelings of loneliness 71 it is shown in this paper that elderly individuals tend to choose selfbuilt outdoor spaces near hightraffic pedestrian routes for two reasons psychologically this can satisfy their desire to observe passersby as there are many people passing by thus increasing the chance for incidental conversations with acquaintances from an objective environmental perspective high pedestrian traffic indicates that there are facilities or spaces nearby that attract people such as markets or garbage stations indicating high accessibility and attractive spatial dynamics strategies for updating community outdoor spaces existing studies often focus on individual activities of the elderly paying less attention to their social activities 7072 some of the literature suggest that the primary reasons for the elderly to visit outdoor spaces are socializing and physical activities 73 in the surveyed zhuguang community the interviewed elderly expressed a clear need for socializing and chatting the 11 spaces spontaneously constructed by residents in the surveyed community are relatively small in area but they all qualify as conversational spaces that can accommodate 412 chairs in some areas where space is ample chairs are arranged in an enclosed way which is more conducive to user interaction therefore the layout of community outdoor spaces should encourage interaction among the elderly rather than solitary use of facilities improving the thermal and noise environments of community outdoor spaces can encourage more elderly residents to stay outdoors 7475 in the zhuguang community elderly residents tend to use outdoor spaces with lower temperatures and higher relative humidity therefore shading facilities can be added to reduce the temperature of outdoor spaces and greenery can be planted to increase air humidity data analysis shows that the elderly prefer to use outdoor spaces with higher noise levels which only indicates that they may enjoy relatively lively outdoor spaces however it cannot be proven whether excessive noise that causes discomfort is detrimental to the use of space in addition to directly improving the environment of outdoor spaces the random forest model resulting from this study can predict the number of people staying in outdoor spaces based on environmental element values this application can be used in community renovation planning and design during community updates there is often a shortage of outdoor leisure spaces 73 therefore the ability to choose a location that effectively utilizes space holds practical significance through the random forest model constructed by this study it is possible to judge whether a particular space in the community is suitable for elderly activities and how many elderly adults would gather there by measuring environmental parameters it is also possible to determine the number of seats in the space based on predicted values the model established in this study demonstrates good adaptability it can assist in community update planning and design help in selecting outdoor spaces and improve the quality of the outdoor environment nevertheless the fact that the data sample is targeted at elderly residents is a limitation of this study the model established is only applicable to urban communities with similar climates and similar age structure of the population however the methods used in this study can be applied to cities with different climates and different population compositions conclusions this study selected the case of outdoor community spaces organically formed by the elderly and used objective methods to analyze the elderlys usage preferences for outdoor spaces the results showed that environmental elements can influence the elderlys choices for using spaces thereby affecting their utilization of these spaces in order to improve the efficiency of outdoor space use creating a comfortable and friendly environment is crucial as a result of this study some findings and suggestions could be presented as follows this study clearly reveals the relationship between thermal environment noise pedestrian traffic and the number of residents staying in outdoor spaces the environmental elements affecting the usage of outdoor spaces by community residents especially the elderly are temperature relative humidity pedestrian traffic and noise in that order the temperature is negatively correlated with the elderlys spontaneous usage of outdoor spaces although the elderlys ability to perceive heat is weakened they prefer to choose shaded spaces for leisure and communication in summer the pedestrian traffic of the road is positively correlated with the number of residents staying in nearby outdoor spaces indicating that the elderly prefer to use outdoor spaces in locations such as traffic intersections and roadsides with large pedestrian traffic noise is positively correlated with the elderlys usage of outdoor spaces elderly residents are not highly sensitive to noise but rather like lively outdoor environments which may have potential association with their psychological state of loneliness the random forest regression model predicts the number of residents staying in community outdoor spaces with the best effect with independent variables being temperature relative humidity pedestrian traffic and noise in that order although the analysis method selected in this study is objective social factors were incorporated when selecting cases all 15 outdoor spaces in the zhuguang community are areas where elderly individuals are densely active among which 11 spaces were spontaneously built by the elderly this not only reflects their preferences for the environment but also expresses the social needs of the group therefore the policy should encourage the elderly to participate in community construction express their needs and preferences and plan outdoor spaces which are of great significance for enhancing the happiness of the elderly and promoting active aging furthermore the communication function of community outdoor spaces is meaningful especially in communities with a high concentration of the elderly they spend most of their leisure time resting in community outdoor spaces and chatting with acquaintances as a result planning and design should fully consider the communication and interaction function of the space ensuring the close connection of the elderly with the natural and social environment data availability statement the data presented in this study are available on request from the corresponding author the data are not publicly available due to the protection of subjects personal information as well as their privacy institutional review board statement the study was conducted in accordance with the declaration of helsinki and approved by the zhuguang community committee informed consent statement informed consent was obtained from all subjects involved in the study

the downtown cores of many cities are characterized by aged communities that tend to host a relatively high population of elderly retirement residents the availability and usage of outdoor spaces within these communities play a crucial role in promoting active aging providing essential locations for rest activities and social interaction among the elderly however in the planning and design of these spaces attention is often focused on the safety and mobility requirements of the elderly population while a lack of research is apparent in the area of elderlyspecific preferences for spaces designed for relaxation and communication in this study we selected an aging community as the research target and conducted a detailed investigation of the outdoor spaces where the elderly residents gather and build up spontaneously in summer our objective was to evaluate the environmental factors influencing the selection of these outdoor spaces by the elderly for relaxation and communication we analyzed the correlations between these factors and the number of occupants in these spaces and developed predictive models accordingly the findings indicate that the environmental factors impacting the utilization of outdoor spaces by the elderly during heat periods within the community are in order of importance temperature relative humidity human traffic flow and noise levels these factors include physical and social aspects temperature is a negative correlation factor affecting the use of outdoor space by the elderly and the rest are positive correlation factors this shows that the elderly like to gather and chat in a cool crowded and lively environment through the data analysis it was determined that the random forest regression model was the most effective in predicting the number of residents remaining in these spaces with a coefficient of determination r 2 of 07958 the model can assist in community update planning and design help in selecting outdoor spaces and improve the quality of the outdoor environment this study discusses the factors influencing the elderlys use of community outdoor space from the physical and social levels and the prediction model is significant for the optimization of spatial elements and spatial location

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introduction mental health disorders are a major health issue for the global community constituting five of the 10 leading causes of health disability in the world botswana saw a moderate rise of 5 from 39 778 psychiatric attendances in 2007 to 41 908 in 2009 the rising number is tantamount to more people being cared for in the home setting the shift in mental health treatment philosophy from institutions to their homes had a profound but rarely acknowledged effect on the family mental illness is a chronic illness and it necessitates family caregiving throughout the lifespan of the relative living with mental illness hence the family caregivers shoulder a large share of the longterm responsibilities research suggests that mental illness is a devastating illness for both the caregiver and the patient caregiving affects the family in various ways caring for relatives living with mental illness affects the physical psychological and socioeconomic wellbeing of the caregivers as well as their capacity to cope with and adjust to those circumstances without support they end up compromising their own health and wellbeing caregivers for relatives living with mental illness face different challenges from other caregivers of longterm conditions in that they sometimes fear for their lives as their relative may become aggressive caregiving may also strain family relations and other coping resources which can be felt more acutely in situations where community rehabilitation resources are lacking various other experiences are also reported in the literature jönsson et al found that families had to contend with feelings of worry and powerlessness to maintain normality in their lives the focus on this study therefore is on understanding the experience of caregiving from the perspective of family caregivers providing care to relatives living with mental illness open access the unfavourable impact of caregiving on family caregivers health has been reported as requiring attention bhatia and gupta contended that it is therefore imperative to provide unrelenting support to family caregivers and individual members to enable them to refocus and learn to manage illnessrelated roles and tasks following deinstitutionalisation and rapid demographic and socioeconomic changes because of urbanisation it is timely or long overdue to consider what is done about caregivers mental health as an essential component of ones overall health problem statement although enormous progress has been made in studying and documenting the lived experiences of family members caring for relatives living with mental illness in africa to date there has not been any integration of available literature and there is not much information about family caregivers support there is thus a need to merge these findings to understand the complexity of caregiving more than looking at isolated pieces of information which in many instances lack contextual relevance consequently the study seeks to present a metasynthesis of phenomenological studies conducted on family caregivers lived experiences of caring for relatives living with mental illness in subsaharan africa and to create a comprehensive chronicle of phenomena in the findings of studies conducted purpose the purpose of the research was to metasynthesise phenomenological studies conducted on family caregivers lived experiences of caring for relatives living with mental illness research design and method the metasynthesis was based on walsh and downes method as well as the strategy by noblit and hare population and sampling the population consisted of phenomenological studies that generated experiential descriptions about caring for relatives living with mental illness bondas and hall recommend that at least 1012 studies should be purposively included in the metasynthesis to create a meaningful and valid metasynthesis a total of 10 purposively selected phenomenological studies were included for the review inclusion criteria were studies that were on family caregivers who have experienced caring for a mentally ill relative in the home environment explored experiences of family who have experienced caring or caregiving from the perspective of a family member were on families who take care of mentally ill relatives and explored qualitative data which is published in english studies were excluded if they were review papers and abstracts or if they were metasynthesis studies on caregivers experiences data collection a systematic search of qualitative research studies was undertaken with the assistance of the university librarian a fourstep process for the metasynthesis based on walsh and downes method as well as the strategy by noblit and hare was adopted the prisma flow chart helps to illustrate the process selection and appraisal of relevant research studies for this metasynthesis the researcher consulted the university librarian to locate and select research studies screening was based on titles and abstracts and eligibility was based on the methodology trustworthiness data analysis and results the search strategy comprised a search to identify relevant keywords contained in the title abstract and subject descriptors however no studies were rejected on the basis of quality relevance and selection of studies in this step an evaluation of the relevance and finalisation of the studies was done in ensuring transparency the researcher reported on the process of selection crosschecking was done for all the selected studies walsh and downes guidelines were used to determine the relevance of the study by comparing various study results trustworthiness walsh and downe stated that there were no widely agreed upon criteria to assess the quality of qualitative studies however the critical appraisal skills programme published a checklist that mentions three broad issues that are to be considered when appraising a systematic review study an important criterion for selection is adhering to the standpoint or research focus therefore in ensuring trustworthiness the criteria of clarity structure coherence scope generalisability and pragmatic utility and walsh and downes methodological rigour were used to appraise the studies this was done in the form of a coding scheme each stage of the research process was assessed for clarity congruence transparency and methodological underpinnings open access a checklist was then developed to rate the quality no studies that met the inclusion criteria were excluded on the basis of quality the quality ratings ranged from 65 to 10 the synthesis and results step involved reviewing studies identifying and summarising key themes these were verified against each other resulting in findings that were synthesised into new concepts following the identification of relevant studies a comparison and contrast exercise of the key concepts in the results was done the authors understanding of concepts and relations were identified in each study summarisation was tabulated to present inferred themes and concepts from the narrative accounts in caregiving thematic synthesis involved linebyline coding of the findings of the primary studies and the development of descriptive and analytic themes the classic method of noblit and hare was followed ethical considerations ethical clearance was obtained from the universitys faculty of health science research ethics committee human subjects were not the objects of the synthesis research therefore the study posed no risks to participants nevertheless the ethical processes adhered to focused on accuracy and honesty in reporting the findings on the research done the researcher did not deliberately misinterpret facts about the studies remained objective and refrained from making value judgements with regard to the conducted studies findings description of selected studies the metasynthesis sample was composed of 10 research studies six of the studies were research theses and four were research articles from various countries in subsaharan africa and from different academic disciplines including nursing and health studies the studies aimed to explore experiences of family members caring for living with or having a mentally ill relative except for one study that focused specifically on schizophrenia the studies identified were undertaken in botswana south africa namibia swaziland tanzania and kenya from various disciplines research results from 102 caregivers experiences are presented data were collected through indepth interviews focus group discussions and naive sketches participants were grandparents parents siblings spouses nephew and nieces participants ages ranged from 17 to 79 years caregiving experiences ranged from less than 2 years to more than 20 years female participants took the lead in the reviewed studies findings of the interviews family caregivers experiences for relatives living with mental illness a line of argument of 10 studies yielded four overarching themes perceived responsibility of caregiving experienced emotional effect experienced support needs and experienced changed perspectives the four themes are presented in this article with direct quotes from the included studies records idenɵfied through database searching ebscohost pubmed 293 open access theme 1 family caregivers experienced perceived responsibility of caregiving family members remain the primary caregivers for relatives living with mental illness the caregiving responsibility was seen in all stages of illness the family caregivers took care of the daytoday needs of the relative with mental illness which included providing meals assisting in activities of daily living monitoring their treatment and their mental state observing for signs of relapse and helping their relatives to access services family caregivers stated that they are responsible for the daytoday care of their relative and this often leads to role shifts and altered responsibility there is no problem that is bigger than caring for the mentally sick brother because he is forever…i dont know when it will end completely i rely on god and mental hospital for care of my relative family caregivers experienced the provision of care family caregivers extended practical support by proving care to meet the needs of their relative living with mental illness a great deal of time and effort was spent in providing care caring required numerous sacrifices with regard to social and occupational life this also included financial support in terms of travel expenses funding treatment and providing food the family caregivers also expressed difficulties in maintaining their relative in terms of providing for their relatives needs when he is well he eats too much but other times when he is given food he just throws it away family caregivers experienced physical exhaustion because of taking care of their mentally ill relative through providing around the clock care family caregivers can become victims of physical and emotional exhaustion it is reported that family caregivers also encountered frustration when their mentally ill relative refused medication and food the support that we give him is to ensure that he has taken his medication correctly because he often refuses to take his medication i always beg him to me the transport fare to collect free medication is almost equivalent to buying the drug …this has caused me a lot of financial problems because i come from very far to come to the hospital and i have to do this every month family caregivers experienced role shift the nature of mental illness affects the family members in various ways caregiving can challenge longstanding family roles everything the family does is planned around the relative with mental illness the caregiver role exposes family members to new experiences and ranges of emotions taking care of a mentally ill relative can interfere with a persons ability to execute daily chores and taking care of the self and other family members family caregivers reported that there was a role shift as they often ended up altering their responsibilities and had to combine caregiving with attending to their everyday roles one family caregiver said he used to take care of himself but now you have to tell him to do everything like washing clothes and asking him to take medicine the family caregivers lifestyle had to change to accommodate the caregiving role similar findings were reported by mavundla toth and mphelane families adjust their social lives to the needs of their relatives living with mental illness which is a source of stress as they no longer have time for themselves family relationships can be weakened because of the caregiving conflict among family members role shifts can affect the family dynamics as it sometimes contributes to disagreements among family members family caregivers experienced altered priorities another common thread among the studies was that there were altered priorities as care was centred on the mentally ill relative mental illness involves impairment in one or more important areas of functioning there is a need for ongoing adjustments in families regarding the constant presentation of changes in mental illness some lifestyle changes are necessary to accommodate the caregiving role the chronic nature of mental illness and the ongoing demand to be available to take care of a mentally ill relative were some of the difficulties reported by family caregivers they expressed concern about their altered priorities particularly when they had to provide for their relative living with mental illness it is very difficult because i am not working and i am selfemployed and whatever i put on the table i share with him family caregivers invest a lot of energy into the caregiving role and tend to put anything that affects them on hold one family caregiver said the biggest problem that i have is that i am never able to work because i have to look after him it requires me to be around all the time theme 2 family caregivers experienced emotional effects this theme relates to the emotional experiences of caregiving the theme is further divided into three subthemes feeling hopeless and helpless feelings of shame and fear and feeling powerless family caregivers experienced a variety of negative emotions family caregivers experienced feelings of hopelessness and helplessness because of the complexity of the nature of the illness it is not surprising that family caregivers responded to caregiving with emotions of their own the emotions were varied and might include a need to help the relative feelings of failure and helplessness as the disease progressed most often helplessness and fear went handinhand the family caregivers felt helpless when they could do nothing about their relatives condition and when they were fearful of his or her aggressive behaviour helplessness was observed when family caregivers could do nothing about the situation this relates not only to basic knowledge on caregiving but also to feeling helpless as well i rely on god and mental hospital family members felt helpless when they could do nothing about their relatives aggressive behaviour one family caregiver said he destroys household utensils and furniture and throws them to the neighbors houses he also throws stones which can hurt when he is like that no one approached him we leave him and he remains alone negative emotions experienced included emotional pain frustration and helplessness family caregivers experienced feelings of shame and fear most of the family caregivers lived in fear of being stigmatised because of the verbal assaults and outburst of their relative this affected their mental wellbeing one family caregiver said i am hurting because of words of rejection and stigma that are uttered by our neighbours about our mentally ill person and us stigma and shame against people living with mental illness remain unabated anything regarding mental illness has negative publicity and caregivers are challenged twice on one hand they have to bear the challenges of having to deal with bizarre behaviour that is often frightening and on the other hand they face prejudice because of misconceptions about mental illness one caregiver said we felt as if we were alone in an island there was nobody to turn to friends and families were at distance there was nobody visiting us the consequences of shame and stigmatisation affected access to social roles leading to social isolation caregivers also experienced fear for themselves and for their relatives safety every time there is fear that he might move away and cause havoc family caregivers experienced feelings of powerlessness powerlessness compounds feelings of uncertainty frustration and fear that the mentally ill relative may become dangerous in all 10 studies family caregivers reported feeling powerless family caregivers experienced negative thoughts related to selfworth hope and power these emotions can affect ones open access sense of wellbeing they felt powerless when they could not do anything about their relatives aggressive behaviour one family caregiver said he will dish up without even washed his face and hands and when i tell him to go and wash first and then you have provoked him he will shout one word and that will be enough for you to keep quiet and leave him to do what he wants family members became powerless because they had insufficient knowledge about chronic mental illness and upon realising that they are dealing with chronic illness factors that affect powerlessness among caregivers are complex and multidimensional they become powerless when they cannot influence the outcome family caregivers also had feelings of frustration guilt and powerlessness invariably communicated to them as the relative living with mental illness did not always appreciate the caregiving efforts and sometimes blamed them for their failures they expressed powerlessness and frustrations as they did not know how their relative would present it is very difficult to plan for him because his behaviour changed every time he does things unexpectedly so you need to watch him closely theme 3 family caregivers experienced support needs the theme is divided into inadequate informational support ineffective coping and societal challenges caregiving can be a lonely and isolating experience for family caregivers social support is considered to be a protective factor against psychological difficulties findings suggest that the stress family caregivers experienced is associated with a lack of essential support family caregivers experienced inadequate informational support most family caregivers reported inadequate informational support this is one of the contributing factors to caregiver burden families often lack the knowledge and skills needed to assist their mentally ill relative with inadequate support family caregivers felt helpless which led to feelings of discomfort as they were unable to assist the relative with mental illness family caregivers reported failing to understand the illness as well as the behaviours displayed by their relative on many occasions they claimed to be unable to assist their relative because they did not understand the illness and thus failed to give continued support family caregivers experienced ineffective coping coping is the process of managing external or internal demands that exceed the resources of the person the majority of the studies reviewed made reference to ineffective coping because of the limited formal support coping with the demands of caregiving becomes difficult the family caregivers described caring for their relative living with mental illness as challenging stressful and painful ineffective coping was twofold firstly family caregivers were in denial and always lived in fear because of their relatives unpredictable behaviour secondly family caregivers lacked knowledge and were uncertain about practically caring for their relative with mental illness this was noted in two articles it is difficult to have a child with an illness that causes confusion family caregivers were less positive about their caregiving experiences this was noted among the majority of family caregivers who are elderly people many were worried about the future because of a lack of support ineffective coping had an impact on their emotional wellbeing because of insufficient knowledge family caregivers became powerless and were unable to cope with caregiving one sister said there is no problem that is bigger than caring for the mentally sick brother because he is forever…i dont know when it will end completely feelings of powerlessness following an increase in symptom severity led the family caregivers to seek support from healthcare professionals ineffective coping sets in when there are feelings of helplessness family caregivers experienced societal challenges the studies portrayed societal challenges the demanding caregiving role did not only interfere with their daytoday work but reduced outside social opportunities as well some reported that they were not invited to events because of the unpredictability of their relatives illness the family caregivers felt cut off from society as they steadily lost friends and social contacts this theme was confirmed by results from studies conducted by wankiiri et al the same findings were also reflected by moahi caregiving has profound effects on the health of the family caregiver caring for a relative living with mental illness because they not only responded to the persons symptoms but also negotiated with other difficult family members family caregivers ended up having to balance their own needs and the needs of relatives living with mental illness sometimes family caregivers worried about their childrens safety which could lead to family breakdown as children were sent to live with other relatives for their safety the family might also be stigmatised stigma could arise from a number of factors such as suspicion lack of knowledge ignorance belief systems fear and the exclusion of people believed to be different this results in a sense of social loss as described by most participants this is what one caregiver said we felt as if we were alone in an island there was nobody to turn to friends and family were at a distance no one was visiting us the mental health benefits of social support were mainly evident during stressful periods taylor and stanton open access reported that social support reduces psychological distress and contributes to physical health and survival the caregivers felt isolated from society because of the disruptions of their social life as they had to care for the patient social discrimination was also caused by the stigma attached to mental illness stigmatisation and social isolation were a prevalent experience among the family caregivers who had to contend with social relationships that were strained by lack of knowledge and negative attitudes about mental illness some statements by caregivers were depictive of loneliness one caregiver said w hen he relapses you cannot call in the neighbors all the time for help… you suffer alone and at the same time you also feel for the child theme 4 family caregivers experienced changed perspective with adequate support family caregiving can be a rewarding experience family caregiving responsibility affected the way family caregivers perceived life they had to learn how to cope with the illness and to find a balance in the provision of care these perspectives were mediated by emotional sequelae feelings of being overburdened and unmet support needs from their family and healthcare professionals family caregivers experienced effective coping mechanisms coping is the process by which an individual contends with or deals with a situation to alleviate relieve or remove stress coping enables the individual to remain unaware of an unpleasant reality as if it did not exist some caregivers used denial and blame an inability to cope has been shown to present in physical symptoms like sleeplessness unrest and anger this can have a negative impact on the caregivers mental health according to wilkinson and lynn the course of the relatives illness shapes the caregivers experience the family caregivers used different coping mechanisms some positive and others negative to decrease stress and thereby maintain mental health family caregivers reported adjusting and adapting to the situation by learning to accept the situation and by implementing alternative coping methods family caregivers mental health can be improved not accepting the behaviour of a mentally ill relative may cause additional stress not only to the family caregiver but also to the relative as well some family caregivers said they made efforts to accommodate and accept their relative living with mental illness they also avoided conflict and upsetting their relative by tolerating their behaviour however to cope with their feelings others tended to be in denial and blame god for the illness one said i even asked god to say what have we done this is supported by endrawes obrien and wilkes who noted that family caregivers sometimes tend to look for someone or something to blame families views linked mental illness to spirituality as some form of coping ngqoboka noted that families could have psychological defence mechanisms to cope with stressful situations a belief in god and hope for the future was identified as such a coping mechanism also despite negative feelings family caregivers had hope that their relatives would be cured if they were kept in hospital i hoped my brother will be cured if he stayed in hospital he would be discharged on treatment so that he continues taking it he is not so bad some have learnt to accept the situation because they felt they had no other alternative one family caregiver said really i have accepted it because i have already been given but its a big task its a very big task one other way of coping that was reported was being optimistic and being hopeful that god would heal the mentally ill relative this was supported by endrawes et al where caregivers learnt to cope better by being hopeful that god would heal the relative living with mental illness family caregivers positive experiences the family caregivers experiences were not unanimously bleak some family caregivers experienced satisfaction and had positive feelings about caregiving especially after empowerment and receiving interventions from the hospital they appreciated the interventions they received from the hospital upon securing treatment for the affected individual family caregivers reported relief and hope i thank the nurses for their support and visits i wish the health workers could continue visiting us and empower us and see that we are meeting the demands of caring for the sick seloilwe stated that family caregiving also brought the family together someone responsible would be accountable for providing care other family members would assist in providing money food or materials necessary for providing care we had a way to decide who was going to take care of my mother… and even pool our efforts to provide her with a salary she was earning discussion of findings the findings provided insight into the caregiving experiences of family caregivers for relatives living with mental illness the important theme was that the family caregivers experienced challenges with caregiving however they also experienced changed perspectives regarding caregiving within the theme of caregiver responsibility the family caregivers felt overwhelmed and were frustrated they did not know how to seek help it has also been reported by various studies that caregiver responsibility may lead to a physical and emotional burden for the caregivers the caregiving impact has been endorsed by trondsen who noted that mental illness strained relationships and affected physical and mental wellbeing of caregivers in contrast to the majority of studies that focused on helping the caregivers to cope with assisting their relative to adhere to treatment this review brought to light the effects of caregiving on mental health a key factor influencing fear was helplessness helplessness seems to be a determinant of fear for most family caregivers however fear also emanated from being stigmatised and fearing for their relatives safety when they did not know what to do knowledge could have helped reduce their fear one clear implication is that helplessness affects fear through a lack of knowledge of what to do it is significant that the experiences of family caregivers seemed to be influenced by support and knowledge the studies portrayed societal challenges the demanding caregiving role does not only interfere with their daytoday work but reduce outside social opportunities as well taylor and stanton reported that social support reduces psychological distress and contributes to physical health and survival stigmatisation and social isolation were a prevalent experience among the family caregivers who had to contend with social relationships that were strained by lack of knowledge and negative attitudes about mental illness the themes show a consistent link between helplessness fear stigma and societal needs the review also reported that family caregivers inability to effectively cope with caregiving could lead to emotional distress however the family caregivers were also able to identify positive aspects of caregiving especially after being empowered and after being able to support their relative the use of respite care where mentally ill relatives were admitted to the hospital to alleviate the effects of caregiving led to caregivers being relieved from caring for their relative based on the findings of the metasynthesis implications for facilitating the mental health of family caregivers are presented as mentioned caregivers got little help in managing the emotional demands of caregiving a study by reinhard et al revealed that healthcare professionals do not prepare the family for emotional challenges the findings were relevant to service improvement in terms of mental health supportive care and to facilitate effective coping of family caregivers one suggestion is that the psychiatric nurses should discuss the role shift assertive communication and positive emotional coping with caregivers to enable better coping the caregiver should also be provided with emotional support the last recommendation for practice is related to the importance of positive perspectives of caregiving being positive helps one to overcome the negative impact of caregiving psychiatric nurses should make the caregiver aware of the importance of being positive and help teach them how to develop positive perspectives by being positive family caregivers will cope better which will also improve their mental wellbeing lastly it is important for future researchers to be aware of the mental effect of caregiving to develop appropriate coping strategies for the caregivers research should be done on the effect of caregiving on mental health and programmes that promote effective coping among family caregivers should be developed limitations the limitations of the study are that the study was limited to english research studies this does not mean that people who speak different languages are exempted from caregiving challenges as is the case in other nonenglishspeaking countries in subsaharan africa based on the study findings caregivers bear all the responsibility in caring for their mentally ill relatives the results suggest that caregivers were not able to care and have control over their relative living with mental illness this might instil a sense of guilt this was however not covered in the study and might need further exploration differences in caregiving experienced across cultural and ethnic groups have been documented elsewhere more research exploring the role that culture plays on the family caregivers experience seems warranted as this was not covered in the study conclusion in conclusion the challenges of coping with caregiving could affect the caregivers mental health the research adds to knowledge about ineffective coping of family caregivers the study found that the family caregivers were frustrated and experienced a lack of physical and emotional support the findings also gave insight into the mental aspect of family caregivers understanding the caregivers experiences could better inform psychiatric nurses on how to assist family caregivers to cope with caregiving although limited by a small sample size and confinement to english journals the research provided insight into the mental aspects of caregiving the clinical implication of this review emphasised the role of psychiatric nurses in ensuring effective coping for family caregivers through ongoing training and other forms of support data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors

background metasynthesis is used to generate and understand new insights from a qualitative perspective caregiving is associated with a range of physical and psychological symptoms caregivers bear the brunt of caregiving and this has become worse since the inception of deinstitutionalisation as more patients are discharged into the community under the care of their familiesthe purpose of this study was to synthesise phenomenological qualitative studies and create a comprehensive chronicle of phenomena of family caregivers experiences of caring for relatives living with mental illness method google scholar and different electronic databases which included cinahl medline ebsco and pubmed were searched using keywords for relevant studies published from 1994 to 2014 to obtain an indepth view of caregivers lived experiences a qualitative metasynthesis was employed to review the findings of 10 studies results a total of 10 studies were included in the metasynthesis the family caregivers described their caregiving experiences under four themes perceived responsibility of caregiving experiences of emotional effect experiences of support needs and experiences of changed perspectivethe metasynthesis revealed a lack of emotional coping among the family caregivers this calls for robust family caregiver interventions to facilitate their mental health

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background the aims of this study were to assess the extent to which parents providing consent for childrens participation in an observational tuberculosis research study in india actively participated during the informed consent discussion and to identify correlates of that participation an essential requirement for ethical research is that participation in trials should be informed and voluntary however operationalization of the principle of informed consent in community settings with low levels of education and research literacy can pose challenges especially since standardized consent protocols may not be applicable across different social cultural and economic settings 1 2 3 medical research in children poses particular concerns for informed consent because of childrens status as a vulnerable population legally incompetent to make decisions about their own participation in research studies 4 a childs parent or legal guardian usually serves as a proxy consenter making decisions about research participation on behalf of the child in many countries including india only one parentguardians signature is legally required to enrol a child in a study however household decisionmaking processes and gender differences in attitudes towards health research mean that researcher decisions about which parent to approach for consent can have implications for the process of informed consent in terms of the amount of information requested by potential research subjects as well as ultimate decisions about whether or not to participate 5 6 7 8 researchers have started to work towards developing crosscultural understandings of research ethics by examining research literacy and the informed consent process in subsaharan africa north africa and asia 5 6 7 9 10 11 12 13 14 a range of issues have been identified with respect to the transferability of a code of medical ethics across different settings these include questions around the relative importance of community versus individual consent 6 15 16 17 and whether consent can be truly informed amongst populations with low research literacy for example it may not be easy to impart key concepts of clinical research such as randomization placebo and future societal good versus current individual benefits 18 a further concern is that organizations that conduct research may also provide health care services which create a high level of trust this can be a barrier to healthy skepticism necessary for asking questions about the aims and consequences of a research project 919 a related issue is the common phenomenon of therapeutic misconception where research subjects incorrectly interpret the primary purpose of a clinical trial to be therapeutic rather than experimental sometimes resulting in false hopes about individual outcomes 2021 recent reviews of the research process in developing country settings have endorsed the importance of communitylevel participation and subsequent individual consent for research particularly in rural areas where community level decisionmaking is more prevalent compared to urban areas 35621 in line with these recommendations most community research studies in developing countries are preceded by communitywide information sessions and handouts as a first step for raising awareness of the research study and procedures however understanding of the nature and purpose of a research study is often low even where informed consent has been obtained through standardized and approved procedures 22 moreover few questions may be asked during the informed consent process although participants continue to have questions about the study and are provided ample opportunities to clarify any doubts or seek further information 18 in order to ensure ethical research across different social and cultural contexts there is a need for more empirical evidence to understand the informed consent process this is particularly important in developing countries where the enforcement of codes of medical research ethics may be weaker the analysis reported in this paper contributes to debates about how to increase researchers engagement with research participants by focusing on the process of consent for enrolling children in a communitybased prospective study to assess the incidence of pulmonary tuberculosis in infants in rural south india we were interested in examining the extent to which individuals giving consent actively participated in the consent process and identifying the correlates of participation the proxy measure for participation was whether any question was asked during the consent discussion methods study setting the study reported here analyses data collected during the informed consent discussions for an observational cohort study that was designed to assess the incidence of tb in infants enrolled within 2 weeks of birth and followed up for a period of 2 years the study was conducted in the palamaner area of chittoor district in andhra pradesh and the study area included villages and towns the area is largely rural and semiurban with the majority of the population being involved in agriculture or agriculture related activities the study area was divided in to 594 population units of discrete villages and towns with a minimum population of 200 these were classified as rural low development rural high development or semiurban on the basis of infrastructure and development indicators including electricity road and transport and presence of a school and health facility infants were included in the study if they were bcgvaccinated and were available for follow up for 2 years after enrollment and a parent or guardian provided informed consent infants were randomized to active surveillance or passive surveillance the study did not involve any investigational product but included a standardized protocol of tb diagnostic procedures if infants were suspected of having tb of a total of 7424 recorded births in the study area 4878 fulfilled inclusion criteria and 4382 were enrolled as participants the study was approved by the institutional ethical review board of the st johns national academy of health sciences and the ministry of health screening committee of the government of india in addition to which it underwent ethical review by a contracted ethical review board of the aeras global tb vaccine foundation informed consent process the field supervisors in the study team were responsible for obtaining informed consent this team of 12 was all male each with a minimum of 12 years of school education a minority of them had received a tertiary education study physicians and research nurses were not involved in the consent process in case the power differential between health care providers and the study population influenced parents decisions about whether to enrol their children in the study study personnel were trained on ichgcp guidelines and on informed consent procedures as part of a professional development program they were sensitized to the historical antecedents of current guidelines for the protection of human volunteers in clinical research specific to this research study all personnel involved in obtaining consent were instructed to encourage questions from the parent providing consent and to note down the questions and comments at the back of the consent form if the questions went beyond simple clarifications of the contents of the informed consent form parental consent was taken from any parent who was available at the home of potential participants initially a confidential setting was sought for the consent process in practice however the discussions often took place in the presence of other family members or neighbours after the parent indicated his or her comfort with their presence in this situation the study team members were instructed to ensure that the decision to participate should be taken independently by the parent without pressure from the other people present research coordinators and study managers would observe the informed consent process on supervisory visits and provide feedback to field supervisors to strengthen participatory consent practices the informed consent form was translated into colloquial telugu the local language it was structured around questions as the study team felt that this approach is more intuitive than a narrative consent form for both the study personnel and parents 8 the main questions addressed in the consent form related to the identity of the sponsor reasons for being selected for participation study procedures including the tb diagnostic process potential risks and benefits confidentiality research organizations responsibilities and whom to contact for further information after consent had been obtained the sociodemographic characteristics of the parents were documented during a subsequent visit as part of the baseline information for each study subject analysis once recruitment for the research study was completed the questions asked during the informed consent were coded into a range of different categories loosely corresponding with the structure of the informed consent document as many of the questions did not correspond exactly to the questions posed in the informed consent sheet new codes were also created the informed consent data were entered into the larger database for the study which included socioeconomic household characteristics the data were analysed in statistical package for the social sciences v 170 frequencies for type of question asked were calculated first subsequently crosstabulations with chi squared tests were conducted to identify statistically significant associations between asking a question during the consent discussion and a range of household social economic and demographic variables these included level of development of settlement in which the household was situated mothers age religion caste and mothers and fathers education and occupation household construction material and household cooking fuel use were also assessed as indicators of socio economic status stone and brick construction was considered higher ses and all other constructions lower ses and liquid petroleum gas was considered higher ses and all other types of cooking fuel use were considered lower ses other variables that were examined were household exposure to tb both parents being present during consenting and which parent mother or fathersigned the consent form finally the relationship between the fieldworker taking the consent and participation in the informed consent discussion was explored in the next stage of analysis a multivariate logistic regression model was constructed to examine the effect of socioeconomic and demographic variables on participation in the informed consent discussion the binary outcome variable was did either parent ask a question during the informed consent discussion all the variables from the bivariate analysis that had shown significant association were included except for the identity of the fieldworker the reason for excluding the fieldworker variable was that our focus in the multivariate analysis was to identify participant related factors affecting participation in informed consent results out of the 4382 children enrolled in the study 4095 of informed consent forms were signed by the childs mother the childs father signed the consent form for 60 children and a guardian signed for 2 children in only 287 cases were both parents present during the informed consent process out of these children the mother signed the consent form for 271 children in total 590 out of 4382 parentsguardians asked any question during the informed consent process table 1 shows the range and distribution of questions asked during the informed consent process some households asked more than one question since each question was captured separately the total number of questions exceeds the number of households where questions were asked the questions covered a range of issues relating directly and indirectly to the content of the informed consent document the highest proportion pertained to the nature of tb diagnostic tests to be performed on the child and possible risks to the child of being in the study the third most frequent question was about benefits to the child or family of participating in the study followed by general questions about tb infection diagnosis and treatment ninetynine people enquired about the rationale or purpose of the study concerns that were expressed were about who to contact with any questions and how being in the study would affect treatment for other childhood illnesses just over 10 of parents who asked any question asked whether free treatment would be available for the child and family members during the period that the research project was being conducted table 2 shows the bivariate analysis of factors associated with asking any question during the informed consent process there were highly significant associations between asking questions and subjects residence higher parental education both parents being present during the consent discussions and the use of liquid petroleum gas as the main household cooking fuel other factors that were associated at the p 005 level were religion caste parental occupation and which parent signed the consent form factors that did not appear to have a statistically significant association with participation during the consent discussion were mothers age the house construction material and reported household exposure to tb table 3 presents the results of the binary multiple logistic regression model to investigate correlates of participation in the informed consent process the model included sociodemographic characteristics household socioeconomic characteristics parental characteristics and characteristics of the informed consent process location had an effect on participation with residents of low development rural areas least likely to ask questions and residents of semiurban areas most likely to ask questions education level was important with those of a higher education level more likely to ask questions than those with a lower education level the number of parents present during the consent discussion had a large effect on participation with questions much more likely to be asked if both parents were present all other variables were not significantly associated with asking questions possibly because they are collinear with education and their effect is captured in the model by the education variable or because of the small number of observations discussion institutional and government ethical review boards play an important role in ensuring that clinical and epidemiological research studies have welldefined and documented procedures for obtaining voluntary and informed consent from research participants however too often little attention is paid to how the processes of obtaining consent are conducted important indicators of these processes are the extent to which research subjects participate in consent discussions and understand the nature of the research study in developing countries a further concern is that many of the principles of medical ethics have been developed within the social context of europe and north america and local considerations for obtaining consent may need to be better understood the conduct of research studies in children poses further questions for how to establish procedures for obtaining parental consent that respect the autonomy of parents as well as protect the interests of the child this study of participation in consent discussions in a communitybased neonatal study contributes to the thinking about research engagement with participants and consent for vulnerable populations only a small fraction of parents asked any questions during the informed consent process one possible reason for low participation could have been that a significant number of doubts and concerns were clarified during the prior community information sessions community sessions had been held in schools and village meeting spaces and were attended by students teachers and parents however when we analysed the focus of the 176 questions that has been recorded over the course of the community information sessions the majority of these were related to doubts about signs and symptoms of tb the relatively few questions asked about the study procedures indicate that the community information sessions are not likely to be a major explanatory factor for low participation in the informed consent process another possible reason for low participation is that the study was being conducted under the auspices of an organization that has provided charitable health services in the community for more than 30 years this may have led to an implicit trust in the beneficence of any study being conducted associated with lower likelihood of expressing doubt or seeking clarification if participation is taken as an indicator of the extent to which consent is informed it is a matter of some concern that so few questions were asked during the informed consent discussions despite significant efforts being made on the part of the research team to encourage open discussion and questioning and allow households to be involved in the consent process this may well result in poor understanding of the nature of the research study as found in other settings 101822 the analysis identified location education level and both parents being present during the consent process as the most important factors affecting participation in the consent process those in more developed areas were more likely to ask questions perhaps indicating a greater exposure to health education media and information about research this could be associated with greater ability to formulate questions and confidence to ask them the effect of education may be related both to those who are educated having a better understanding of research processes and having greater confidence to ask questions a study of the quality of informed consent in south africa reported similar findings with regard to education 13 the fact that more questions were asked in our study when both parents were present may indicate a greater confidence to ask questions in a group setting however some of this effect may also be genderrelated with fathers more likely to ask questions to researchers than mothers this effect may be even more pronounced in our study since all of the study team members obtaining consent were male these findings suggest that further research is needed to understand the extent to which participation in informed consent discussions is influenced by the gender of both the research participant and study team members there are some limitations to this study first asking questions during the consent process is taken as an indicator of the extent to which consent is informed this may not necessarily correspond with actual knowledge and understanding of the research process second we made the assumption that field supervisors were equally likely to write down any questions asked during the consent process it is possible however that the likelihood of recording questions asked was related to the abilityinterest of fieldworkers we believe that the periodic supervision by the project coordinator of field supervisors for the consent process and recording of questions strengthens the validity of data another issue is the possible relationship between fieldworker characteristics and parents comfort asking questions in bivariate analysis we found an association between the fieldworker who took the consent and whether any question was asked however we did not have sufficient information on fieldworker characteristics to conduct further analysis of this important area given that previous research in south africa found that the quality of informed consent was better when consenters had more experience 13 and other authors have suggested that research workers do not always have the necessary communications skills to encourage open discussion and questioning of a research project 7 this is an important area for future research a final limitation is that the findings are limited to one study however the number of cases is large and the data can be said to be broadly representative of rural india conclusions our findings provide two important lessons for planning the process of informed consent for enrolling children in research studies in developing country settings first given that socioeconomic status and education are significant predictors of whether any questions were asked during the informed consent process it is critical to put more effort into considering innovative approaches for making discussions during the consent process more interactive this may involve including pictures stories and some test of understanding of the study aims and procedures a primary concern for researchers should be to make the process more accessible and meaningful for research participants of all socioeconomic groups and to raise the level of research literacy within the community apart from carefully considering the content of informed consent procedures the impact of training research team members in communication skills on research subjects participation and comprehension should be examined in future research the collection of data on participation can also serve as a useful monitoring indicator for quality of informed consent processes within research studies a second issue for consideration in conducting research with children is the amount of effort that should be put into seeking two parents participation in the consent process where possible although mothers are the primary caregivers of children and are likely to be easier to reach in a household study our analysis showed that fathers were much more likely to ask questions during the informed consent process in order to promote consent that is truly informed it may be desirable to create more opportunities for fathers to discuss research studies with research workers given that fathers are harder to reach during working hours this could increase the costs of the consent process significantly which can be a deterrent where research funds are constrained if mothers are targeted as the primary consenters for childrens studies participation in consent may be increased by having female research workers conduct the consent discussion it would be valuable to conduct further research to test this hypothesis finally this research points to the importance of generating more empirical evidence on consent and understanding of informed consent in different settings and of building quality assurance of these procedures into research protocols with the growing volume of health research being conducted across different social cultural and economic settings it is critical for researchers to continue to introspect on ethical aspects of their work and increase their engagement with research participants author details 1 division of epidemiology st johns research institute bangalore india 2 formerly with aeras global tb vaccine foundation maryland usa 3 the gade institute section for microbiology and immunology university of bergen bergen norway 4 department of microbiology and immunology haukeland university hospital bergen norway authors contributions dr conducted the primary analysis and drafted the manuscript nj was involved in conceptualizing the study coordinated the data collection contributed to the interpretation of the data and reviewed the manuscript lg was involved in conceptualizing the study and reviewing the manuscript sb was involved in interpreting the data and reviewing the manuscript hg was involved in conceptualizing the study interpreting the data and reviewing the manuscript mv was involved in conceptualizing the study contributed to the analysis and interpretation of the data and reviewed the manuscript all authors read and approved the manuscript competing interests the authors declare that they have no competing interests prepublication history the prepublication history for this paper can be accessed here

background a requisite for ethical human subjects research is that participation should be informed and voluntary participation during the informed consent process by way of asking questions is an indicator of the extent to which consent is informed aims the aims of this study were to assess the extent to which parents providing consent for childrens participation in an observational tuberculosis tb research study in india actively participated during the informed consent discussion and to identify correlates of that participationin an observational cohort study of tuberculosis in infants in south india field supervisors who were responsible for obtaining informed consent noted down questions asked during the informed consent discussions for 4382 infants who were enrolled in the study these questions were postcoded by topic bivariate and multivariate analysis was conducted to examine factors associated with asking at least one question during the informed consent process results in total 590 out of 4382 134 parentsguardians asked any question during the informed consent process we found that the likelihood of parents asking questions during the informed consent process was significantly associated with education level of either parent both parents being present and location conclusions the findings have implications for planning the informed consent process in a largely rural setting with low levels of literacy greater effort needs to be directed towards developing simple participatory communication materials for the informed consent process furthermore including both parents in a discussion about a childs participation in a research study may increase the extent to which consent is truly informed finally continuing efforts need to be made to improve the communication skills of research workers with regard to explaining research processes and putting potential research participants at ease

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introduction as an important comprehensive indicator to measure peoples quality of life and mental health subjective sentiments have attracted attention from various fields according to the world health organization 322 million people were affected by depression worldwide in 2017 due to rapid urbanization the number of people with depression in china has reached 54 million 736 are in a state of psychological subhealth and 161 have psychological problems of varying degrees although residents subjective sentiments are largely influenced by individual and family status such as income marriage age economic status genetic indicators and individual subjective indicators environmental indicators comprise 4050 of all factors affecting subjective sentiments studies have shown that people spend an average of 87 of their time indoors and about half of their time in their neighborhoods due to increasing urbanization there is widespread awareness that improvements in the built environment of neighborhoods may improve the residents sentiments research on the relationship between the living environment and psychological factors is a core topic in urban planning and environmental psychology and the improvement of residents sentiments is one goal of urban planning research on sentiments and living environments encompasses areas as diverse as inequality space deprivation and policy which are critical to the health of rapidly urbanizing cities in developing countries empirical studies based on questionnaires have shown that land prices location spatial form and the built environment in neighborhoods may affect residents sentiments however the largest challenge in this field is the largescale quantification of sentiments the concept of subjective sentiments has been typically used to evaluate an individuals sentiments however subjective sentiments are difficult to monitor or quantify in real time for example most studies relied on questionnaires which have limitations such as limited quantitative measurements low coverage recovery and efficiency and difficulty in replicating the results in the past 2 years few studies have used big data to quantify the sentiments of urban residents however these data have rarely been used to conduct neighborhoodlevel research on residents sentiments more importantly as discussed in the next section objective largesample nondiscrete and reproducible quantitative sentiment measurements may provide a detailed reference for studying multilevel and nonlinear relationships between the built environment and sentiments this study uses social media text data and natural language processing to quantify the residents sentiments in xiamen china a multilevel regression model is established at the neighborhood and subdistrict levels to investigate the relationship between the built environment and residents sentiments at different levels we use the gradient boosting decision tree model to evaluate the nonlinear correlation between variables with a significant impact we attempt to answer the following questions what is the sentiment difference between residents living in different subdistricts of the city which are the built environment indicators affecting individual subjective sentiments at the neighborhood and subdistrict levels is the relationship between the built environment indicators and the sentiments nonlinear or linear this study uses objective social media text data to quantify longterm sentiments instead of shortterm happiness to provide a reference for interdisciplinary research on urban planning and public mental health in addition determining whether the relationship between the sentiments and the built environment at multiple levels is linear or nonlinear is critical for optimizing the built environment of neighborhoods to improve residents sentiments the rest of this article is organized as follows section 2 is a literature review of the quantification of sentiments the built environment at multiple levels and nonlinear studies of sentiments to identify current research problems section 3 introduces the data sentiment quantification methods variables of the built environment and multilevel and nonlinear regression modeling methods sections 4 and 5 present the results and discussions the final section summarizes the paper and discusses policy implications literature review research on the quantitative analysis of residents sentiments questionnaires are commonly used in sentiment studies and social research however this method may not be objective and may not reflect the psychological state of the subjects the results of psychological state studies are influenced by the subjective feelings of the research participants and by the questionnaire design uncertain and confounding indicators may exist such as the same questions applicable to different environmental conditions and inappropriate measurement methods moreover discrete variables are typically used in questionnaires thus the results need to be reclassified and scored to conform to a normal distribution and meet the requirements of statistical inference a reproducible quantitative method can avoid some of the shortcomings of traditional surveys a limited number of studies have used social media data for sentiment analysis to determine the objective sentiments of residents in cities social media capture thousands of interactions between individuals and large groups over a long these data can be used to assess mental health and public sentiments one advantage of using social media data rather than questionnaires and interviews is the large sample size for analyzing sentiments text analysis and geographical analysis have been used to process social media data to obtain nondiscrete and reproducible quantitative sentiment data with high spatial and temporal resolution in general the use of social media data to quantify sentiments is a widely used and accepted method in the academic community complex relationship between the built environment and residents sentiments multilevel analysis of the impact of the built environment on residents sentiments studies on the influence of the built environment on residents sentiments have been conducted primarily at two levels the neighborhood and the surrounding environment baker and steemers stated that in britain we spend on average as much as 90 of our time inside buildings 70 of it in our own homes therefore the built environment of a neighborhood probably has the largest influence on residents sentiments most studies are in agreement for example it has been shown that unsafe inadequate facilities and poorly designed landscapes can significantly reduce residents sentiments potentially leading to psychological stress and mental problems in contrast environments with welldesigned facilities beautiful landscapes low noise and more daylight are more likely to evoke positive sentiments however some disagreement exists on the effect of some indicators such as the impact of building density indicators on sentiments most studies found that a higher building density is more unpleasant and results in negative sentiments however a study conducted in oslo reported that high building density might promote social relationships to improve residents sentiments provided that the environment is safe and not noisy urban planning considers spaces outside neighborhoods to enrich residents daily activities research has focused on five aspects land use spatial form development intensity property ownership and transportation organization early studies focusing on land use have consistently shown that neighborhoods far away from industrial areas have better public health safety and welfare can promote a clean environment and improve the quality of life a large amount of urban green space in neighborhoods can provide good air quality and landscape conditions to enhance sentiments in contrast disagreement has developed over the impact of commercial land use on residents sentiments some studies have found that areas of commercial land around neighborhoods can promote travel reduce the dependence on cars and lower residents travel time and costs however the proximity of commercial land to residential sites results in more litter high traffic noise and low visual quality potentially evoking negative sentiments studies on the spatial form found that a large proportion of mixed land use reduced the average walking distance of residents from their homes to sites of interest and increased social interaction improving the residents sentiments however some empirical studies did not produce consistent results foord observed that mixed land use improved the convenience and diversity of amenities for residents to meet their lifestyle needs cao found that mixed land use in the twin cities mn provided more amenities but also resulted in more noise traffic congestion and possibly stranger danger resulting in positive and negative effects on the residents sentiments however the overall impact was statistically insignificant higher development intensity results in higher population density and diverse impacts on the residents sentiments some studies reported that a higher population density caused overcrowding unemployment poverty and mental stress other studies suggest that a higher population density may improve residents sentiments by enabling them to walk through their neighborhoods some studies on property ownership reported that the migrant population caused a sense of insecurity and instability increasing the mental stress of residents when the proportion of the migrant population reached a specific size the formation of group identity caused a stabilization of the sentiments many studies have examined the impact of road design on residents sentiments some found that a higher road density provided increased connectivity between neighborhoods and significantly reduced congestion improving residents sentiments it has also been argued that a high road density in neighborhoods can reduce the quality of life in a subdistrict due to landscape fragmentation too many road crossings can reduce access efficiency and make residents travel experiences less enjoyable it has also been found that residents sentiments are considerably influenced by traffic efficiency and that transportation organization and sentiments may not be correlated early empirical studies primarily used simple linear regression models to explore the impact of the built environment on residents sentiments subsequently more complex regression models such as multiple linear regression and structural equations were used although theoretical and empirical evidence suggests that the impact of the built environment on sentiments is multilayered most studies focused on a single level and individuals studies on the nonlinear correlation between the built environment and sentiments existing studies show that the built environment has nonlinear relationships with overall sentiments referring to maslows theory residents needs regarding the environment can be divided into three categories basic needs intermediate needs and advanced needs negative sentiments occur when basic needs are not met and vice versa positive sentiments occur when advanced needs are met but negative sentiments do not occur when they are not met negative sentiments occur when intermediate needs are not met and vice versa studies on residential environments found a nonlinear relationship between negative sentiments and basic needs such as street lighting residential safety absence of noise and nearby facilities a nonlinear relationship was also observed between sentiments and advanced needs such as diverse architectural styles outstanding education and good streetscape design however questionnaire methods used in most sentiment analysis studies provide mostly discrete data and there may be errors in analyzing nonlinear relationships using an ordinal scale to classify the sentiments of residents is subjective and does not provide a trend making it difficult to determine whether the variance in the data is the result of random errors or curve fitting when assessing nonlinear relationships although theoretical and empirical studies in public health and planning indicate a multilevel and nonlinear correlation between the spatial environment and residents shortterm satisfaction most multilevel analyses have focused on the individual and the environment in contrast the impact of multilevel differences in the spatial environment on residents longterm sentiments has been based on theoretical approaches and few empirical studies have been conducted however public health studies focused more on longterm sentiments than shortterm satisfaction researchers started to use social media data to analyze the longterm sentiments of people ∼2 years after the development of nlp techniques these studies found complex relationships between peoples sentiments and the built environment in boroughs with different region no quantitative analysis was conducted furthermore most studies used discrete data from questionnaires which are highly subjective and contingent making it difficult to replicate the results and assess the nonlinear relationship between sentiments and the environment assessing the variable and nonlinear relationship between the different elements of the built environment and the multilevel needs of residents requires more accurate and comprehensive data data and methods we use tweet text data from social media platforms and the sentiment knowledge enhanced pretraining algorithm to score the sentiments multilevel regression analysis and nonlinear correlation analysis are used to assess the relationship between the built environment and residents sentiments the approach uses 4 steps acquisition of social media tweet texts and data cleaning using nlp to perform semantic analysis of the social media tweets establishing a multilevel regression model to evaluate the correlation relationship between different levels of the urban built environment and residents sentiments using the gbdt model to determine the nonlinear relationship between different indicators of the urban built environment and residents sentiments study area the study area is xiamen china xiamen is located in east china in the southeast of fujian province it has 50 subdistricts the city covers an area of 169939 square kilometers and the permanent population of xiamen was 401 million in 2017 xiamen has repeatedly ranked first in chinas economic life survey as the happiest city in china it has an excellent urban environment a comfortable climate and is a safe city with high urban development and numerous social and cultural activities in addition xiamens urban development ranks high in china attracting a large migrant population for work the complex population structure has also contributed to the formation of many urban villages which are called chengzhongcun in china these are highdensity villages surrounded by urban communities that have poor living conditions and are located in areas with high land prices in addition the old city of xiamen is limited by the terrain and the building density and housing prices are much higher than those of the new city therefore the built environment of xiamen is highly unbalanced and complex making it ideal for this type of research many studies on the residents sentiments and lives focused on tourism and housing have been conducted in xiamen we used the 2018 landuse map of xiamen city to select the highgrade and mediumgrade residential land and urban villages for this research data sources data of residents sentiments obtained from social media tweets social media tweet data include the social media users geographic information time and text since checkin events are based on peoples conscious behavior people only post at a location if they stay for a relatively long time and think they have information worth recording thus these tweets reflect the users psychological state the amount of data is larger than that obtained from questionnaires unlike mobile phone data and night lights social media checkin data contain information on human sentiments thus they are more suitable for studying the state of residents we used sina weibo checkin data sina weibo is a widely used social networking platform in china users are encouraged to check in frequently recording their daily activity patterns and behaviors the data used in this article was obtained by crawling the annual weibo tweet data using the sina weibo application programming interface in 2017 including public data such as weibo tweets generation time user id and location the data were filtered to remove repetitive garbled and other meaningless text or symbols in the text such as urls html tags curly single or double quotes email addresses and nonascii characters the weibo data with a neighborhood was extracted and a total of 146147 tweets were obtained there were 1096 neighborhoods with more than 10 tweets exceeding the amount of data obtained from a questionnaire the quantification of the residents sentiments was performed using deep learning classifiers they can identify emojis and text in social media tweets analyze subjective texts with sentiment overtones and score the sentiments we used the open access model skep based on ernie 30 to analyze the sentiments first we used the pretrained model dataset to build a learning platform based on sentiment knowledge then we manually labeled 50000 weibo texts with sentiments machine learning based on pretrained samples teaches computers how to quantify sentiments in tweets unlike scoring methods such as sentiment dictionaries and cloud sentiment analysis the skep method is similar to human subjective thinking and the method is reproducible the sentiment scores of the tweet text have a range of 0 1 the closer the score is to 1 the more positive the sentiments are and vice versa the sentiment analysis preprocessing model was shared in figshare a comparison of the publicly available chinese corpus annotated by baidu intelligent cloud sentiment analysis showed that the classification accuracy of the skep model was 958 the precision and recall for the positive sentiments were 957 and 964 and those for the negative sentiments were 96 and 951 respectively demonstrating the reliability of the sentiment classification results are reliable built environment data we obtained statistical data for the neighborhood and subdistricts in china a neighborhood is the smallest residential unit for urban planning and management it is constructed by a developer or the village collective and the boundaries of the neighborhood determine in urban planning depend on the land granted a subdistrict consists of several neighborhoods and is an administrative unit in china it is subject to the urban planning goals of the government the neighborhood data was obtained from the website of fangtianxia a chinese real estate market website typically internet real estate data are collected by designated staff and uploaded to the internet by relevant institutions the data include neighborhood construction information such as neighborhood location boundary land value number of households building density plot ratio and greening rate we extracted the neighborhood boundaries from the current map of the urban master plan and calculated the information on living facilities population public facilities and other information within 1 km of the neighborhood urban dwellers spend most of their time in neighborhoods that provide the most important functions of daily life multiple indicators affect sentiments for example the housing area building density plot ratio and greening rate may affect the living experience of residents the number of households the proportion of the migrant population and population density affect residents social activities property fees and land values affect the living expenses of residents cultural public and transportation facilities affect the living experience of residents we used two types of indicator statistics one is a numerical variable for the number of neighborhoods population structure and land value the other is a categorical variable eg for cultural facilities and proximity to water the subdistrict characteristics were extracted from the 2018 landuse map of xiamen city including the subdistrict area name and region we derived statistics for the subdistrict including land use spatial form development intensity property ownership and transportation the average of the sentiments for each neighborhood was used as the dependent variable since a subdistrict is used by urban residents for jurisdiction and communication activities the spatial elements have the largest impact on the residents sentiments for example different landuse types of the subdistrict can provide different functions the public service facilities may affect the residents accessibility and the building density may reflect the development level of the subdistrict the proportion of the migrant population in the subdistrict may affect the interpersonal experiences of residents and road density may affect traffic quality the indicators and their calculation are listed in table 2 x n is a neighborhoodlevel indicator and s n is a subdistrictlevel indicator statistical analysis of the correlation between residents sentiments and built environment indicators multilevel regression model the sentiments of urban dwellers may have a multilevel relationship with the built environment some scholars have conducted hierarchical studies on the built environment at different administrative levels and under different development conditions to determine the impact of the built environment factors on residents sentiments at multiple levels our sample data had a hierarchical structure with lowlevel neighborhood data nested within highlevel subdistrict data the objective of this study is to determine the effect of the built environment on the populations happiness thus we focus more on public health than individual attributes or satification therefore a multilevel regression model was used to analyze the differences between subdistricts and neighborhoods multilevel regression models can also explain the relationship of variables at different levels with the dependent variable as a result we used neighborhoodlevel indicators and subdistrictlevel indicators to construct a twolevel regression model the first step is to analyze the data hierarchy using an empty model with no explanatory variables in this case there are two levels i is the neighborhood and j is the subdistrict y ij represents the observed variable of neighborhood i in subdistrict j the model is defined as y ij β 0j ε ij 1 the change in the intercept between neighborhoods can be expressed as β i0 γ 00 u i0 2 the empty model is defined as y ij γ 00 u i0 ε ij 3 where γ 00 is the mean intercept β i0 is the neighborhoodlevel intercept u i0 is the random effect of the neighborhoodlevel intercept and ε ij represents the estimated neighborhoodlevel difference in the built environment the intergroup correlation coefficient can be calculated using the empty model it is defined as the ratio of the variance between groups to the total variance icc σ 2 0j σ 2 0j σ 2 4 the empty model equation can estimate the variation across all subdistricts σ 2 0j is the neighborhoodlevel variance and σ 2 is the subdistrictlevel variance the significance of σ0j and the size of the icc determines whether the sentiment difference is significantly affected by the subdistrict and whether a multilevel model is required if there is a difference a subdistrictlevel variable is added to equation to create equation five models are constructed land use spatial form development intensity property ownership and transportation organization the significant built environment variables at the neighborhood level are retained and the subdistrictlevel variables are added β i0 γ 00 γ i0 s j u i0 y ij β i0 γ 0j x i ε ij equations and are combined to obtain the final model y ij γ 00 γ 0j x i γ i0 s j u i0 ε ij 7 where x j denotes the neighborhood variables and s i denotes the subdistrictlevel variables that remain in the final model only if they are significant γ 00 γ 0j x i γ i0 s j is the fixed effect γ 0j is the main effect of explanatory variable x i at the neighborhood level γ i0 is the main effect of the explanatory variable s j at level 2 and u i0 ε ij is the random effects an empty model was constructed to determine the difference in peoples sentiments between neighborhoods and subdistricts we established a singlelevel model with five indicators at the neighborhood level we then added variables at the subdistrict level to establish different models several indicators were removed to prevent multicollinearity nonlinear gbdt regression model the sentiments of city dwellers may have a nonlinear relationship with the built environment we used the gbdt method to describe the nonlinear relationship between sentiments and neighborhood spatial features the gbdt uses decision trees and gradient boosting regression trees indicates that the indicator is dimensionless the gradient boosting is based on the residuals of the previous tree we used the mean of the response variable to predict and calculate the residuals and determine the difference between the observed and predicted values then a tree was added to predict the residuals the new predicted value of the response was the sum of the predicted values from the previous step the predicted residuals were multiplied by the learning rate and the new residuals were obtained by subtracting the new predicted values from the observed values we repeated the second step until the addition of a tree did not improve the prediction result or the maximum number of trees was reached the gbdt method uses additive regression models by sequentially fitting a simple parametric function to the current residuals using least squares at each iteration we selected index x i with a significant correlation in the multilevel regression model first the optimal constant model was initialized to minimize the loss function l f 0 arg min γ n l y ij γ 8 in the second step each iteration of m had four substeps first we calculated the negative gradient using equation next we fit a regression tree to the target the third substep was to calculate the gradient descent step size based on different tree expansions using equation in the last substep equation 11 the model was updated based on the results of equation for m 1 to m for i 1 2 n calculate the pseudoresiduals r im ∂l y ij f ∂f f f m1 9 fit the target edge of the regression tree and determine the terminal area r jm j 1 2 m for j 1 2 m compute γ jm arg min y x∈r jm l y ij f m1 γ 10 update f m f m1 j m j1 γ jm i x i ∈ r jm 11 the third step is to generate the final model as follows f f m 12 where y ij is the sentiment mean γ is the step size r im is the pseudoresidual r jm is the terminal region m is the number of iterations n is the number of eigenvalues and j is the size of each constituent tree the regression curve was plotted according to the model fitting results and the influence of different indicators on the sentiments was assessed positive sentiments occur when an intermediate need is met and vice versa according to the threefactor theory positive sentiments also occur when advanced needs are met but negative sentiments do not occur when they are not met the thresholds in the nonlinear relationships were analyzed results results of variable preprocessing table 3 list the descriptive statistics of the mean sentiments and variables at different levels figure 4 illustrates the high accuracy of the tweet data classification and the distribution of the nondiscrete sentiment data it was verified that the mean sentiments of the neighborhood followed a normal distribution and the sample size was sufficiently large to reflect the sentiments of the neighborhood residents the average sentiment in xiamen is 066 representing an average of 66 positive sentiments per 100 weibo texts the average sentiment on xiamen island is 067 and the average value outside of the island is 063 indicating a higher sentiment level on the island than outside the island figure 5 depicts the difference in the sentiments for different subdistricts therefore it is necessary to perform multilevel regression multilevel regression results the multilevel regression results in table 4 show that in the empty model the intergroup variance of the twolevel regression model is 01986 the withingroup variance is 08270 the icc is 01937 and the p 0001 indicating that ∼19 of the total variance in the sentiments occurred among subdistricts the variance inflation factor of model 1 is 15 indicating no multicollinearity between the indicators at the neighborhood level the land value and proximity to water are significantly positively correlated with the sentiments the plot ratio and population density are significantly negatively correlated with the sentiments at the subdistrict level the proportion of green space the proportion of commercial land building density and road density are significantly positively correlated with the sentiments the proportion of industrial land and the proportion of the migrant population are significantly negatively correlated with the sentiments mixed land use and the number of public service facilities were not significantly correlated with the sentiments nonlinear regression results obtained from gbdt model according to the results of the multilevel regression model we selected indicators with significant correlations and used them in the gbdt model to assess the nonlinear relationship between different indicators on residents sentiments we set the parameters in the gbdt model by focusing on the key parameters such as the number of trees and the shrinkage following fan et al we used the following gbdt model parameters the number of trees was 10000 the shrinkage was 00001 and the minimum number of observations in the terminal nodes of the trees was 20 the results are plotted in figure 6 since there were positive and negative correlations between different indicators we plotted the growth of the built environment in the positive direction of the horizontal axis the larger the indicator value the more influence it has we observed different degrees of nonlinear correlations between the neighborhood and subdistrict variables that significantly affected the sentiments the land value had a greater impact on sentiments when the indicator value was low and it was difficult to meet residents needs this is referred to as a basic need in the nonlinear relationship population density the proportion of industrial land building density and the proportion of the migrant population had a larger influence on sentiments when the indicator values were high ie an advanced need in a nonlinear relationship a linear relationship was observed between the sentiments and the proportion of green space and the proportion of commercial land table 5 summarizes the nonlinear characteristics and thresholds discussion advantages of using social media data for sentiment quantification the data used in previous related studies had either low spatial resolution or lacked quantitative information using questionnaires to survey residents sentiments is costly and provides small sample sizes making it difficult to capture residents sentiments objectively inconsistent results may be obtained and it is not possible to analyze the nonlinear correlation between the built environment and sentiments using social media data for sentiment analysis allows for quantitative analysis multilevel relationships between sentiments and the built environment we observed differences in the relationships between sentiments and the built environment between the neighborhood and subdistrict at the neighborhood level housing with a high land value and close proximity to the waterfront evoked positive sentiments consistent with previous research a low plot ratio and low population density resulted in negative sentiments which is in line with residents needs for highquality housing our research also revealed the relationship between population density and sentiments previous research found that a highpopulation density worsened environmental conditions and increased noise causing negative sentiments however several studies found that an increase in population density in lowdensity areas improved the residents sentiments by increasing opportunities for interpersonal interactions however in compact cities like xiamen residents prefer lowdensity settlements reducing the population density of residential areas can improve the quality of life thus it is one objective of urban planners at the subdistrict level more green spaces and commercial land improved the sentiments of the residents whereas a large proportion of industry resulted in negative sentiments an increase in the proportion of commercial land use significantly improved residents sentiments suggesting that residents enjoy the convenience offered by nearby commercial facilities and are not bothered by the negative impacts such as traffic congestion and noise that some studies have associated with commercial land use a higher proportion of the migrant population in the neighborhood significantly worsened the residents sentiments previous studies have also concluded that too many foreign renters affected the living experience of local residents and made it difficult for outsiders to integrate into local life resulting in negative sentiments a high road density in a subdistrict indicates a higher level of development increasing traffic and meeting the travel needs of more residents nonlinear correlation between sentiments and the built environment the gbdt model can predict complex nonlinear associations and is particularly efficient when the nonlinear associations differ for different independent variables figure 6 shows the relationship between different indicators and the sentiments the land value is a basic need of residents these indicators had nonlinear relationships with sentiments the home owners sentiments can be significantly affected by a change in the housing price when the price is 60 of the maximum value at this price most people in lowincome and middleincome groups can own a house home owners are not affected by a change in house prices it the price is higher than 60 of the maximum value in contrast the plot ratio population density proportion of industrial land and the proportion of the migrant population were advanced needs and had a nonlinear correlation with sentiments the plot ratio had a threshold of 3 a plot ratio of 03 usually indicates lowrise and middlerise housing the lower the plot ratio in this range the more spacious the living place thus a decrease in the plot ratio improved the residents sentiments when the plot ratio was more than 3 in middlerise and highrise residential houses an increase in the plot ratio did not affect the housing type therefore there was a negligible effect on the sentiments the lower the population density in the neighborhood the more positive the sentiments of the inhabitants were at densities of 300 people per hectare at greater densities the sentiment remained relatively stable the threshold for the proportion of industrial land within the subdistricts was 10 above this threshold the sentiments of the residents were not significantly affected in contrast below 10 as the percentage decreased the sentiments of the residents improved substantially which is in line with the planning and construction criteria of keeping neighborhoods away from industrial areas to improve their quality when the migrant population in the neighborhood was 20 the sentiments of the residents were largely unaffected and remained high between 20 and 40 a significant increase in the migrant population caused a significant decrease in the sentiments in the neighborhood the residents exhibited more xenophobia and the migrant population showed a decrease in their sense of belonging when the proportion of the migrant population exceeded 40 the sentiments stabilized in general advanced need represents the residents desire for a highquality residential life and should be the focus of highquality construction in urban renewal projects the findings of this article indicate inequalities in the sentiments in xiamen due to differences in the built environment of neighborhoods and subdistricts these differences may lead to inequalities in the health of residents therefore planners and designers should focus on meeting the various needs of urban residents to promote health equity highdensity development in xiamen currently meets the needs of residents at the middle and lower levels although residents desire a highquality built environment with low plot ratios low population density low proportion of industrial land and low proportion of the migrant population in the neighborhood and district these factors are considered in the current peopleoriented urban renewal and transformation projects in xiamen the nonlinear correlations and thresholds obtained in this study can inform decisionmakers in other cities to meet the needs of residents at different stages of development this information enables the use of planning and design tools in a targeted manner to improve the living experience of residents conclusion we used social media data and the skep model to quantify residents sentiments in xiamen china multilevel regression models and gbdt models were used to investigate the effects of various indicators on sentiments in the neighborhood and subdistrict and determine the nonlinear correlation between different indicators and sentiments the multilevel regression results showed that neighborhoods with a higher land value lower plot ratio lower population density and water frontage were more likely to evoke positive sentiments at the subdistrict level more green spaces and businesses less industry higher building and road densities and a smaller migrant population were more likely to result in positive sentiments approximately 19 of the variability in the residents sentiments was explained by the subdistrict indicators we used the gbdt model to derive the nonlinear correlations between the sentiments and different indicators the proportion of green space and commercial land and building and road density were linearly correlated with residents sentiments the land value is a basic need and exhibited a nonlinear correlation with sentiments the plot ratio population density the proportion of industrial land and the proportion of the migrant population were advanced needs and had nonlinear correlations with sentiments the basic needs should be met first during planning and construction whereas advanced needs are a direction for developing a highquality living environment quantitative analysis of sentiments can provide powerful data support for urban planners and decisionmakers this analysis is superior to using traditional questionnaires which provide discrete data that do not reflect global attributes combining social media data and intelligent sentiment analysis algorithms can greatly improve the efficiency and accuracy of sentiment quantification priorities for planning and construction can be determined based on the needs of residents at different levels decisionmakers should consider the correlation of different indicators with sentiments to optimize resource allocation future research should focus on assessing sentiments with larger sample sizes and including more built environment variables to reveal the complex relationship between the urban built environment and residents mental health from a peoplecentered perspective in addition our study on the relationship between environment and human emotions is exploratory in nature there are currently no models that explain both multilevel and nonlinear relationships further analyses of multilevel and nonlinear relationships are needed data availability statement the original contributions presented in the study are included in the articlesupplementary material further inquiries can be directed to the corresponding author publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

introduction humans spend most of their time in settlements and the built environment of settlements may a ect the residents sentiments research in this field is interdisciplinary integrating urban planning and public health however it has been limited by the di culty of quantifying subjective sentiments and the small sample size methods this study uses weibo text checkins in xiamen from to quantify residents sentiments in neighborhoods in the city a multilevel regression model and gradient boosting decision tree gbdt model are used to investigate the multilevel and nonlinear e ects of the built environment of neighborhoods and subdistricts on residents sentimentsthe results show the following the multilevel regression model indicates that at the neighborhood level a high land value low plot ratio low population density and neighborhoods close to water are more likely to improve the residents sentiments at the subdistrict level more green space and commercial land less industry higher building density and road density and a smaller migrant population are more likely to promote positive sentiments approximately of the total variance in the sentiments occurred among subdistricts the proportion of green space and commercial land and the density of buildings and roads are linearly correlated with residents sentiments the land value is a basic need and exhibits a nonlinear correlation with sentiments the plot ratio population density and the proportions of industrial land and the migrant population are advanced needs and are nonlinearly correlated with sentiments discussion the quantitative analysis of sentiments enables setting a threshold of the influence of the built environment on residents sentiments in neighborhoods and surrounding areas our results provide data support for urban planning and implementing targeted measures to improve the living environment of residents

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introduction guided by a set of dynamic principles regenerative farming uses a combination of complementary and adaptive techniques in order to rebuild soil health and fertility increase water percolation and retention enhance synergetic biodiversity and ecosystem health recycle nutrients and energy reduce carbon emissions and atmospheric co2 levels and minimize the use of agrochemical and energyintensive inputs processes of regenerative agriculture may include crop and intensive livestock grazing rotations multispecies cover cropping chopping and dropping minimal tillage integrated livestock and pest management and the integration of native plants and pollinators although these methods are most often operationalized in rural settings with broader swaths of land a growing number of urban agrarians are finding creative ways to incorporate regenerative techniques into their practices to deepen our understanding of the possibilities and challenges for regenerative cultivation in and around calgary we formed a partnership between the university of calgarys department of anthropology and archaeology root and regenerate urban farms1 and the young agrarians connecting the western provinces of british columbia alberta saskatchewan and manitoba ya is a farmer to farmer educational resource network for new and young ecological organic and regenerative farmers in canada2 formerly housed under the nonprofit organic alberta ya is now a program of the agrarians foundation a charitable organization that provides public education on agriculture community development and environmental sustainability in addition to networking events farm tours business bootcamps land access programming and reconciliation training for farming communities ya offers an annual apprenticeship program that matches aspiring farmers with mentors to hone their farming philosophy and techniques funded by a social sciences and humanities research council vanier canada graduate scholarship and a university of calgary faculty of graduate studies transformative talent scholarship we established a mentormentee partnership from may to september 2021 to document the processes barriers and opportunities of small plot intensive farming in calgary primarily practiced in urban centers with lowimpact technologies this farming technique utilizes consecutive planting intense rotations and close proximity of crops to one another to allow for a large amount of food to be grown in small spaces thus maximizing productivity we asked how and to what extent can urban farmers employ landbased regenerative practices to grow food for a local alternative food network how can experiential learning partnerships between graduate student researchers farmers and agricultural organizations support more socially and ecologically sustainable food and farm systems in southern alberta although calgarys afn has experienced a beneficial boom in advancing indoor growing for our colder climateincluding container aquaponic vertical hydroponic and greenhouse growingwe seek to highlight the viability of agricultural techniques that are in relation with the land to grow food ecosystem resilience and community we intentionally use the term with the land as opposed to in or on to demonstrate the relationality between growers and landscapes as well as to reflect our application of nodig agriculture the three main principles of nodig include not tilling to minimize soil disturbance covering the soil as much as possible either with living plants or mulch and leaving the roots of crops in the soil after harvest the scope of this essay does not address conventional practices that rely solely on cultivating in the soil nor does it discuss indoor operations that sit atop the land we recognize that overlaps exist between these practices and that it is important to disrupt the notion of isolated 3 silos within food studies discourse research producer certifications and consumer marketing nevertheless framing our experience as growing in relation with the land best spoke to the values and approaches of our work along with companion planting crop rotation and natural pest management we employed spin farming techniques in household yards on an apartment rooftop designed by calgarybased modern office of design and architecture 3 between offices in the city core and among green spaces adjacent to businesses and buildings over the course of five months we collected data on the growing spaces seeding and management practices yields and distribution streams for root and regenerate urban farms to evoke the multiple senses of experiential learning with the land the next section will include a land acknowledgement and two reflective vignettes following the seasons michael gavin will take readers behind the scenes of an urban farming business chelsea rozanski will then focus on a day in the fieldboth ethnographically and agriculturallythrough the lens of an agrarian anthropologist in the subsequent section we will situate our experiential learning research on urban agriculture in albertas food landscape and in broader grassroots movements seeking socially and ecologically resilient food and farm systems our reflective essay will conclude with an acknowledgement of our limitations recommendations for future research and the overall significance of regenerative urban farming efforts in rapidly changing environmental and political climates reflections on regenerative farming in an urban context before we sow seeds and harvest yields we offer gratitude and acknowledge those who have stewarded the lands and waterways of southern alberta for generations this region of turtle island is the traditional territory of the blackfoot confederacy who include the siksika piikani and kainai first nations the tsuutina first nation and the ìyethka nakoda including the chiniki bearspaw and goodstoney first nations calgary is also home to the métis nation of alberta region iii inuit and indigenous peoples newcomers and visitors from around the world also live work and play as members of treaty 7 relying upon the waters soils and pollinators of calgary to grow plants for foods and medicines we situate ourselves and this research within the legacy of colonialism as authors of european ancestry we have been privileged to learn and cultivate at the historical displacement of indigenous peoples we acknowledge that the only voices we can represent are our own and take responsibility for any misrepresentations in this reflective essay the growing season in calgary officially begins while the snow is still flying in this area the winter months offer a rest but also a time for preparing and planning for the upcoming season farming at any scale ones tools equipment seeds and materials need to be inventoried assessed and replaced as needed taking stock of equipment and tools starts at the end of the season around late october when winter approaches and we put everything away for things like remay a cotton and synthetic fabric blend used to protect plants from frost and insects we measure the lengths check for holes and replace as needed this goes for all the different parts that make up intensive farming operations such as irrigation components starter trays and the like in december we start ordering materials this is when the farm expenses are the greatest we replace supplies and repair equipment take stock of what we need to grow and collect membership fees needed to purchase the necessities to grow food in the summer programs such as community supported agriculture are invaluable in helping offset some of these early and expensive purchases with presold shares or csa membership subscription fees the most important part of planning for the following season is done from december to january when climatesensitive crop designs are made for the season with urban farming plots and growing beds are not uniform nor do they have equal conditions such as wind and light availability this adds a certain level of complexity in planning that rural farms do not often have to factor in all our planning is compiled on spreadsheets using information from past growing seasons to create garden maps action dates volumes and all the details needed to produce food at this intensive pace this gives us a clear vision of how the season is going to look inevitably the season will not go as planned however having this baseline plan allows us to adapt and refocus without being lost the first seedlings are planted indoors under lights at the beginning of march and hardened off in a passive solar greenhouse in april from this time the number of seedlings gradually increases to a peak around the first two weeks of may at this point the shelves in my office are bursting with seedlings waiting to be transplanted in unfrozen soil transplants will continue to be produced and planted through the middle of august though in lower quantities from april to may is when we also complete most of our outdoor plot preparation beds are cleared of winter covers and old plant debris which are added to the farms compost and gently loosened with a broadfork compost is added to the topsoil and drip irrigation is installed for increased water conservation this period requires a lot of multitasking as other projects need to be completed concurrently such as greenhouse construction and repairs to coolers fences and compost bins some crops and flowers are directly seeded during these weeks but most transplants will not be planted until the middle of may midmay to midjune is a particularly busy period with thousands of plants transplanted and many rows directly seeded some plants need special care to protect them from harsh spring conditions while other plants are being attacked by flea beetles a major pest covering the plants with remay fabric can help on both counts keeping pests away from plants and insulating them from the wind and cold come the latter half of june we enter into a bit of a lull most crops are planted but not ready for harvest giving us time to catch up on any weeding that may be needed harvest is underway by the end of june to fill our three major outlets local farmers markets a csa and wholesale markets we continue with weekly plantings to maintain a steady vegetable supply farmers markets and csa pickups are held multiple times a week for the next 1517 weeks daily activities become more predictable and routine at this point as we rinse and repeat the tasks that go into filling orders week after week as we approach the late seasonend of september into midoctoberthe rhythm changes once again crops are coming to completion with nothing to be replanted this is when we start to put away irrigation and other equipment cover beds with mulch and cut down crop debris for compost odd jobs or new growing spaces are being completed sales come to an end for our market csa and wholesale distributor and the season winds down until we reach one of the last jobs of the season at the end of october to early novemberdepending on the forecast for snow and frostwe plant next years garlic crop in the ground and keep it cozy with a thick layer of straw after that we relish the brief respite in november before starting the cycle again in december i load up my suv with old pallets gleaned from the side of a dumpster tomorrow we will be expanding the outdoor compost system up up lets go buddy with my fourlegged friend in tow i set out on the road to meet michael at one of the household yards when we arrive michael is already pulling back the white row cover on the spinach good morning i exclaim as i secure my pup a distance away from the garden under a tree drink your water bud we will be working for the next hour or so with a rubbermaid bin pruning shears and a scale we harvest the biggest leaves of each spinach plant filling the bins to the rim we weigh them before stacking one atop the other into our trunks once finished we slide the row cover back onto the metal hoops and stake it into the ground not today flea beetles ten minutes later we park at the next plot hop out and go through a similar process with radishes we begin pulling up the larger radishes from the base of the stem tying bunches of five to six bulbs with a rubber band and placing them in the bins i run into a patch with compacted soil and use my hori hori knife to loosen the roots without cutting the plant to our delight we observe only a few bulbs with root maggot damage which is to be expected in organic farming bending at the knees i jigsaw the heavy bins between pallets and harvested spinach my stomach alerts me that it is now midmorning off we go pup up back in the car i devour two oats n honey bars before arriving at the headquarters of root and regenerate urban farms with the pallets unloaded michael and i begin shuffling the yields into a locked cooler so they dont wilt while we wash and package them for a yyc growers and distributors 4 order taking off my shoes and socks i fill one radish bin with water to soak while michael sets up the sundrying racks bunch by bunch we hose any remaining soil off the plants and lay them out to dry i close my eyes briefly to focus on the cool water between my toes opening my eyes to a lapping sound on pavement is that runoff water tasty ah to be an agrarian researchers dog turning the radishes over periodically we move into the cooler to bag spinach thirty minutes and 350 150g bags later we are ready to pack up while michael reloads the dried radishes into clean bins and drives the orders to the yycgd warehouse i prepare for this afternoons market foldable tables and tablecloths check whiteboard markers and moneybox check tent chairs crates and coolers check i go through the mental rundown today we will be selling large bok choy red russian kale collard greens rainbow swiss chard carrots purple kohlrabi fennel turnips and radishes green onions cherry tomatoes tatsoi parsley dill romaine heads and bagged lettuce arugula microgreens and pea shoots we will also have eggs available from happiness by the acres pastureraised hens and haskap berries from west raven farms michael returns and we soak in the sunrays over lunch stop chasing the wild rabbits and come have a snack we pack up the cars yet again drop the dog off at my house and head to the market by the time we finish setting up the first marketgoers over the course of the growing season we grew approximately 7000 lbs of 48 vegetable varieties across nine urban spaces totaling 026 acres this was roughly broken down into 3015 lbs of 20 varieties of greens herbs and brassicas 2624 lbs of moreover 765 lbs of surplus produce were donated to social agencies that serve foodinsecure populations and work to mitigate hunger including the calgary food bank and the alex community food centre while we did not collect consumer demographics our small urban farming operation contributed to the nourishment of roughly 300 individuals per week for a quarter of the year producing this quantity of food required roughly one and a half fulltime employees root and regenerate urban farms does not rely on volunteer labor to complete its work but welcomes those interested in handson learning to take part in plot building planting packaging harvests and more one to three days per month we were joined by volunteers who were compensated inkind with produce upon harvest we calculated the total weight of yields we also gathered cropand climatespecific data for direct sowing versus transplant dates and ages days to maturity for both sowing types jang seeder roller sizes and feet needed per unit based on space and depth of plants rows and beds additionally we made observations of the diversity of pollinators frequenting blooming vegetables and flowers in the urban growing spaces flowers and medicinal plants that we sowed in the garden spaces included comfrey delphinium lupin sunflowers tobacco yarrow aster strawflower calendula coneflower cosmos vetch and phacelia we also collected information on water usage and retention using drip lines and hemp mulch on beds we noticed a decrease in flea beetle and cabbage moth presence on plants under remay participated in soil sampling with yycgd and tarped new plots to suppress weeds for the subsequent summer our outcomes demonstrate the viability of growing food outdoors despite calgarys climate while building soil health and supporting native pollinators through strategic landscape design and landsharing opportunities the growing spaces in which rruf operates are obtained through partnerships with homeowners businesses and apartment managers accessing land is one of the biggest barriers facing aspiring agrarians both in urban and rural settings the ability to arrange landsharing contracts which can range from fully donated spaces to affordable leases or barter agreements opens up the doors for urban farmers to actually make a living some homeowners opt for up to two csa shares in exchange for the land provided at rrufs main plot michael provides landscaping and lawn care throughout the season this arrangement is a fairly minimal burden for an urban farmer though it can differ from contract to contract nevertheless nodig spin farming requires a high investment in resources and time therefore the lack of longterm security is a shortcoming of landsharing where only one partner owns the land michael faced this scenario in 2021 when one plots homeowners moved and the new buyers wanted the gardens removed a similar scenario happened to leaf lyre urban farms one of the first spin operations in calgary although a plots property owner had the intention of selling their house the landlord and urban farmers were not informed so that the yard would continue to appear lush to potential buyers i felt used and frustrated because i put in so much love and attention i built a relationship with that soil over the course of years i couldnt just leave it there said leaf lyres owner rod olson i was never the one in charge of the yards with which i built a relationship there was always the feeling of uncertainty another urban farm that has faced similar vulnerability is grow calgary which originally produced its food on cityowned land from 2013 to 2018 when expansions to a major roadway were imminent the farm was required to find a new location and start from scratch it took a year to secure a new land partnership and in spring 2020 the organization was able to operate once again after four seasons of cultivating and rebuilding infrastructure on this privately owned land in balzac just outside municipal bounds the organization had to relocate again in 2023 as the 73 acres were to be developed driving in any direction from calgary one can see a new neighborhood or warehouse being built where cropland or pasture once grew highfield regenerative farm and land of dreams are two more operations situated on public land holding municipal and provincial leases respectively that allow for the production of food above ground neither organization is allowed to alter the landscape in any major way nor graze animals to break up the compacted soil caused by heavy machinery moreover neither have reliable access to water or power which makes the stretches in summer without rain precarious the renewal of leases depends on the perceived outcomes of targets outlined in contract agreements which holds both farms accountable to their intended projects but leaves them vulnerable to changes in land use nevertheless with creativity determination and social organization all three operations have been able to succeed in growing food with the land and in building stronger relationships with the city of calgary to highfields operations manager heather ramshaw the world of urban agriculture in calgary is growing a lot but theres not a lot of widespread municipal understanding the department we work with gets it we have a supportive municipal liaison who needs more support themselves to push these agendas forward but generally if youre trying to make policy and bylaw changes thats when you hit walls here and there existing as a pilot project of the city puts us highfield in a very unique position where we can comment on certain things such as best practices in agriculture when a bylaw was being rewritten we were consulted to ensure it would not negatively affect us to make sure highfield still fits in with the citys plans we are continuing to report and we still have access to this property which is amazing but we arent sure what other steps of support will be taken by the city calgary is years behind canadian cities like toronto and vancouver in policy execution and support for urban agriculture although the change here seems slow its gaining momentum and its exciting to be a part of it the network of urban farmers and people looking into food access has started to come together and collaborate especially in the past year as we work towards a similar vision at rruf the limitations we faced for growing on an apartment rooftop were more logistical to get to the 16 planter boxeswhich were filled by a lift with 1800 ft 3 of soilwe had to squeeze tools storage bins and trays of transplants into one elevator and then climb up two flights of stairs at the top there was no setup for compost tool storage or shade and the irrigation installed was inefficient despite these shortcomings it was a great experience to grow food alongside the apartment tenants who had their own boxes with proper architectural design that accounts for weight capacity and accessibility we argue that integrating more rooftop gardens for growing food and native plants would add ecological and social value to urban centers growing food in between buildings downtown also had its perks and setbacks the actual space and available parking was quite limited which meant hauling supplies down several blocks since the plots were located on 17th avenue an area dotted with bars and restaurants nothing could be stored at the site itself as theft was an unfortunate reality the water source was outside of the locked fence so installing automated water ing wasnt feasible which in turn required more frequent labor since quite a bit of shade was cast by the surrounding buildings we were mindful to plant crops that did not require full sun exposure the space was maximized with leafy greens while the sunny rooftop garden overflowed with heatloving plants nevertheless it was a unique opportunity to grow produce for a restaurant right down the street passersby would stop and ask questions and sometimes spontaneously get involved due to the aforementioned challenges with this downtown site rruf decided to not renew its contract the following summer we connected the property owner with amber cox a cree métis artist and gardening enthusiast who has since stewarded the space for community gatherings finally we recognize the spatial temporal and climatic limitations of our experiential learning research as we are focusing on a single growing season in southern alberta canada nonetheless framed within the ethos of ecological responsibility social responsibility and economic viability we argue how similar regenerative spin farming operations can be scaled up and out to not only grow food but ecosystem resilience and community networks the following summer 2022 root and regenerate took on two more ya apprentices underwent a rebranding updated its website and marketing added 10 more shareholder spots to its csa program and acquired a passive solar greenhouse which boosted the quantity of heatloving crops the farm team harvested a total of 6127 lbs consisting of 2290 lbs of roots 2909 lbs of greens and 928 lbs of other assorted produce of that 615 lbs were donated to local food access agencies the farm welcomed two more ya apprentices for the 2023 growing season and has continued to slowly scale up its customer base production and collaborations with other urban farms as farmland is blanketed by everexpanding residential developments and shopping centers and is increasingly controlled by concentrations of agribusiness conversations around urban regenerative agriculture are more and more relevant in the next section we will situate our experiences farming in calgary in the patchwork of albertas food landscape situating urban farming in local to global food landscapes in canada urbanization and the decline of farming populations has been visible across all provinces while one in three canadians lived on a farm in 1931 less than 2 of the total population now run farming operations canadian farm operators are primarily males over 50 with more female and young farmers on a steady rise in alberta for instance approximately 9 of farm operators are under 35 while 62 are aged 55 and over while there are fewer farmers and farm operations in canada the average area per farm has grown with more area devoted to crop production and ranching over the past century from 1921 to 2021 the total number of reporting farms decreased by 73 while the average farm area increased from 198 acres to 809 acres with an average provincial farm size of 1000 acres albertas agricultural landscape is reflective of the top two national farm production types oilseed and grain farming and beef cattle farming including feedlots these statistics and agricultural demographics are reflective of past current and future challenges for smallscale farmers in canada at large including cost of land and competition with investment companies producing oilseed grain and beef lyle weigum cooperator of winters turkeys farm and aspiring farmer landon grams spoke to these barriers to entry lyle shared both my parents were farmers and their parents were farmers my father started a farm from scratch and has now reached the point of retirement my sister has taken over if she didnt it would have been absorbed by either another bigger farm or a hutterite colony people that want to get into agriculture have to start on such a small scale then they see what it takes to be successful which is usually largescale there are such high capital barriers to entry that it discourages or bars a lot of people from entry its not that there are fewer people that want to farm there are a lot of people that want to do this work but getting started is so difficult its so big and so there are fewer and fewer farmers the people who are passionate and industrious about it i hope they can find a way landon observed farming in alberta is vastly industrial with feedlots and monocropped fields monopolized by large corporations it is hard for small farmers to compete in todays market and make any money small farmers face many challenges from setting up the necessary infrastructure to rebuilding soil in a field that has been damaged by years of conventional tillage to acquiring crop insurance when i apprenticed at a regenerative farm through the young agrarians our crops not only suffered from low precipitation but a severe hailstorm that swept through fortunately the farm has a loyal customer base and network of other producers who got them through it another agrarian research participant spoke to the emphasis provincial and federal governments place on increasing canadas export market technologies and infrastructure are not only funded for growing crops and animals but for preparing them for export the national goal is not to help achieve an infrastructurally and foodsecure local or regional economy some money attention and policy is being directed to growing regional economies but its not where the majority of energy is being funneled so many farmers have felt pushed along this treadmill to get big or get out while chasing profits they need more land and special equipment then pesticides herbicides special seed etc but where are the costs felt what are the externalities that are made invisible for the average consumer although there has been a heightened demand over the past 20 years for products grown and raised in alberta the landscapes are still dominated by a productivist conventional agrifood model additionally what smallscale growers can actually do and who they can feed are further limited through municipal provincial and federal policies that are shaped by hegemonic development frameworks in most canadian cities the dominant approaches to agrarian and community development are reactionary and needsbased focusing on increasing food access and security with limited ability to disrupt hierarchies of power food insecurity is often framed within poverty discourseto which the solution is adequate income a strong social safety net and integration into the market food insecurity is tackled by secondary markets that function within a dependency model shaped by an uneven global capitalist economy although food banks hampers and free meals are currently essential for meeting basic needs work done under the auspices of food security has often reproduced the socially inequitable conditions and relations it nominally seeks to address moreover the focus on productive intensification and agrobiotech solutions externalizes the socioeconomic ecological and political implications of global industrial agriculture our research is not claiming that the answer to solving global hunger is regenerative urban agriculture we acknowledge the limitations of production in terms of scalability vulnerability human capacity and environmental impact nevertheless urban farming can be a tool to highlight the mismanagement of how internationally traded food is grown and circulated as it is controlled by an increasingly corporatized agrofood sector urban farming can be a pathway of collaboration between local food movements and emergency food systems and can be integrated into federally funded school farming programs or into a business model wherein a corporation could employ urban farmers to grow food for its employees with over 5600 parks and natural areas spanning 10000 hectares there are ample opportunities for regenerative farming to be incorporated into the city of calgarys parks operations for instance a targeted grazing program was initiated in 2016 for goat and sheep herds to support land management and naturalization projects across the citys bluffs whats more as demand for renewable energy grows at national and international levels urban farmers could support the transition to electric vehicles due to their close proximity to charging stations between sites of production and distribution many urban farmers utilize indoor spaces such as containers and warehouses to grow microgreens herbs and leafy greens and mushrooms yearround in yards and urban farms one can find apiaries stewarded by mob honey buzzy bee honey forever bee and the urban bee hive who receive support and guidance from the nonprofit calgary and district beekeepers association offering workshops and resources for urban growers the calgary horticultural society and urban farm school strengthen partnerships and build cultivation skills among community members if community members are interested in learning about permaculture or acquiring a permaculture design certificate they can reach out to the permaculture calgary guide verge permaculture or prairie sage permaculture other permacultureoriented organizations include permeate regenerate design urban farm permaculture project and the métisled social enterprise foodscape cooperative sponsored by the permaculture calgary guild calgary harvest is a nonprofit organization that connects homeowners with registered fruit trees to calgarians interested in picking their apples crabapples plums pears and sour cherries in addition to rruf chefs table is another spin farming operation that grows produce for local farmers markets restaurants csa programs and yycgd connecting calgarians to 24 farmers in southern alberta this farmerowned cooperative offers an online farm store vegetable harvest box and addon subscriptions customers can access gmo and glyphosatefree produce microgreens grassfed meats fresh eggs bc fruit and locally roasted coffee with 20 pickup locations across calgary cochrane airdrie okotoks and langdon yycgd emphasizes the importance of healthy ecosystems regenerative practices and seasonal goodness to increase the regions food resilience5 the growth of calgarys agricultural scene has been supported over the years by the city of calgarys 2012 food action plan6 covid19 food resilience team and food access collaborative the introduction of affordable mobile markets and advocates of food justice have also supported calgary agriculture while situating our ethnographic experiential learning research in calgarys approaches to agrarian and community development it is important not to fall into the local trap the importance of local control to democratic decisionmaking is invaluable in supporting communities to rebuild socially just economically viable and ecologically sustainable food systems however as dupuis et al make clear the local is often a site of inequality by practicing a reflexive politics of localism regenerative urban farmers can apply a progressive sense of place in which the scope of inequalities wrought by globalization and neoliberalism can be articulated in order to work toward a rightsbased food system in these ongoing processes and relationships it is essential to connect with global resistance movements such as conscious planets save the soil movement7 to support those facing similar barriers imposed by the system moreover it is crucial to build alliances for collective action that span spatial and political bounds around the world grassroots organizations have been resisting the concentration of landgrabbing inputheavy production environmental degradation volatile markets and the cooptation of water and seeds through protests farmertofarmer workshops and social movements one notable international movement is la vía campesina founded in 1993 lvc emerged as a counterforce to neoliberalism through 182 organizations and more than 70 popular education training programs lvc connects over 200 million farmers on small and mediumsized farms landless workers indigenous people fishers pastoralists migrant farmworkers rural women and youth from 81 countries grounded in a food sovereignty approach this global voice of the peasants works toward equitable access to and control over resources and social rights equal participation and representation in food politics and the eradication of violence against women in canada two member organizations of lvc include union paysanne an agricultural and civic organization operating in quebec and the national farmers union a countrywide union of canadian farmers seeking to achieve policy and reform within the national farmers union ya advocates on behalf of new agroecological farmers such as ourselves supporting global and placebased efforts for social ecological and food justice from canada have also been alternative food initiatives idle no more campaigns provincial networking organizations and food policy councils the peoples food commission for example brought together thousands of actors in canada into conversations around the food system the conversations set the stage for the national food security assembly food secure canada canadian association for food studies peoples food policy project un special rapporteur on the right to food visit and regeneration canada among others another organization connecting rural farmers and ranchers across alberta specifically to share climate strategies is rural routes to climate solutions in addition to a regenerative agriculture lab solar lab podcast series and blog rural routes has partnered with the siksikaitsitapi agriculture project which is an avenue for the blackfoot confederacy of southern alberta to highlight onfarm and onranch climate solutions on blackfoot territory8 dawn morrison of the secwépemc nation and director of the working group on indigenous food sovereignty9 urges canadians rather than subsuming indigenous food activism to engage with indigenous cosmos struggles and narratives and utilize our respective platformssuch as this publicationto promote indigenousled organizations responding to community needs around food 10to share our experiences experiential methods and findings with the public and fellow scholars we copresented at the 2022 university of calgary graduate students association symposium and in the department of anthropology and archaeology talk series we also cohosted farm tours with the ya apprenticeship program and the calgary institute for the humanities food studies interdisciplinary research group through our academicagrarian partnership we hope to continue building alliances both locally and globally conclusion one of the biggest challenges facing our global food and farming system is the feasibility of simultaneously supporting economically viable farmers sustainable or regenerative environments and sufficient food for all humans at the production level almost all urban and rural farmers in southern alberta participate in the market economy as relative living costs are reinforced by the economic modelwhich regulates prices in housing transit gas and other expensesfarmers must market to those who can afford plants and animals grown by well caredfor workers and soil this predominantly includes middleand upperclass households with sufficient financial capital to participate in an alternative food network in our season of experiential learning research our csa shareholders yycgd harvest box clientele and farmers market attendees were able to purchase the cad 7 freerange eggs cad 5 carrot bunches and cad 450 microgreens we offered but this is not the case for the majority of calgarians beyond cost the spaces in which afns operateincluding farmers markets csa programs and community gardenshave been critically examined for their whiteness and assertion of privilege as demonstrated by kato and hanson et al other factors hindering participation in an afn or csa include limited choice in fruits and vegetables unfamiliarity of the model high upfront cost and purchase options and timeintensive provisioning the accessibility and hours of pickup locations have also been criticized as they are most often located in areas where profit can be made from sales and not in regions with lower economic incomes in calgary distributors have partnered with the city to provide more accessible pickup and popup locations at ctrain stations and community association centers as well as offering doortodoor delivery services for an additional fee rruf also observes the aforementioned barriers in its operations and strives to address them the best they can while functioning in the existing economic model the farm diversifies produce options wherever possible and offers csa customers the option to swap produce at pickups this diversity can be limited by what can be feasibly grown to produce a profit or at least break even split payments are also made available as opposed to the full cost upfront and relative to similar csa programs rruf offers a lower share cost finally shareholders can choose between two different pickup locations and timeframes although these remain a persistent barrier the logistics and costs associated with increasing options are currently not feasible the handful of farmerled initiatives that do work directly with foodinsecure populations to build capacity in farming or grow with the intention of streaming yields into food access agencies still function within a cycle of dependency upon donors and volunteers this has been critiqued as an unsustainable and privileged organizational structure particularly for women who may already carry a double burden of household and productive labor when a single mother of four is already overburdened with responsibilities how could she be expected to farm and provide food for her family even with increased opportunities for relationshipbuilding and knowledgesharing between growers and consumers in an afn farmers and farmer cooperatives are challenged with engaging local residentsand therefore scaling up production coowner of yycgd rod olson expressed how they are now down to 300 csa harvest boxes a week 500 is their sustainable target during the pandemic we saw an uptake in shareholders people could not travel and so they put their interests and dollars in the local economy but now postcovid people are wiped out they just need to do the most convenient thing regenerating our food system is not convenient we are fighting against the convenient mecca of the industrial food system urban agriculture will not end world hunger solve climate change or increase global soil fertility alone to kolby peterson the ya alberta apprenticeship coordinator regenerative farming is needed en masse the scale needs to be in broad strokes across the landscape but in thinking about how human beings myself and the people on this farm how we meet our needs regenerative agriculture needs to be broadened to include all of living what does a regenerative life look like as urban populations and development expansion continue to rise as do barriers to accessing rural land there need to be frameworks and policies in place that support agrarian and soilbuilding initiatives in urban spaces as urban agriculture becomes more prolific our recommendations for further research include the incorporation of landbased learning in urban farming processes among postsecondary courses and the contradictions and convergences of indigenous food and land sovereignty efforts with urban farming expansion we also recommend researching the possibilities for landsharing and cooperative farming models and communityled organization strategies to grow and circulate food outside of the market economy if a spin farming model were to be replicated in thousands of urban plots all over the world it would be extremely valuable to gather quantitative data on its cumulative impact as well as qualitative data on customers feelings toward accessing local food and perceptions of health benefits across different ethnicities classes sexes and so forth further comparative research could examine the yields of a spin operation compared to those of an average rural vegetable farm of similar acreage the comparison could show the cost of a vegetable bed in terms of water plants irrigation time in hours yields and returns this comparative analysis could be expanded to include the number of families served per bed and an estimate of nutrients per bed of a popular crop in and around calgary the number of organic regenerative and agroecological producers has visibly increased alongside beekeepers permaculturists indoor growers coffee roasters brewers and more this growth in alternative food and farming is greatly needed in a time of corporatized industrial agriculture at the same time the city has seen a rise in demand for social agencies registered charities and community groups working in food banking hamper rescue and redistribution programs in the past few years there have been more interactions among food producers distributors and social agencies but most of the work continues to take a siloed approach most often researchers conduct theoretical studies from within the university while farmers spend long hours tending their crops and animals agencies race to meet a growing demand for basic necessities and policymakers adapt to everchanging governing agendas if research networks are to truly help regenerative agriculture better deliver on its promise of providing enhanced social and environmental benefitsthe theme of this special issuethen we need to look beyond our agrarian collaborations to see how academic seeds of praxis are being tended in the dynamic social soil that supports our work in this reflective essay we depicted the collaborative approach taken between a graduate student researcher and an urban farmer coordinated and supported through a regional agricultural organization the young agrarians we contextualized our fivemonth fieldwork in the broader characteristics of albertan agriculture and the dominant approaches to agrarian development in calgary connecting local experiences to global movements our paper emphasized the importance of growing the grassroots up and out while staying grounded with the land to address the structural inequalities that affect smallscale farmers in both rural and urban settings our hope is that practitioners and researchers working in food systems and coalitionbuilding will be able to draw upon the frameworks and ideologies put forth while tailoring them to the people and networks of their area conflict of interest disclosure second author michael gavin is the owner and operator of root and regenerate urban farms and is therefore selfemployed and financially invested in his agricultural business

the food landscape of calgary canada is sown with an abundance of polycultures alongside placespecific indigenous foodways are food rescue banking and hamper programs food studies scholars a city of calgary food resilience plan and a growing number of alternative food network producers within the local alternative food network there has been a boom in advancing indoor growing for our colder climate including container aquaponic vertical hydroponic and greenhouse growing situated as an agrarian ethnographer and an urban regenerative farmer we seek to highlight the viability of agricultural techniques that are in relation with the land to grow more special section sponsored by funding disclosure

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introduction young people who identify as lesbian gay bisexual transgender and queer continue to experience inequitable health and social outcomes compared with their heterosexual peers for example epidemiological evidence indicates that lgbtq youth in the province of british columbia canada are more likely to have experienced sexual orientation discrimination used injection drugs been involved in an unwanted pregnancy been sexually abused or to have had thoughts of suicide 1 2 3 many lgbtq youth are exposed to a set of social conditions that influence their healthrelated outcomes including heteronormative and cisnormative assumptions 45 stigma 6 and social exclusion 7 and thus they constitute what has been described as a socially vulnerable population subgroup 8 there is a strong public health impetus to improve the inequitable social and health outcomes experienced by lgbtq youth and several notable structural interventions have recently been advanced to address the inequities experienced by lgbtq people in canada for example in 2005 canada legalized samesex marriage and this legislation has been described by some as an intervention with farreaching impacts 9 within some regions of canada school boards have institutionalized support for the development of gaystraight alliancesstrategic alliances that seek to provide community resources and peer support to lgbtq students and their heterosexual allies thereby providing opportunities to improve the health and social wellbeing of students attending these schools 10 from conceptual and theoretical perspectives primary clinical health care provision for lgbtq youth can be positioned as an opportunity to intervene at the individual level as well as at a structural level 411 12 however as various populationlevel interventions seek to address lgbtq inequities the degree to which clinicians address or consider the determinants of lgbtq youth sexual health within their clinical practice remains unclear much of the previous literature in this area has been focused on the perspectives of young people who identify as lgbtq which has been particularly useful in identifying barriers to accessing care for example some studies have shown that fears related to breaches of confidentiality present significant barriers for lgbtq youth accessing sexual health care services 13 lgbtq youth may also feel uncomfortable disclosing their sexual identity andor sexual behavior during a clinical encounter due to the stigma associated with embodying a nonheterosexual andor noncisgender identity 4 14 15 16 within some settings lgbtq youth are more likely to avoid their family doctors for fear of having their confidentiality breached 17 even when lgbtq youth do access services recent research has detailed how they are often assumed to be heterosexual resulting in missed opportunities for promoting lgbtqspecific sexual health promotion within clinical encounters 41415 although this and other research have delineated many of the barriers lgbtq youth face when accessing sexual health services similar attention to the experiences of clinicians providing these services to lgbtq youth in canada is conspicuously absent with a few notable exceptions indicating that some clinicians report that they feel uncomfortable or underprepared when providing sexual health care provision to lgbtq youth 415 thus we undertook the following analysis to begin to better understand the perceptions and reflections of their clinical interactions and experiences with lgbtq youth in sexual health care settings methods funded by the canadian institutes of health research this study was part of a program of research that examines the social determinants of young peoples sexual health particularly as it pertains to their interactions with sexual health care services our work is informed largely by postmodern and feminist theoretical approaches in which we critically interrogate various forms of social oppression based on these theoretical underpinnings we designed this study to interrogate the extent to which sexual health service provision responds to structural issues that influence lgbtq youth thus although we use the term lgbtq to represent a heterogeneous and diverse group of various gender identities and sexual orientations we do so in order to distil how clinical experiences may exacerbate health inequities for youth who do not identify as heterosexual or cisgender study setting data were collected in five communities in bc canada a southern urban community a southern suburban community two northern urban centers and a northern rural community thus a broad range of opinions was sought from a number of different health service settings across various bc communities for the international reader it is helpful to contextualize how health servicesparticularly sexual health services for young peopleare provided in the bc setting in bc sexual health services are available through specialized sexual health andor youth clinics in addition to general medical clinics hospital emergency rooms and family physicians clinicians experiences with lgbtq youth sexual health the canadian health care system is publicly funded in bc a monthly premium to the provinces medical services plan is required on a sliding scale based on income level with a perperson cost of between 0 and 6650 monthly 18 however the youth clinics in our study did not require proof of being registered in the medical services plan this confidential approach to sexual health care has been shown to decrease perceived barriers to accessing sexual health care 19 it is important to note here that although health care in bc is publicly funded physicians often own their practice and bill the provinces medical services plan according to a billing schedule for this and other reasons although clinics are required to meet specific rules and standards in terms of service provision clinical interactions can often vary widely based on a clinicians previous experiences and protocols associated specifically with their clinics recruitment participants were recruited through clinic visits a purposive sampling strategy was used to select clinicians from clinics that specialized in providing sexual health services by appointment or drop in and which included youth clientele accessing sexual health services in these clinics our study received ethics approval from the university of british columbia interviews data were collected using indepth semistructured interviews with 24 clinicians before beginning the interview participants provided a written informed consent and completed a sociodemographic questionnaire interviews were conducted by experienced researchers who met regularly with the full research team to discuss emerging themes as well as to engage in interpretive discussions pertaining to how our own experiences and social positions influenced both our interactions with research participants as well as our interpretations of the data challenges as they arose interviews concentrated on the clinicians perceptions and practices when providing sexual health services to youth as well as how protocol and risk assessment strategies were perceived to influence their clinical interactions with young people the interview guide was designed to address a variety of topics that might arise within clinical interactions with youth regarding their sexual health as the interviews progressed and new issues emerged interview guides were revised in an iterative fashion to reflect new themes that arose in previous interviews by examining transcripts and field notes as well as regular research team meetings the interviews took place in private settings at each clinic each interview lasted an average of 1 h data analysis interviews were recorded transcribed and accuracy checked by another team member and then uploaded to nvivo 10 for analysis coauthors read and reread transcripts employing constant comparative techniques 20 to begin we used an opencoding approach in which coding was first organized into trees to group the codes thematically for example we iteratively developed codes within the trees as subsequent themes emerged in doing so we conducted a thematic analysis with both an inductive analytic approach to develop our initial coding schema and general themes 21 as well as deductive approaches in which our findings were used to compare and contrast the existing literature 22 pertaining to clinicians experiences providing sexual health services to lgbtq youth consistency of coding was assessed by team members and any discrepancies were discussed and resolved at research team meetings results study participants we interviewed 5 doctors and 19 nurses each study participant selected or was assigned a pseudonym and researchers also assigned r e knight et al each participant a unique alphanumeric code three main themes were identified experiences providing lgbtq youth sexual health care within the heterosexual status quo reflections on clinical practice and the social determinants of lgbtq youth sexual health and changing practices or reproducing the heterosexual status quo a variety of responses within daytoday clinical practice experiences providing lgbtq youth sexual health care within the heterosexual status quo we asked clinicians to describe their experiences providing sexual health services to lgbtq youth and many immediately expressed frustration that they were not adequately equipped with a clinical skill set to effectively and competently counsel lgbtq youth about issues related to their sexual health for example eve explained her frustration providing services for men who have sex with men i feel as if i have a lack of knowledge myself and i dont know where to get more providing services for guys who have sex with guys i dont really know how to make it a more comfortable experienceespecially for the younger guys maybe they havent really told anyone other than the person theyve been with i dont have a whole lot of comfort in that area and where to send them and whos out there for them several clinicians described how providing sexual health services to transgender clients represented a situation that required a significant departure from standard clinical protocol for example rob explained trans youth are a population thats sensitive to rejection or have been treated badly just the whole question of do you still have a penis can be really difficult and it has to be handled really sensitively i cant say that im really always that good at it or not as good as id like to be exposed within this narrative are the ways in which youths biological sex and gender identity are influenced by broader social norms that have the capacity to influence clinical interactions thereby leaving both patient and clinician feeling uncomfortable representing complex and difficult clinical interactions this nurse acknowledges that he would like to improve his capacity for providing these servicessomething that would make both himself and his clients feel more comfortable several clinicians explained that they would like to develop outreach programs to respond to the needs of lgbtq youth with an aim of promoting uptake of sexual health services however these clinicians explained that their clinics lacked the adequate resources and institutional commitments to implement effective lgbtq youth outreach programming within their communities for example beth explained ive been talking to colleagues and saying where are all the lgbtq youth how come nobody is coming to see me unfortunately financially we just dont have the capacity to do the outreach that we would like to be doing thus the lack of institutional support for providing tailored sexual health services to lgbtq youth emerged as a dominant theme within our findings these narratives reveal how sexual health service provision is entrenched clinicians experiences with lgbtq youth sexual health within a system that has not responded to the needs of service providers or the clients they serve that some health care providers believe they are not serving any lgbtq youth also brings into question the extent to which their patients are being presumed straight reflections on clinical practice and the social determinants of lgbtq youth sexual health we asked clinicians to discuss how their own social positioning might influence their interactions with lgbtq youth within their explanations some clinicians emphasized that due to their own heterosexual identity they could not fully relate or identify with lgbtq youth and the experiences that flow from these nonheterosexual identities for example moo expressed a sense of disconnect between her own experiences as a heterosexual woman and the everyday experiences of her young gay men clients i will never be a gay man and there are just certain things that are attached to being gay and that whether its around your sexuality or expression of your sexuality that theres a lot of times that youre more likely to find yourself in a risky situation and you know its hard to address that even if i had two hours with someone i dont know if thats my area of expertise right so i have to be as respectful as possible open to talking about it while recognizing that i cant fix it although this nurse expresses a sense of disconnect between her own social position and that of her gay youth clients she acknowledges that young gay men may not be afforded sufficient opportunities to discuss their sexuality in doing so she begins to elucidate how social positioning and structural features frustrate her within her own practice and she acknowledges that she may not have the capacity to sufficiently address these broader influences some clinicians suggested that nonclinical services were more appropriate spaces to attend to the needs of lgbtq youth for example christina explained if you are not heterosexual you have more room to move into a group where your sexuality is acknowledged and it might be something very formal like pride which is a formal group on campus or it might be much more informal like the people you feel comfortable and you hang around with who might understand that youre not heterosexual within these descriptions clinicians described how the contextual conditions in which youth live might be best improved by ameliorating the social conditions particularly through sectors that operate outside the scope of their clinical practice as a result some described how they provided lgbtq youth with referrals to access these sorts of nonclinical services several clinicians emphasized that the role sexual health service providers can play in directly addressing heteronormative assumptions related to sexual identity and gender for example rob from an urban centre explained how his clinic employs a variety of strategies in order to normalize sexual diversity within his clinical interactions with lgbtq youth we try to treat people every person who comes in like a real human being with as much respect and humour to normalize the process of whatever youre going through if youre straight if youre gay if youre pansexual if youre into s m its all cool so i really without using a hammer i try to push that point for rob the emphasis remained on issues related to social processes that could serve to r e knight et al ameliorate the heteronormative and heterosexist influences on lgbtq youth sexual health within these descriptions the complexity of addressing both contextual as well as individuallevel risk concerns was frequently distilled gay kids are still not given permission to be gay and if youre not given permission to be gay then its a huge step even to take care of yourself do they need more information they need so much more than that they need to know that its okay and youre still a good person your mother loves you and you should love yourself and then put a condom on it revealed here are the complex situations in which clinicians in primary care find themselves tasked with responding to both the structural conditions in which health behavior occurs as well as focusing on individuallevel behavior change thus a variety of different responses emerged in our data in which clinicians distilled the challenges of ameliorating both social and individual risk within clinical interactions changing practices or reproducing the heterosexual status quo a variety of responses within daytoday clinical practice in recognizing the institutional limitations in which they work some clinicians described instances in which they challenged their institutions rules and norms related to lgbtq sexual health for example beth described a situation in which she circumvented institutional barriers by breaking the rules at her clinic and smuggling gay sexual health educational resources into the clinic to provide to her gay youth clients i have a book that we smuggled in from the states that goes through gay male sexuality and safety around hiv prevention and stuff in a very graphical gay male way we try to keep resources around things that we just have no experience in this quote illustrates the degree to which heteronormativity both influences and infiltrates clinical practice while actively resisting the institutional protocols that reify heteronormative social practices within her clinic setting the nurse simultaneously labels the gay material as very graphical other clinicians described the need to modify their normal clinical routine when providing sexual health services for lgbtq youth for example erica explained that when she provides sexual health services to lesbians she does not push services as strongly as she explained there are a lot of barriers for young lesbian women with health care so we try to make it as open as possible to say lets go along at your pace you tell us when youre ready for the pelvic exam and we never push it although we acknowledge previous theoretical work in this field that has critiqued public health practices that systematically monitor womens bodies 23 this nurses narrative brings into question issues related to health equity and how health care service provision is distributed within and across socially defined population subgroups particularly among groups who are historically positioned as being socially vulnerable some clinicians explained that the clinical protocol they were required to follow did not adequately align with or respond to the needs of lgbtq youthparticularly within clinics that required the use of a standardized stihiv risk assessmentand a few clinicians described this as being a particular challenge when providing services to transgender youth for example valerie described her experiences asking transgender clients questions about their biological sex some people say im neither ill say well look at my screen i have to pick one or the other the screen wont let me go on why dont we base it on your genitals it would probably be better to offer as many options as you can give clinicians experiences with lgbtq youth sexual health together some of these narratives demonstrate how heteronormative protocols within some sexual health settings are challenged whereas other practices continue to reproduce heteronormative and cisnormative assumptions surrounding the intersections of gender identity and biological sex discussion the narratives within our findings reveal how many clinicians provide services to lgbtq youth with a lack of cultural competencyeither implicitly or explicitly clinicians included in this study both reified and rejected entrenched normative values and actions related to heterosexual patriarchy however regardless of whether clinicians described actions or practices that had the potential to either reproduce or reject heteroand cisnormative assumptions an overall theme of frustration arose generally this frustration was expressed at the institutional arrangements in which they were trained and practiced according to the national collaborating centre for determinants of health in canada core competencies can contribute to improved health of the public by encouraging evidencebased populationfocused ethical equitable standardized and clientcentered care 24 based on the current findings it appears that the organizational standards in which these clinicians work have failed to adequately provide lgbtq youthappropriate competencies to the clinical staff as such these findings reveal how clinicians are frequently unprepared in giving consideration in their practice to the upstream determinants of lgbtq youth health providing culturally competent skills to clinicians during their education and as a means of ongoing training are possibilities for increasing clinicians ability to effectively respond to lgbtq youth needs 24 responding to the inequitable health outcomes experienced by lgbtq youth requires both upstream structural approaches that attend to the fundamental causes of vulnerability 8 as well as agentic factors related to individual behavior and agency 25 our findings confirm conceptual and theoretical perspectives that position primary clinical health care provision as having the capacity to intervene at both the individual and structural levels 425 for example as some of the clinicians in our study described clinical interactions are inherently social in nature and thus provide opportunities to engage lgbtq youth in conversations that can serve to deconstruct social structures that contribute to lgbtq social and health inequalities within this field both approaches are considered essential in order to competently and effectively promote health 24 and within the canadian setting strategies to attend to the social determinants of health in clinical settings represent a key priority 26 although we agree with others who have argued that offering services at the individual level does not represent a structural intervention 27 we argue that individually oriented health services have the capacity to influence the social practices of individuals and populations 425 without conceptualizing clinical practices in a more sophisticated approach the practice of medicine remains focused solely on the individually driven determinants of health outcomes thereby remaining somewhat desocialized 28 p 1690 bringing the social into the clinic represents an important opportunity to address influences that render individuals and populations vulnerable to inequitable social and health outcomes as a result integrating practices that address social issues within clinical practice have the opportunity to decrease health inequity not only among lgbtq youth but also among older generations of lgbtq and heterosexual populations for example heteronormative sexual health care interactions with heterosexual young men have been associated with experiences that serve to hurt everyoneincluding r e knight et al heterosexual men 4 nonetheless we recognize the challenges associated with attending to the frustration expressed toward institutional barriers within the canadian health care setting clinics are often owned and managed privately 29 with clinicians paid on a feeforservice basis as such this fiscal reality alone likely contributes to a broad disparity in the complexities associated with accessing appropriate resources in order to improve sexual health care provision for lgbtq youth however several exemplary situations were revealed in which clinicians described their practices for providing lgbtqappropriate and tailored services for example the actions of some of the clinicians in our study who chose to respond outside heteronormative institutional norms to better support the sexual health needs of lgbtq youth merits acknowledgement these potentially emancipatory practices and individual efforts are both admirable and encouraging there are several limitations to our study including sampling and participation biases and a relatively small sample that does not fully reflect all variations of sexual health care clinicians in bc as such it was not possible to reach theoretical saturation in our data analysis nonetheless our study provides rich insights into how clinicians from various clinical and sociogeographic settings in bc experience the provision of sexual health services to a vulnerable population subgroup lgbtq youth as a subpopulation who rarely see themselves reflected in any form of traditional sexual education 30 p 373 lgbtq youth are a key population who are poised to benefit from positive and transformative interactions with sexual health care clinicians by positioning the clinical interaction as an opportunity to interrogate heteronormative assumptions and practices that shape the broader societal experiences of lgbtq youth clinicians can provide pathways toward an array of improved health outcomes conflict of interest statement none declared

although barriers related to lesbian gay bisexual transgender and queer lgbtq youths experiences accessing sexual health services have been examined in detail research into the experiences and perceptions of clinicians providing these services has been conspicuously absent the aim of this article is to explore the perceptions and experiences of clinicians providing sexual health services for lgbtq youth drawing on indepth semistructured interviews this study examines 24 clinicians experiences providing sexual health services to lgbtq youth in five communities in british columbia canada our findings reveal how many clinicians provide services to lgbtq youth with a lack of cultural competencyeither implicitly eg by describing heteronormative practices or explicitly eg by expressing frustration that they had not been sufficiently provided with appropriate training related to lgbtq youth sexual health institutional norms and values were identified as the dominant barriers in the effective provision of lgbtqtailored services many clinicians find themselves unprepared to provide culturally competent sexual health services that have both the capacity to address individuallevel issues eg promoting condom use while considering and adapting services to the broader sociocultural and structural conditions that can render lgbtq youth socially vulnerable

19858_0

evaluate how the permanence of racism drives our organizational policies and practices and scrutinize the role we individually play in establishing and maintaining such policies and practices within applied psychological research weird samples have historically been the standard serving as the basis for our theory development and organizational best practices white io researchers must consider how whiteness influences the theories we utilize the research questions we ask the participants we recruit the analyses we conduct the findings we articulate and the infrastructure within which we operate in parallel white io practitioners must critically evaluate the lens under which decisions are made including who makes the decisions and whose voices are not heard in the process positionality and subjectivity should be at the forefront of white io psychologists minds as we consider how racism is operating internallyboth in ourselves and in our field kendi claims one either allows racial inequities to persevere as a racist or confronts racial inequities as an antiracist there is no inbetween safe space of not racist notably we cannot evaluate how racism is operating internally if we are stuck on concerns of being not racist white io psychologists must move beyond these concerns to instead ask what we are doing to directly confront racism in our research and practice counterstorytelling counterstorytelling relies on critiquing dominant narratives and challenging assumptions that are rooted in whiteness as mentioned white people may not recognize themselves as racialized beings who can speak about racialized experiences however neglecting to consider white frames of reference allows colonial research and practices to persist unchecked instead io psychologists must consider how dominant ideologies dictate our research questions and workplace policies one important step for our field is to redefine psychological theories which requires listening to the narratives of people of color instead of trying to adapt or fit people of color into conceptualizations derived from the white majority culture in terms of practice io psychologists should reflect on how dominant ideologies inform organizational norms and human capital management stewart encourages us to flip the dominant narrative by shifting from asking questions such as have everyones ideas been heard and how many more of pick any marginalized identity group do we have this year than last to asking questions such as whose ideas wont be taken as seriously because they arent in the majority and what conditions have we created that maintain certain groups as the perpetual majority here white io researchers and practitioners can engage in counterstorytelling by monitoring when how and why our questions and beliefs stem from dominant ideologies further white io psychologists can apply the notion of counterstorytelling by working alongside bipoc colleagues to elevate the voices of historically excluded and underrepresented communities critique of liberalism critique of liberalism challenges liberal thought that has consistently failed people of color including colorblindness neutrality and incremental change as io psychologists we must acknowledge that identityblind ideologies uphold dominant narratives facilitating prejudice and discrimination instead white io psychologists should reflect on how our social identities and lived experiences influence our frames of reference and examine whether we have been conditioned to maintain order via incremental change or to challenge systems that enable white supremacy white io psychologists may be inclined to reevaluate feel good dei efforts that are informed by identityblind ideologies catering toward making white people and those in power comfortable instead of aggressively disrupting structural racism interest convergence in the words of lopez interest convergence is the belief that whites will tolerate and advance the interests of people of color only when they promote the selfinterests of whites interest convergence is particularly evident in institutional and organizational diversity efforts that rely on a business case for example initiatives marketed toward advancing women in the workplace often advance white women whereas women of color do not experience similar development or promotion opportunities accordingly when making organizational dei decisions white io psychologists have the responsibility to reflect on whether progress is advancing at a pace that is appropriate for meeting underrepresented and historically excluded persons needs or whether progress is incrementally being made at a pace that is tolerable for those in power further when conducting research with bipoc communities white io psychologists must critique their impetus for pursuing such work questioning whether their goals are to further selfinterests to help a community that needs to be rescued andor to dismantle systemic inequities to spur action white io psychologists may consider passing the mic by inviting bipoc colleagues to collaborate as a means to further the interests and opportunities for others while simultaneously decentering our whiteness whiteness as property whiteness as property is associated with coloniality and ownership which we observe when white io psychologists are cultural outsiders conducting research or otherwise serving a community with different racial or ethnic identities in scientific research a presumption is made that researchers have the right to intellectually know interpret and represent others white io psychologists must reflect upon the role we play in directing and owning our work by considering when this notion of ownership comes at the expense of others through continuously monitoring our westernized ways of knowing we can ask ourselves why and in what instances we are delegitimizing other forms of knowledge in doing so we will take steps toward the decolonization of our research practice and field as a whole conclusion although the tenets of crt are generally not intuitive for white people who have yet to reflect upon their racial experiences we can adopt a longterm approach toward examining our whiteness through application of crt to guide our reflection and reflexivity white io psychologists may be emboldened to reevaluate all steps of the research process from the questions we ask to the implications we make we may be inspired to challenge how why and by whom organizational decisions are made and for whom such decisions benefit we may be spurred to critique our dominant ideologies and westernized ways of knowing and instead consider strategies to decenter our whiteness such as by elevating the voices of our bipoc colleagues by grounding the five tenets of crt in our reflection and reflexivity processes white io psychologists can spark change in ourchange that is instrumental to tackling systemic inequities permeating our teams institutions and organizations and our society at large

following the death of george floyd many white people including me the author of this commentary joined book clubs that centered on examining whiteness in a racialized society after finishing the final chapter of books such as how to be an antiracist by ibram x kendi 2019 the hate u give by angie thomas 2017 and white fragility by robyn diangelo 2018 my book club like others disbanded and further reflection would seemingly dwindle until the next brutal police shooting of an unarmed black man industrialorganizational psychology scientists and practitioners alike formed diversity equity and inclusion dei committees with lofty goals to tackle systemic inequities that permeate our institutions and organizations yet the reticence of addressing whiteness in our research and practice has persisted in conjunction with hylands 2023 recommendations for engaging in reflective practice white io psychologists across research and practice areas ie not just those in dei spaces must consider how white ears and eyes that is a white frame of reference influence our work through participation in ongoing reflective and reflexive processes racial blind spots will unveil themselves propelling forward a future wherein io psychologists are better positioned to meet employees varying needs across a diversity of lived experiences and social identities with that said it is challenging for white people to know where to begin in examining our whiteness white people are typically not taught to understand their whiteness as a race and are often not made aware of how race influences their experiences calls to ban critical race theory crt in our classrooms organizations and other contexts further inhibits discussions about whiteness including the history of racism and its embeddedness in our current society however by learning crt as an academic and legal framework we can embrace a more equitable future for the field of io psychology crt may serve to guide white io psychologists ongoing reflection and reflexivity by considering its five tenets a permanence of racism b counterstorytelling c critique of liberalism d interest convergence and e whiteness as property decuir dixson 2004 prior to diving into these tenets i must acknowledge that as a white person i am using this commentary as a platform to speak directly to other white io psychologists but i recognize that nonblack people of color can also use crt to engage in reflection and reflexivity as they examine their roles in perpetuating systemic whitenessas io psychologists we cannot assume that our research and practice are free from racism because whiteness is the norm in us society we must instead name racism as active in our field

19859_0

yüksek eği̇ti̇mli̇ i̇şgücü göçü yeni̇ zelanda örnek i̇ncelemesi̇ öz yeni zelandada araştırma ve eğitim olanakları çok yüksektir ülke çok çeşitli dünya standartlarında programlara sahip uluslararası popülerlikte eğitim kurumlarına sahiptir yeni zelandanın eğitim sisteminin cazibesi denizaşırı introduction the best possible allocation or use of the resources available is essential to a nations economic progress natural resources capital assets and human capital assets are some of these resources population migration behaviour in the context of human resource development is motivated by strategies to overcome obstacles or a lack of necessary resources needed to advance knowledge and skills which can then become assets to increase ones income potential and competitiveness in the job market additionally there are two primary methods to raise a persons quality of living by raising their educational level and by shifting their regional economic conditions through migration urbanization or the growing migration of people especially from rural to urban regions is a result of indonesias industrialisation and urban area growth urbanization or the movement of people from rural areas to cities is one kind of population migration that is motivated by the desire for a higher quality of life urbanization is a result of the social economic and living conditions in rural and urban regions that differ from one another particularly in indonesias industrial zones industrialization significantly impacts how the job structure has changed in the setting of activities successful industrialisation can then drive the growth of urbanization rural industrialization is viewed as a transformation of the local economic structure defined by a movement in employment from the agriculture to the industrial sectors rural economic sectors are transformed into urban economic activity as a result of the industrialization of rural regions individual migration decisions according to lee are influenced by both push and pull influences push factors are associated with regional disparities in economic development and infrastructure for instance relative to rising unemployment rates income gaps across regions deplorable economic conditions in the place of origin and educational levels high population density results in few work options on the other hand pull factors are linked to the migration of workers from areas with poor economic development to those with strong economic growth this includes the existence of numerous amenities in the destination location that increase worker productivity as well as the availability of more employment possibilities higher earnings good environmental conditions and favourable environmental conditions therefore the pull factors for those with higher education are things like work prospects a decent infrastructure earnings and a higher standard of living the development of human resources and economic expansion in migration destination regions depend heavily on the accumulation of human capital contributed by highly educated migrant workers by giving the local people and economy more purchasing power the presence of highly educated migrant workers promotes economic growth furthermore the presence of highly educated migrants contributes to local population knowledge growth human capital expansion and improved availability and accessibility of social services furthermore an area with a high concentration of human capital may be better protected when it faces perilous economic circumstances the destination regions are negatively impacted by the flood of highly educated migrants the downsides of the influx of highly educated migrants are less obvious than the upsides but at least certain demographic groups in the destination regions might possibly lose out as a result of the highly educated migrants moving into their neighbourhoods the entry of highly educated workers which would increase the supply of labour and at the same time the demand for essential needs could have negative effects on the local economy these highly educated workers would increase the supply of labour and at the same time the demand for essential needs furthermore the regional variety that if not well handled can result in disputes and mistrust between population groups will be impacted by the presence of highly educated migrant workers from different sociocultural backgrounds than the local population the appearance of migrants exhibits unpredictable migratory patterns flexibility and brief circular or repeated motions migrations from highly educated or skilled backgrounds are directly related to such territorial movements migrants migrate with the intention of acquiring assets such as educational qualifications and a variety of job experiences which improve their capacity to relocate to other places offering greater economic prospects furthermore the regional variety that if not well handled can result in disputes and mistrust between population groups will be impacted by the presence of highly educated migrant workers from different sociocultural backgrounds than the local population the appearance of migrants exhibits unpredictable migratory patterns flexibility and brief circular or repeated motions migrations from highly educated or skilled backgrounds are directly related to such territorial movements migrants migrate with the intention of acquiring assets such as educational qualifications and a variety of job experiences which improve their capacity to relocate to other places offering greater economic prospects one such example is new zealand historically a country that welcomed immigrants it quickly shifted the emphasis of its immigration policy to a generalandor occupational skills concept as the arguments for a growing need for skilled workers started to take shape despite worries about a brain drain caused by skilled workers leaving the country the arguments frequently referred to the positive distributional effects of skilled immigration and the notion that people with indemand skills adapt quickly to domestic labour market conditions and are more likely to significantly contribute to economic growth in the 20 years leading up to 2022 employment in new zealand has grown by 50 two factors contributed to this first the workingage population increased by 36 and second a higher percentage of persons of working age were employed population increase and labour force utilisation were both influenced by several reasons higheducated workers pull factors for new zealand due to a number of strong pull factors new zealand has become a desirable location for highly educated employees first off the great quality of life and worklife balance in the nation are a major draw for professionals new zealand provides an unmatched lifestyle because of its stunning natural scenery energetic cities and a strong focus on leisure time activities initiatives for worklife balance such as flexible scheduling and friendly culture also help to better integrate personal and professional lives second there are numerous job prospects in important industries thanks to new zealands vibrant and varied economy one of the main industries that draw highly educated employees is the healthcare and medical sector followed by engineering and technology information technology and digital innovation education and academics and research and development for professionals looking for employment opportunities new zealand is a desirable location since these industries not only provide exciting and fulfilling careers but also opportunities for growth and progress the chances for research and education in new zealand are very wellrated internationally famous educational institutions with a wide range of topnotch programs are located in the nation the attraction of new zealands educational system is further increased by scholarships and funding options for overseas students higheducated people seeking to advance their academic and professional goals are drawn to the stimulating research environment created by collaborative research initiatives alliances with industry and access to stateoftheart facilities and resources higheducated employees find new zealand attractive because of its wellknown reputation for having a kind and inclusive culture the nation encourages multiculturalism and variety creating a setting that encourages cooperation innovation and creativity new zealand is an appealing option for professionals looking for stability and a good level of life because of the robust social welfare system universal healthcare and safety that all contribute to a sense of security and wellbeing for both people and their families comprehensive analysis of the significance and innovations in the impact of an educated workforce on economic growth the different ways in which education promotes economic prosperity have been thoroughly examined in relation to the effect of a welleducated workforce on economic growth education is a key factor in economic growth because it gives people the opportunity to pursue highpaying careers and raise worker productivity as a whole an educated workforce has positive effects on both people and companies as well as the economy as a whole studies have demonstrated that investing in education has financial benefits since greater levels of education are linked to better salaries for people furthermore a highly educated workforce fosters innovation in the work industry resulting in higher productivity and economic expansion businesses understand the value of having educated employees and may decide to move to places where the workforce is more educated highlighting the economic relevance of education because education leads to higher gross domestic product and better productivity states with a larger percentage of educated employees are more likely to enjoy economic growth the relationship between education and income shows that states may grow their economies over time by hiring more educated employees underscoring the need to prioritize education spending to boost economic competitiveness a welleducated workforce is vital for economic growth and development since spending on education boosts state economies and draws highwage firms the idea that education is essential for promoting economic success at both the individual and social levels is supported by a thorough review of how an educated workforce affects economic growth researchers employed a quantitative approach as their research strategy explanatory research also known as descriptive or hypothesisbased research is the method used in this study the information gathered for this study was obtained from the central statistics agency and includes information on the movement of a highly educated workforce into 57 industrial districts and municipality regions in new zealand the same source also provided information on issues including minimum salaries economic growth and employment rates that influence the movement of highly qualified workers to industrial districts and municipal regions crosssectional and timeseries data are combined to form panel data using repeated observations on a certain issue across a variety of time periods this panel data is utilized to uncover key factors this approach is used to comprehend how a factor such as migration the minimum wage economic development and so on periodically affects a particular issue multiple linear regression is a development of panel data regression the parameters of a regression model can be predicted using either technique the following describes the form of the regression model to be utilized in this investigation which is based on a generic model modified with several simplifications 𝐻𝑆𝑀 𝑖𝑡  0  1 𝑀𝑊𝐶 𝑖𝑡  2 𝐸𝐺 𝑖𝑡  3 𝐸𝑂𝑅 𝑖𝑡 𝑒 𝑖𝑡 data transformation using the natural logarithm will be carried out because the data in this study have different units including the highskilled labour migration measured in individuals the minimum wage of cities measured in new zealand dollars the economic growth measured in percentage and the employment opportunity rate measured in percentage to prevent bias in the logarithmic transformation this is done the following describes the logarithmic model applied in this study 𝐼𝑛 𝑖𝑡  0  1 𝐼𝑛 𝑖𝑡  2 𝐸𝐺 𝑖𝑡  3 𝐸𝑂𝑅 𝑖𝑡 𝑒 𝑖𝑡 the panel data regression model is estimated using the following method 1 first the common effect model combining time series with crosssectional data is the easiest way to use the panel data model this methodology may estimate the panel data model using the ordinary least square strategy or the least squares method to model panel data a linear model with the following general form can be used 𝐻𝑆𝑀 𝑖𝑡  0  1 𝑀𝑊𝐶 𝑖𝑡  2 𝐸𝐺 𝑖𝑡  3 𝐸𝑂𝑅 𝑖𝑡 𝑒 𝑖𝑡 2 fem or fixed effect model a fixed effect model is a method for estimating panel data by capturing intercept differences using dummy variables the fixed effect model is represented in the following way random effect model 𝐻𝑆𝑀 𝑖𝑡 𝛼 1 𝛼 2 𝐷 2𝑖 𝛼 3 𝐷 3𝑖 𝛼 𝑛 𝐷 𝑛𝑖  1 𝑀𝑊𝐶 𝑖𝑡  2 𝐸𝐺 𝑖𝑡  3 𝐸𝑂𝑅 𝑖𝑡 𝑒 𝑖𝑡 3 random effect model the distinctive effects of every person are taken into account as part of the error component which is random and independent of the observed independent variables in contrast to the fixed effect model the random effects models equation is as follows 𝐻𝑆𝑀 𝑖𝑡  0  1 𝑀𝑊𝐶 𝑖𝑡  2 𝐸𝐺 𝑖𝑡  3 𝐸𝑂𝑅 𝑖𝑡 𝑒 𝑖𝑡 conducting descriptive statistics comes before any data processing descriptive statistics can be used to learn more about the characteristics of each independent variable including migration values and all other independent variables that are thought to significantly affect changes in the migration of highly skilled workers to industrial districts in new zealand from 2018 to 2022 the following table shows the descriptive statistics utilized which include the maximum minimum mean and standard deviation of each variable examine the data to see if they fit a normal distribution for this the mean and standard deviation of the data were calculated the calculated value of 57 industrial areas and municipal districts is 83514 and the calculated value of standard deviation is 2617 the shapirowilk test was used to confirm normality assumptions the shapirowilk statistic is 099 and since p0192 005 the data are observed to be normally distributed auckland is the most popular destination for immigrants whereas nelson is the least popular the highest real salaries in 2020 and 2021 will be 87022 and 89799 respectively from 2018 to 2021 the lowest real salaries were 68183 and 70838 per year respectively since the 1970s the percentage of new zealanders who are working age who are in the labour force has climbed to about 66 percent this surge is mostly attributable to significant increases in both the proportion of women working and the number of parttime employments high labour force growth will undoubtedly boost production if those who join the workforce do so and find employment the topic of whether labor force expansion boosts output per capita is more debatable on the one hand extra labour may experience diminishing returns when added to a base of finite other productive resources lowering the average level of production per person however a bigger labor force could boost production per capita through economies of scale or by allowing workers to learn by doing while they are employed overall the most important factor affecting the impact on productivity per person is likely the additional labourers workplace abilities model analysis the empirical approach is panel data analysis it is possible to conduct analysis using a data collection that combines crosssectional and timeseries data using panel data analysis it is suitable to employ the panel data analysis approach for the analysis since the studys data come in both crosssection and timeseries form due to its benefits panel data analysis is quite helpful first a significant number of observation values will be available in the crosssection and timeseries data forms the estimations will therefore be more trustworthy additionally the crosssection and size of independent variables vary as a result multicollinearity issues are less likely 𝐿nhsm𝑖𝑡 𝛽0 𝛽1∆𝐿𝑁mwc𝑖𝑡 𝛽2∆𝐿𝑁eg𝑖𝑡 𝛽3∆𝐿𝑁eor 𝑢𝑖𝑡 uit 𝑢𝑖𝑡 𝜇𝑖 𝑣𝑖𝑡 the econometric model utilized for panel regression estimation is shown in equation i stands for nations in equation and t stands for time highskilled labor migration is represented by the dependent variable the independent variables included in the analysis are the minimum wage of cities the economic growth and the employment opportunity rate which is an independent variable that affects the migration of highly trained workers in equation it stands for the error terms while uit represents the unobservable individual impact i define specific effects that are not timedependent and are not taken into account in regression equation is calculated using a fixedeffects randomeffects or pooled regression technique to choose amongst these techniques the hausman breuschpagan and f tests are run finally diagnostic tests including heteroscedasticity autocorrelation and multicollinearity are carried out these statistical issues allow for the employment of robust estimators aside from the migrant stock three variables thought to influence highskilled labour migration were investigated in this study the research is based on 57 industrial districts and municipality areas in new zealand with varying income levels where these factors better safeguard their social and economic assets and may provide migrants with a more viable job market with a higher educational level as a result higher education is also in the spotlight in terms of wealth pay and work opportunities as a result new zealands economic expansion is predicted to have a beneficial impact on highskilled labour migration flows all data utilized is from the years 20182022 highskilled labour migrant statistics for these time periods and on a yearly basis are available in the united nations and world bank statistical databases regression that is spurious is the result of analyzing nonstationary series thus the series has to be stable for the studies to produce meaningful and trustworthy conclusions in terms of both economics and statistics the stationarity of the series that will be utilized to make the model estimates is examined before beginning in choosing the unit root test for the investigation of the series stationarity the crosssection dependence problem of the series is taken into consideration in the panel data analysis the crosssectional dependencewhere all units in the same crosssection are correlatedis a key issue the secondgeneration unit root test is utilized when a crosssectional dependence issue exists in the series table 2 shows the outcomes of the pesaran cd test which examines the crosssectional dependence problem and the cadf and cips unit root test which examines the stationary of series numerous tests are used to examine crosssectional dependence including the breuschpagan lm pesaran scaled lm biascorrected scaled lm and pesaran cd test when the panel data set is n t pesaran cd test produces accurate findings all variables have a crosssection dependence issue as shown by the pesaran cd test findings in order to identify stationary of series pesarans cadf unit root test and the cips unit root test are utilized the lnhrs is stationary at level according to the findings of the cadf test whereas the other variables are stationary at the first difference taking the difference has resulted in the series becoming stagnant the findings of the diagnostic tests are displayed in table 3 first it is determined if the model to be estimated is appropriate for the fixed effect random effect and pooled regression models first the hausman test was successful the alternative hypothesis in this test is that there is a connection between the unique mistakes and the models regressors contrary to the null hypothesis which states that there is no link the null hypothesis is disproven using the hausman test so instead of using the randomeffects model use the fixedeffects model instead the f test results contradict the null hypothesis the fixedeffects model is thus recommended over the pooled regression approach as a consequence the econometric model in equation was estimated while taking into consideration the fixed effects to identify statistical issues with estimates certain tests have been run the findings of the pesaran cd and friedman r tests show that crosssection dependence is a concern in estimates the modified wald test indicates that the models estimations are heteroskedastic the statistical values for the modified bhargava durbinwatson and baltagiwu lbi tests are computed as 046 and 068 respectively it has been determined that there is an autocorrelation issue with the estimations as the statistical values are less than two aside from the migrant stock three variables thought to influence highskilled labor migration were investigated in this study the research is based on 57 industrial districts and municipality areas in new zealand with varying income levels where these factors better safeguard their social and economic assets and may provide migrants a more viable job market with a higher educational level as a result higher education is also in the spotlight in terms of wealth pay and work opportunities as a result new zealands economic expansion is predicted to have a beneficial impact on highskilled labor migration flows eviews is used to do panel data regression analysis on the independent and dependent variables the estimation results of the above three different models are shown in table 4 it can be seen that in model ii except eor one of the variables has a statistically significant effect on the number of highskilled migrant workers and the aic value indicates the applicability of the model ii specification which is included together with eor in mwc and in eg the signs of the parameter estimates are as expected diagnostic metrics indicate that the error terms for all models are not autocorrelated and have constant variance according to the results obtained it can be said that the higher the urban minimum wage the higher the economic growth rate and the higher the employment opportunity rate the more highly skilled migrant workers will come to the countryside it turns out that variables representing institutional quality and stability have parallel effects on expectations and the existing theoretical and empirical literature as expected based on new zealands higher economic growth the country appears likely to attract more highly skilled migrant workers it can also be concluded that increased democratization demand for more workers in the labor market and improved living standards will lead to more highquality migrant workers entering the country considering that the regression equation is more sensitive to its components the immigration variables in different specification models generally retain a significant positive effect which can be interpreted as an indicator of the robustness of the relationship between education and immigration following is the equation for the common effect model methods regression result on the panel data 𝐿𝑂𝐺𝐻𝑆𝑀 𝑖𝑡 161425 04278𝑀𝑊𝐶 𝑖𝑡 000647𝐸𝐺 𝑖𝑡 02105𝐸𝑂𝑅 𝑖𝑡 𝑒 𝑖𝑡 for panel data utilizing the fixed effect model approach the regression result equation is as follows 𝐿𝑂𝐺𝐻𝑆𝑀 𝑖𝑡 010247 051736𝑀𝑊𝐶 𝑖𝑡 000541𝐸𝐺 𝑖𝑡 000841𝐸𝑂𝑅 𝑖𝑡 𝑒 𝑖𝑡 using the random effect model approach the following equation represents the regression result 𝐿𝑂𝐺𝐻𝑆𝑀 𝑖𝑡 44879 05107𝑀𝑊𝐶 𝑖𝑡 000412𝐸𝐺 𝑖𝑡 002871𝐸𝑂𝑅 𝑖𝑡 𝑒 𝑖𝑡 the next stage is to run tests to choose one of these three models after studying the three different sorts of models eviews is used to do panel data regression analysis on the independent and dependent variables these are the outcomes for each model following is the equation for the common effect model methods regression result on the panel data 𝐿𝑂𝐺𝐻𝑆𝑀 𝑖𝑡 161425 04278𝑀𝑊𝐶 𝑖𝑡 000647𝐸𝐺 𝑖𝑡 02105𝐸𝑂𝑅 𝑖𝑡 𝑒 𝑖𝑡 for panel data utilizing the fixed effect model approach the regression result equation is as follows 𝐿𝑂𝐺𝐻𝑆𝑀 𝑖𝑡 010247 051736𝑀𝑊𝐶 𝑖𝑡 000541𝐸𝐺 𝑖𝑡 000841𝐸𝑂𝑅 𝑖𝑡 𝑒 𝑖𝑡 using the random effect model approach the following equation represents the regression result 𝐿𝑂𝐺𝐻𝑆𝑀 𝑖𝑡 44879 05107𝑀𝑊𝐶 𝑖𝑡 000412𝐸𝐺 𝑖𝑡 002871𝐸𝑂𝑅 𝑖𝑡 𝑒 𝑖𝑡 the next stage is to run tests to choose one of these three models after studying the three different sorts of models selecting a model the following assumptions are tested using the chow test to evaluate whether the common effect model or the fixed effect model is more suitable 𝐻 0 ols pooled common effect model 𝐻 1 lsdv fixed effect model grounds for decision if the probability h0 is acceptable h1 is true if the probability is the null hypothesis is rejected since both the crosssection f and crosssection chisquare probability are 00000 which is less than  005 as a result it suggests that the fixed effect model which is the best model is relevant in assessing the panel data in order to choose between a random effect and a fixed effect model the following hypotheses are tested using the hausman test h0 the model error does not depend on any of the independent variables h1 the model error and one or more independent variables are related rationale for the decision if the probability  which denotes that a random effect model was utilized 𝐻 0 is acceptable if the probability  suggesting that a random effect model was utilized then 𝐻 1 is acceptable the pvalue is less than  005 because the probability value for crosssection random is 00049 supporting the null hypothesis therefore it shows that the fixed effect model is the optimal model to utilize for the research determining the best panel regression models interpretation fixed effect model is the top panel regression model the constant has a positive value of 010247 as shown by the linear regression findings on the panel data above accordingly if the minimum wage of cities economic growth and employment opportunity rate remain unchanged the inflow migration of highly educated workers to industrial locations in cities will grow by 010247 percent minimum wage city coefficient is 051736 accordingly if all other variables remain constant a 1 percent rise in the minimum wage in a district or city will result in a roughly 051736 percent increase in the average inflow of highly educated personnel to such places the economic growth coefficient is 000541 this suggests that assuming all other factors remain constant a 1 percent rise in economic growth will result in an increase in the average inflow of highly educated workers to industrial regions and cities of around 000541 percent the employment opportunity rate coefficient is equal to 000841 results based on the results of the studies it has been concluded that the minimum wage of cities has a beneficial and significant influence on the migration of highly educated people to industrial areas in indonesia this result is supported by everett s lees migration theory which holds that one of the factors luring individuals to move is the presence of higher salaries at the destinations this supports ricardos wage theory according to which highly skilled workers are less affected by minimum wages because of their indemand skills they could prefer seeking for work in locations with higher minimum pay if their country of origin has lower minimum wages in particular a positive relationship between worker salaries and education level was discovered by the central statistics agency with higher levels of schooling comes higher incomes higher education degree holders often make more money than other types of workers conversely those with merely a high school graduation or fewer frequently earn less money the typical workers monthly salary decreased slightly from around nzd 276 million in 2020 to nzd 274 million in 2021 but when salaries are compared according to education level those with more advanced degrees frequently make more money amounting to nzd 399 million per month it was also less than the previous year 2020 when it was over nzd 41 million each month the lowest wage or almost nzd 165 million per month was still provided to persons with only a primary education this is unchanged from the prior year for individuals with a high school certificate or a vocational degree the average monthly pay varies from nzd 262 million to nzd 269 million the complete populace should make an attempt to locate honorable careers with higher pay in this regard the involvement of the government is essential this is consistent with the international labor organizations mission to advance just working conditions for individuals to sustain their families the trials findings indicate that economic growth has a positive and significant impact on highly educated peoples decisions to relocate to industrial areas in indonesia this result is supported by lees migration theory which contends that fast economic expansion attracts highly educated workers to a location particularly cities or neighborhoods with industrial zones the idea holds that a regions robust economic development promotes the construction of businesses and industries that require highly educated workers such as engineers doctors and lawyers among others this researchs findings are further supported by the ravenstein theory which holds that a new locations quick economic development stimulates the migration of highly educated workers there this is so because the wages and career prospects there are more attractive this agrees with the spillover effect justifications put out by vernon ruttan michael porter and paul romer this theory holds that having educated residents may increase local output and innovation which can indirectly have a positive impact on the local economy the spillover effect can manifest itself in the economic environment in a number of different ways including in relation to technology innovation knowledge skills and social impact for example firms close by can benefit from the technology and knowledge developed by a regions cuttingedge and thriving sector this can increase the productivity and caliber of local workers and encourage the growth of related economic sectors strong economic growth is strongly tied to the influx of highly educated migrant workers which raises the quality of the labor force and increases productivity and efficiency in sectors that require highly educated employees foreign companies looking for highly educated workers are increasingly preferring to invest in countries with a large pool of labor the wellington region has continued to provide the largest contributions to the growth of new zealands gross domestic product in terms of manufacturing sometimes immigrants from locations with more advanced technology bring with them more advanced knowledge and technology in the aforementioned areas or territories this can help to increase innovation and productivity in certain industries it supports the growth of higherquality human resources there and produces spillover effects which can increase output and economic growth this is also in line with the idea of virtuous cycles which holds that a developing industrial sector may be able to create a virtuous cycle in which job possibilities and economic advancement have a mutually beneficial relationship strong economic expansion may attract investment and create new jobs which in turn raises the populations purchasing power and accelerates economic growth conclusion in light of the research findings using panel data regression on the factors influencing the migration of highly educated workers to industrial areas in new zeland 1 highskilled workers in new zealand frequently move to industrial areas where the minimum wage is greater 2 it has been demonstrated that economic growth attracts highly educated employees to new zealands industrial zones 3 due to indonesias employment rate highskilled workers do not seem to be moving to the countrys industrial areas in order to give more detailed findings the researcher suggests many areas for more investigation including involving industry labor unions municipal governments and research institutions as decisionmaking stakeholders is the first step constructive discussions and exchanges can help to clarify the viewpoints of various parties about minimum wage increases and help to establish a balance between worker protection and company sustainability the second phase is to include sustainability principles in the design of industrial zones to ensure sustainable economic growth ecosystem protection natural resource management and consideration of environmental implications may be useful in maintaining a balance between economic growth and environmental sustainability third expanding employment opportunities outside of urban centers and industrial areas to deter people from relocating increasing investment in nonmanufacturing sectors including tourism agriculture fishing and other service industries as well as the unorganized sector and improving infrastructure and accessibility may all help achieve this peer review independent doubleblind author contributions çağatay tunçsiper 100 funding and acknowledgement no support was received for the study

research and education opportunities in new zealand are very high the country has educational institutions of international popularity with a wide variety of worldclass programs the appeal of new zealands education system is further enhanced by scholarships and funding options for overseas students highly educated individuals seeking to advance their academic and professional goals are invited to the stimulating research environment created by collaborative research initiatives alliances with industry and access to cuttingedge facilities and resources because of these attractive factors new zealand has become a desirable destination for highly educated workers first of all the countrys high quality of life and worklife balance is a major attraction for professionals new zealand offers a unique lifestyle due to its stunning natural scenery energetic cities and strong focus on leisure activities the aim of this study is to examine the phenomenon of highly educated workers migrating sometimes called brain gain or brain drain in relation to new zealand it examines the pull factors from their home country the pull factors that attract highly educated people to new zealand and the effects of this migration on both their homeland and new zealand the research also looks at the idea of brain gain through return migration and how overseas students impact the local labour market government actions and initiatives aimed at retaining highly educated workers and maximizing the advantages of migration are also covered by assessing these factors the research provides insight into the dynamics of highly educated worker migration in new zealand

19860_0

introduction the alleviation and elimination of poverty is a common goal of human development and a worldwide challenge in 2020 the chinese government announced that it had achieved the goal of eradicating absolute poverty which is an important milestone in the history of the fight against poverty in humanity however smallholder households in rural china especially in the western region are still at serious risk of poverty on the one hand chinas poverty standard is only roughly equivalent to the world banks extreme poverty line1 if the lowmiddle poverty line and the highmiddle poverty line are applied china still has a large number of lowincome people on the other hand many families are at risk of returning to poverty nearly 2 million people who have escaped poverty are at risk of returning to poverty and nearly 3 million of the marginal population are at risk of becoming poor reducing the risk of poverty among lowincome groups is therefore the central task in chinas rural revitalization strategy between 1979 and 1984 chinas land system underwent a dramatic shift from collective farming based on production teams to a familybased system of responsibility under the household joint production contract the central feature of this system is the decentralization of the management of arable land from collective to family management under chinas family contract responsibility policy farmers motivation to produce gets a boost however it also brings with it the difficulty of agricultural decentralization most farming households have a small landholding with an average household size of less than 067 hectares the small scale nature of agricultural production activities makes it necessary for smallholder farmers to allocate their resources between rural and urban areas in order to obtain sufficient income to meet household consumption expenditure this leads mainly to three distinct vulnerabilities of smallholder households how effective is education in fighting poverty researchers are still divided on this question an analysis of pakistani households found that educational attainment was negatively associated with the incidence of poverty among farming households and that access to higher levels of education reduced the likelihood of farming households falling into poverty however some studies have found that some of the educational reform in uganda designed for low income groups did not achieve poverty level reductions finally social networks are an important part of social capital enhances action by playing a role in instrumental and expressive action with resources embedded in social networks by embedding social capital in external social networks cooperatives build close and strong relationships with other network actors and gain greater access to knowledge and information exchange to improve the efficiency of resource acquisition social capital plays a role in signaling monitoring steering reducing interorganizational transaction costs collateral substitution and risk reduction and by reducing the level of mistrust between individuals it improves collective cohesion and promotes cooperation small farmers mainly leftbehind farmers have been integrated into the traditional social life of the countryside where social relations are more closed for most smallholder farmers it is often difficult to effectively enhance their capacity for autonomous development simply by relying on their own efforts farmers cooperatives as selforganizations of farmers have attracted the attention of many scholars in terms of increasing farmers incomes and reducing poverty some scholars argue that cooperatives should be regarded as an efficient organizational innovation in rural poverty governance because of their ability to fundamentally improve the efficiency of the use of poverty reduction funds and to improve the income capacity and rights poverty of farm households cooperatives convey agricultural knowledge while improving the market competitiveness and social adaptability of poor farmers by enhancing their individual capacities and repairing the capacity deficits of farmers in the new economy the mechanisms inherent in the participation of poor farmers in cooperatives to reduce poverty and increase income are partly the result of the individual empowerment of members through their business capital and management participation in the cooperative and this capacityenhancing effect is greater for middleand highincome farmers in general most of the available studies confirm the positive role of cooperatives in reducing poverty and increasing income cooperatives have an advantage over scattered smallholder farmers in terms of largescale farming use of advanced technologies coping with market risks and access to policy subsidies increasing the added value profitability labor productivity and employment of farmers engaged in agricultural production cooperatives not only help farmers reduce transaction costs in the procurement of agricultural materials and agricultural production services but also improve their bargaining power in the sale of agricultural products they also provide various types of training and activities to help farmers improve their ability to obtain information express their needs and apply technology thereby increasing their income however some scholars have also found that farmer group differences have a key impact on the povertyreducing effects of cooperatives some cooperatives have evolved into selfrun enterprises that do not contribute to the development of their members or to the income of farmers as a whole the natural heterogeneity of smallholder farmers in terms of their initial resource endowments such as production and management capacity risk tolerance and household livelihood capital may lead to elite capture resulting in the diversion of poverty alleviation resources and misalignment of project implementation creating new income inequalities some scholars also argue that small and mediumsized members of cooperatives are prone to freeriding behavior unwilling to pay for the cooperatives public services and enjoy the benefits without contributing much affecting the efficiency of the organizations operations and distributional equity the abovementioned studies provide an important theoretical basis for this paper but there are still shortcomings firstly although scholars have focused on the impact of cooperatives on poverty reduction among farmers they have not yet reached a unanimous conclusion and most of them are based on theoretical discussions lacking qualitative and quantitative studies on the impact of cooperatives on farmers ability to reduce poverty secondly few scholars have studied the heterogeneous effects of cooperatives on the future poverty reduction capacity of smallholder farmers from the perspective of farmer differentiation especially the lack of discussion of groups of farmers with different poverty attributes and different human capital endowments the main contribution of this paper is that it uses the cooperative empowerment dimension as an entry point to quantify the reduction effect of cooperatives on farmers poverty vulnerability and the differences in their effects on heterogeneous groups between groups enriching the research framework on the multidimensional propoorness of cooperatives by using the predominant score matching method the remainder of the paper is organized as follows section 2 proposes a theoretical analysis and four research hypotheses section 3 introduces the identification strategy variables and data for this study section 4 tests four hypotheses and presents the regression results and covers the heterogeneity analysis and robustness testing section 5 provides the discussions conclusions and related policy implications theoretical analysis and research hypothesis the main reason for attracting farmers to join a cooperative is the economic return it can bring to them attached to the economic function cooperatives also generate positive externalities by helping farmers to overcome barriers to market access improve scientific and cultural literacy increase social capital stock and empower management they also have positive externalities in terms of helping farmers overcome barriers to market access improving scientific and cultural literacy increasing social capital stock and empowering management which in turn reduce the poverty vulnerability of smallholder farmers with the development of the market economy agricultural markets are becoming more and more mature for decentralized smallholders due to their weakness asymmetric information high transaction costs and low standardization of production they face high barriers to market entry and lack sufficient competitiveness and voice in large markets and are unable to connect effectively with markets on their own collective action ie the formation of cooperatives is an effective mechanism to help resolve the conflict between smallholders and large markets and to increase farmers participation in the market collective action provides relevant information and services to smallholders including technical information and services educational services etc it improves the efficiency and management of farmers access to agricultural technology and also promotes the sustainable and healthy development of the cooperative the human capital of the farmers is accumulated and the endogenous motivation for development is further stimulated in terms of management participation democratic management and control is the foundation and core principle of the cooperative system the participation of members in general meetings councils and supervisory boards and the full expression of their views and demands not only helps to safeguard their own property rights and interests and to obtain more residual claims but also increases trust within the membership helps to reduce conflicts in decisionmaking and the cost of control or supervision in management ensures the smooth implementation of collective decisions and minimizes opportunistic behavior on the part of cooperative managers in general cooperatives are effective in reducing the poverty vulnerability of smallholder farmers through market access accelerated human capital formation and empowerment of management on this basis we propose hypothesis 1 h1 cooperatives can reduce the poverty vulnerability of smallholder households from the beginning of their development cooperatives have been characterized by an external market environment embedded in the vertical integration of agriculture and supply chain management smallholder farmers are at a distinct disadvantage in terms of enjoying the benefits of global value chains due to their low sales volume and limited bargaining power as well as the fact that smallholder farmers are often severely limited in their participation in markets by human capital and credit especially with the increasing trend toward globalization of agricultural markets and the need for higher management skills and logistics techniques to market agricultural products and meet higher standards of food safety certification the problem of smallholder participation in integrating into global value chains has become more pronounced and they even face the risk of being marginalized as far as the internal environment is concerned with socioeconomic development and the expansion of cooperatives the structure of group membership has stratified and the heterogeneity of members has increased significantly therefore when studying the impact of cooperatives on the poverty vulnerability of smallholder farmers different group characteristic factors should be included in the examination in terms of poverty attributes on the one hand poor farmers tend to have a strong will to escape poverty but show vulnerability characteristics such as poor labor skills sick and disabled members of the family heavy childrearing burden and few riskaverse means the greater the vulnerability to poverty the more risksensitive and riskaverse they are they are reluctant to join a cooperative or even if they do join they are reluctant to invest in shares thus becoming passive or dormant members the stratification between poor and nonpoor farmers and the resulting unequal power patterns may constrain the accumulation of a virtuous cycle of poverty vulnerability reduction among poor farmers on the other hand from the perspective of cooperatives although cooperatives are an effective way to reduce poverty through the organic combination of market and government mechanisms and objectively have a povertyreducing effect some cooperatives do not have an obvious motivation to reduce poverty subjectively let alone a mature concept of poverty alleviation most of the leaders of cooperatives have a philosophy of serving their own economic performance and their deliberate care for the poor tends to be weakened based on economic rationality cooperatives are exclusive toward poor farmers who lack resources and have low development capacity and tend to favor nonpoor groups who are well endowed with large scale operations and dedicated investments in poor areas even when cooperatives open their membership to poor farmers in general taking care of poor farmers in a unified operation would mean lower returns for nonpoor members the more poor farmers a cooperative takes on the greater the risk it may face of a decline in overall benefits on this basis we propose hypothesis 2 h2 the effect of poverty vulnerability reduction due to cooperative membership is higher on nonpoor farming households than in poor farming households poverty is a vague concept but it has some basic characteristics namely that it is mainly marked by lack which appears as low income and lack of material and services but in essence is a lack of means capabilities rights and opportunities education levels are closely linked to the ability of smallholder households to escape poverty bettereducated farmers tend to have a greater ability to accept new knowledge and new things and to understand and learn and their rich knowledge base makes them more likely to accept the organizational system business philosophy and production techniques of the cooperative which makes it easier for them to join the cooperative moreover the stronger the ability to accept new knowledge and technology the clearer the perception of the cooperatives ability to enhance its own development on this basis we propose hypothesis 3 h3 cooperatives are more effective in reducing the vulnerability to poverty of households with high human capital endowments than those with low human capital endowments institutional norms of rural cooperatives mainly include formal institutional arrangements and informal institutional norms we have found that rural cooperatives in china tend to be memberbased and rely closely on related enterprises in terms of management the cooperative has adopted the practice of two brands and one set of staff with the enterprise the daytoday management sales and technical guidance of the cooperative are all dependent on the relevant enterprise with the core members responsible for the management of the enterprise and the ordinary members only involved in the business work the heterogeneity of the membership structure of cooperatives is shaped by the differentiation of farming households this heterogeneity is reflected in the distinction between core members and general members of the cooperative these two types of members have different levels of income and different levels of participation in the cooperative resulting in different roles and division of labor which leads to differences in their ability to improve their skills showing typical asymmetrical characteristics compared to core members general members are usually lowincome lowcapital participation groups and such groups often lack the interest and ability to participate in the public affairs of the cooperative or even the opportunity to do so they rarely participate in the daytoday management and supervision of cooperatives and are mostly limited to basic aspects such as participation in the purchase of agricultural inputs and materials the sale of agricultural products and access to specialized technical services and policy concessions for core members their material resource endowments are at an advantage and they hold the majority of shares in the cooperative control most of the residual control and residual claims have more say in the daily production and management activities of the cooperative and can make full use of their resource endowments and effectively spill over thus becoming the biggest beneficiaries of the development of the cooperative on this basis we propose hypothesis 4 h4 cooperatives are more effective in reducing the poverty vulnerability of middleand highincome households than of lowincome households based on the above analysis the theoretical analysis framework of this paper is shown in figure 1 materials and methods data the data in this article comes from a comprehensive survey on the status of rural poverty in southwest china julyseptember 2021 the region covers four provinces yunnan guizhou sichuan and chongqing including eight statedefined poor counties in fengjie wanzhou yunyang xishui puding guangan xuyong and dongchuan 136 villages with 12 farmers per village a total of 1632 households in the sample the research sample was selected based on a threestage sampling cluster analysis sampling the original 592 statedefined poor counties were divided into three categories of overall poverty status with experts empirically assessing the worst category and selecting sample provinces and counties in the worst category probability proportional scale sampling sample villages were selected in proportion to the size of the poor population random sampling a sample of 12 farmers was randomly selected in each village to answer the questionnaire this sample data represents to a large extent the group of farming households that need the most attention in the less developed counties of china and is representative and typical since the focus of this paper is on smallholder households farmers with average arable land above 067 ha are excluded after data cleaning and elimination of the 10 questionnaires that did not meet the requirements the actual research population of this paper is 1622 households method poverty vulnerability measurement poverty vulnerability which connects risk shocks to the degree of household welfare is often seen as unobservable dynamic and forwardlooking with a focus on poverty generation expectations poverty vulnerability is the probability that a household or individual will fall into poverty or fail to escape from poverty as a result of exposure to uncertainty risk shocks poverty vulnerability is calculated as follows where ˆi v is an estimate of the probability of future poverty for farmer i c i is the value of per capita household consumption z is the delineated poverty line φ is the cumulative distribution function of the normal distribution ˆfgls β and ˆfgls θ denote the expected value and variance of future household consumption estimated by the flgs method respectively x i is an observable variable referring to wang et al in their examination of poverty vulnerability by introducing household characteristics variables and household head characteristics variables l ln n ln i fgls i i i i fgls z x prob c z x x v β θ     φ     econometric model we constructed an ols model to examine the impact of cooperatives on poverty vulnerability of smallholder households the ols model is set up as in equation y c ooperatives x i i i i α β θ ε among them y i is the poverty vulnerability of smallholder households cooperatives i represents the participation in a rural cooperative and x i indicates a series of control variables mainly including family characteristics village characteristics and head of household characteristics propensity score matching model the propensity score matching method is a counterfactual inference method the basic idea of which is to find a sample of controls similar to the treatment group to compare their effects thus effectively solving the endogeneity problem arising from sample selection bias since differences in farmers initial endowments can directly cause a selective bias in their willingness or behavior to join a cooperative and whether or not to join a cooperative often reflects the ideological tendency of rational farmers to pursue optimal utility a simple ols regression of equation which estimates the capacityenhancing effect of farmers ignores their own subjective initiative yields only the conditional expectation effect of the explanatory variables on the explanatory variables and the results obtained may be biased the psm propensity value matching method can effectively solve these problems by finding a control group with similar characteristics that can simulate the counterfactual state of the treatment group thus maximizing the elimination of endogeneity problems due to selfselection bias the specific steps are as follows step 1 we used a logistic model to calculate the conditional probability of a household participating in rural cooperatives ie the propensity score step 2 based on the propensity scores obtained through three methods nearest neighbor matching radius matching and kernel matching we found a sample of farmers in the control group with propensity scores as similar as possible to those in the treatment group in order to control and eliminate selectivity errors step 3 psm model requires that the variables used for matching meet the common support domain assumption and the balance test and after the sample has been matched and the matching effect has been achieved we calculate the average treatment effect the att is calculated as shown below a theoretical model of the impact of cooperatives on poverty vulnerability of smallholder households i i         pr 1 0 x e x i i att n y wy t i i s i j i s ij j t c ∈ ∩ ∈ ∩ ∑ ∑ 1 among them n t is the number of samples i t is the sample set of the disposal group i c is the sample set of the control group y i is the observed value of the sample of the disposal group and y j is the sample of the control group the observations of j s is the common support domain set w ij is the matching weight and att is the average disposition effect variables dependent variables to forecast household poverty vulnerability this article uses household per capita consumption one reason for using consumption to define poverty is that income is easily underestimated in microsurveys whereas consumption can better reflect the level of family welfare and the other is that using income as an explanatory variable can easily lead to strong endogenous problems in the measurement model regarding the choice of the poverty line there are primarily two standards of per capita daily consumption of us 19 and us 31 proposed by the world bank in 2015 which we convert into ¥2800 and ¥4570 per capita annual consumption based on chinas average purchasing power and cpi index in the subsequent analysis we focus on ¥4570 as the poverty standard line independent variables the core independent variable is whether or not one participates in a cooperative the ability of cooperatives to bring significant capacity enhancement effects to farmers at different stages of agricultural production depends on whether or not farmers participate in cooperatives the core explanatory variable is whether or not the farmer participates in a cooperative which describes the impact of cooperatives on the poverty vulnerability of smallholder households control variables with reference to existing studies this paper introduces three types of control variables namely variables on individual household head characteristics variables on household characteristics and variables on village characteristics household head characteristics include gender age and education level household characteristics include the number of household labors net household income per capita level of household poverty whether there are family members working in the city total productive assets and annual gift expenses village characteristics include village transportation conditions and economic status the descriptive statistical characteristics of the specific variables are shown in table 1 empirical results benchmark regression results table 2 reports the results of the benchmark regression of the impact of rural cooperatives on the poverty vulnerability of smallholder households in model 1 we only control for the characteristic variables of the household head in model 2 we further controlled for household characteristics variables of smallholder farmers in model 3 we included household head characteristics household characteristics and village residence characteristics as control variables the results show that controlling for a range of variables participation in cooperatives can significantly reduce the poverty vulnerability of smallholder farmers the impact factor is 00162 and is significant at the 5 level which basically supports hypothesis 1 that cooperatives can reduce the poverty vulnerability of smallholder farmers the coefficients and signs of the control variables remain consistent with existing studies the level of education of the household head the net household income social capital and the distance from the village to the county have a significant positive impact on the reduction in poverty vulnerability of smallholder farmers age of head of household and level of household poverty have a significant negative effect on reduction in poverty vulnerability of smallholder farmers in addition the number of laborers and migrant workers also show a negative impact on the reduction of poverty vulnerability which may be closely related to the demographic disadvantage of smallholder households robustness tests of the psm model the benchmark regression results show that joining a rural cooperative can significantly reduce the poverty vulnerability of smallholder farmers however there is also a potential problem that ols regression results are susceptible to sample selection bias and those factors that are not observed may affect the precision of the estimates in order to ensure the credibility and robustness of the regression results we further used the come psm model to verify the poverty vulnerability reduction effect of cooperatives on farm households we have selected control variables that were significant in the baseline regression model for the propensity score matching in order to eliminate the variability of the characteristic variables between the two sample groups after propensity score matching the question of conditional independence between the two sample groups needs to be checked ie there are no significant differences in the characteristics variables between the matched sample groups except for differences in the poverty vulnerability of the farmers table 3 reports the results of the conditional independence hypothesis tests for the explanatory variables before and after psm matching after psm matching the pseudo r 2 decreases from 0013 before matching to 00010003 after matching lr chi2 bvalues and mean biasvalue have all fallen substantially all p values are greater than 10 thus after matching by the psm model we significantly eliminate systematic differences in the distribution of explanatory variables between the treatment and control groups minimize sample selection bias and propensity score estimation and sample liu et al 103389fsufs20231222455 frontiers in sustainable food systems 07 frontiersinorg matching are more successful significantly weakening estimation bias due to selfselection in table 4 we used five psm methods to estimate att atu and ate for the impact of cooperatives on the poverty vulnerability of smallholder farmers among them att represents the average treatment effect of the treatment group atu represents the average treatment effect of the control group ate is the average treatment effect for the overall sample the results show that the five matching methods att atu and ate all passed the test at the 1 significance level which indicates that the results of matching between samples are relatively robust the mean value of att is 00252 which suggests that cooperatives have a significant dampening effect on the poverty vulnerability of farm households in other words the poverty vulnerability of farmers who joined cooperatives was reduced by 00252 compared to those who did not join cooperatives results of the heterogeneity analysis heterogeneity analysis based on educational level of household heads the level of education of the household head is largely representative of the overall human capital endowment of the smallholder household therefore we examine the heterogeneity of the effect of cooperatives on reducing the vulnerability of farm households to poverty in terms of the educational attainment of the based on chinas school system this paper classifies the years of education for heads of households into two categories namely lower education group and higher education group as shown in table 5 the effect of cooperatives on reducing poverty vulnerability is 205 times greater in the high quality group than in the low quality group for the education level of the household heads which suggests that farmers with high quality human capital endowments are more likely to improve their poverty status after joining a cooperative than those with low quality hypothesis 3 was tested heterogeneity analysis based on the level of household poverty we divided the sample into two groups according to whether the households were registered as living under the poverty line or not as shown in table 6 cooperatives have a negative impact on the poverty vulnerability of farmers across different poverty attributes but there are differences in the magnitude of the effect the reduction effect of cooperatives on poverty vulnerability of nonpoor households is 437 times greater than that of poor households this shows that nonpoor households are more likely to benefit from cooperative seeds than poor households hypothesis 2 is verified heterogeneity analysis based on the household incomes this paper classifies farm households into lowerincome and higherincome groups based on their median per capita income levels and removes the variable of net household income from the regression as shown in table 7 the reduction effect of cooperatives on poverty vulnerability of higher income households is greater than that of lower income households overall the cooperatives had a dampening effect on poverty vulnerability for both the lower and higher income groups of farmers but there were differences in the magnitude of the effect with a greater reduction effect for the higher income group than for the lower income group and hypothesis 4 is tested discussion and conclusions discussions our explorations of the heterogeneous characteristics of smallholder farmers leads to a topic worth exploring namely whether cooperatives in reality can meet the development aspirations of a wide range of disadvantaged groups and whether they really have the desired organizational effectiveness in driving smallholder farmers according to classical cooperative theory alleviating the inherent tension between smallholders and the larger market is the purpose of forming a cooperative for weak smallholders however an important prerequisite for the effective operation of cooperatives is a high degree of homogeneity in membership in reality farmers are highly heterogeneous and this is difficult to eliminate in the short term as a result the organizational objectives of cooperatives deviate from the assumptions of classical cooperative theory and the organizational performance is biased toward members with superior resource endowments thus the organizational objectives of cooperatives deviated from the assumptions of classical cooperative theory and organizational performance was biased in favor of members with superior resource endowments so that the development and profitability of small farmers was reduced cooperatives are an important vehicle for industrial poverty alleviation the vast majority of studies have affirmed the positive role of cooperatives in reducing poverty and increasing income cooperatives have an advantage over scattered smallholder farmers in terms of largescale operation of farmland use of advanced technology coping with market risks and access to policy subsidies increasing the added value profitability labor productivity and employment rate of farmers engaged in agricultural production cooperatives not only help farmers reduce transaction costs in the procurement of agricultural materials and agricultural production services and increase their bargaining power in the marketing of agricultural products they also provide a variety of training and activities to help farmers improve their viable capacity to access information express their needs and apply technology which helps reduce the poverty vulnerability of smallholder households in practice some researchers have focused on the alienation of cooperatives caused by differences in groups of farmers some cooperatives have evolved into selfrun enterprises that do not contribute to the development of their members nor do they contribute to the incomes of farming households as a whole the natural heterogeneity of smallholder farmers in terms of their initial resource endowments such as production and management capacity risk tolerance and household livelihood capital may lead to elite capture resulting in deviated resources for poverty alleviation and misplaced project implementation creating new income inequalities some scholars also argue that small and mediumsized members of cooperatives are prone to freeriding behavior unwilling to pay for the cooperatives public services and enjoy the benefits without contributing much affecting the efficiency of the organizations operations and distributional equity heterogeneous characteristics make a difference in both the motivation of farmers to join and their factor inputs resulting in differences in the impact of cooperatives on farmers incomes it has been generally agreed that farmers with better resource endowments and more factor inputs are more likely to seek more control over their surplus to accurately detect the impact of cooperatives on the poverty vulnerability of farm households it is necessary to distinguish between the heterogeneity of farm households and focus on which groups cooperatives work more significantly for the findings of this paper also confirm this phenomenon farmers whose heads have higher levels of education nonpoor families and higher household incomes have gained a more pronounced reduction in their poverty vulnerability after joining the cooperative in research in less developed areas poverty alleviation work generally suffers from strong policy input but weak endogenous motivation enhancement etc most cooperatives only objectively absorb poor farmers into their societies as a matter of policy but subjectively they do not pursue the effectiveness of bringing poverty and are not willing to absorb poor farmers in addition the riskaverse nature of poor farmers with inherent lack of production endowments and social network resources often makes them reluctant to join the society or even if they do the shares they put in are low due to financial constraints which inevitably leads to the problem that the cooperatives are pro the capable rural people and anti the disadvantaged the problem is that cooperatives are inevitably pro rural people and pro disadvantaged groups however it is also important to note that the value of cooperatives in benefiting the poor should not be dismissed because of their affinity to the rural and disadvantaged groups the empirical results also show that even if poor farmers find it difficult to participate in cooperatives because they are excluded or less willing to join them they can still benefit indirectly through the spillover effects of cooperatives additionally farmers in different income brackets and education levels have different levels of involvement in the operations and management of the cooperative leading to differences in their poverty vulnerability reduction farmers with less physical capital and less learning capacity have less control and say in the daytoday operations of the cooperative and tend to be in a lower position in the cooperative than those with more material resources and higher levels of education accordingly cooperatives are also less effective in reducing their poverty vulnerability than members with superior physical capital and high levels of education conversely farmers with strong economic resource endowments usually have sufficient accumulation of their own resource factors and can make full use of and effectively spill over their economic resource endowments as a result the decision to join the society is more effective and more rewarding for these farmers conclusion based on microsurvey data from smallholder farmers in eight counties in four provinces in the underdeveloped regions of western china this paper analyses the impact of farmers membership in cooperatives on their poverty vulnerability and further explores the differences in the poverty reduction effects of cooperatives on groups with different poverty attributes different human capital endowments and different income class heterogeneity the main conclusions are as follows cooperatives have a significant dampening effect on the poverty vulnerability of smallholder farmers cooperatives have a positive external impact in terms of helping farmers to overcome barriers to market access accelerating the formation of human capital and empowering management which in turn has a combined effect on improving the ability of farmers to develop themselves which has a combined effect on the improvement and enhancement of farmers capacity for autonomous development after overcoming the sample selection bias using the psm model the results show that participation in cooperatives still reduces the poverty vulnerability of smallholder farmers by an average of 00252 and the result remains robust to multiple tests of the methodology the impact of cooperatives on the poverty vulnerability of smallholder farmers is significantly heterogeneous across groups specifically participation in cooperatives has a more pronounced effect on poverty reduction among nonpoor higher human capital endowment and higher income bracket households than among poor lower human capital endowment and lower income bracket households the validated conclusions outlined above can contribute and assist in emerging policy enlightenment firstly enhancing the linkages between the interests of rural elite figures and weak small farmers policy makers should guide and encourage farmers to join or start cooperatives and support the development of cooperatives as an effective initiative to reduce poverty among smallholder farmers but they should also see the limitations of the effectiveness of policy implementation a topdown push for cooperative development and the pursuit of incremental growth in order to achieve an increase in the ability of farmers to reduce poverty will likely lead to a further widening of the gap in the ability of farmers to escape poverty in the future the government should on the basis of cultivating the stock of cooperatives keenly identify the fit between elite figures and weak small farmers in terms of business areas and cooperative relationships and strengthen the linkage between the interests of cooperatives and small farmers in order to minimize the negative effect of elite capture secondly cooperatives are an effective way for smallholder farmers in less developed areas to escape poverty even if poor farmers find it difficult to participate in cooperatives because they are excluded or have a low willingness to join they can still benefit indirectly through the spillover effects of cooperatives there are still many limitations in this paper which can be seen in the following aspects firstly we have focused more on the heterogeneity of farmers and neglected the heterogeneity of the cooperatives themselves the variables in this paper are selected from the perspective of farmers only and are based on a single dimensional characteristic of farmers without detailed descriptions and statistics of cooperatives second the paper does not consider the willingness of cooperatives to take on board whether farmers can become members of cooperatives is not only based on whether they have a demand for membership but also on whether cooperatives have the willingness to open up membership to the public which is the result of a combination of demand and supply factors however on the supply side the willingness of cooperatives to take up membership varies depending on the organizational model governance and other characteristic factors of cooperatives in less developed western regions thirdly social capital and the governance model of cooperatives play an important role in the poverty reduction effect of rural cooperatives however we did not conduct an indepth analysis of these two areas due to the availability of data finally the paper does not include the factors of policy intervention in cooperatives in its examination if the policy is to support excellence and strength cooperatives will choose to exclude the rural disadvantaged because they want to improve their competitiveness in contrast if the policy is to regulate the development of cooperatives and advocate their propoor attributes then the relevant policy interventions will affect the exclusion decision of cooperatives as well as the demand of farmers to join the society policy interventions affect both the willingness of cooperatives to take in and the demand of farmers to join the construction of an analytical framework that incorporates policy interventions cooperative and farmer characteristics is an important direction for future research data availability statement the original contributions presented in the study are included in the articlesupplementary material further inquiries can be directed to the corresponding author ethics statement ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements written informed consent from the participants was not required to participate in this study in accordance with the national legislation and the institutional requirements publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

introduction poverty eradication is one of the global challenges and rural cooperatives provide an effective path to address smallholder households poverty however the effect of poverty reduction can show heterogeneity depending on the economic capital human capital and social capital of householdsbased on comprehensive research data on the poverty status of 1622 smallholder households in four provinces in the less developed regions of western china using ols and psm models this paper empirically analyzes the impact and heterogeneous characteristics of rural cooperatives on the poverty vulnerability of smallholder households resultsdiscussion the results show that rural cooperatives have a significant dampening effect on the poverty vulnerability of smallholder farmers and the findings hold true after robustness tests using multiple methods the impact of rural cooperatives on the poverty vulnerability of farming households differed significantly across smallholder households with different characteristics specifically participation in cooperatives had a more pronounced effect on reducing poverty vulnerability among nonpoor higher human capital and higher income farm households compared to poor lower human capital and lower income farm households the results of the study can provide a useful reference for policymaking on rural mutual assistance and poverty reduction among farmers

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introduction the aim of this paper is modest it is an attempt to explore some possibilities for what might be called a foucauldian education it draws from and builds upon a number of existing forays into the use of foucaults later work to think differently about teaching and learning among others nonetheless the task is made particularly challenging in as much that the space in which to think differently that foucaults critique intends to produce is a space of transgression and experiment not a space of prescription thus what is offered here can only be some possibilities and starting points provocations rather than firm proposals the paper adds to an existing string of dots and temporary abutments there is also a problem regarding terminology i use the terms pedagogy curriculum and assessment and teacher at points in the paper when there is no alternative to refer to aspects of educational experience while at the same time starting from a position of critique that seeks to displace these concepts and practices and all their connotations the paper begins by outlining foucaults use of critique as a means of maintaining mobility of mind and spirit of avoiding a fixed stabilized view of the everchanging present of maintaining a critical awareness of oneself and the place and time in which one resides critique is a technology for clearing away things we take as natural and necessary in order to begin elsewhere critique is also a tactic for establishing the contingency of truth power and subjectivity from that starting point the paper outlines the possibilities of refusal and selfformation as the basis of a pedagogy as ethicopolitics that is as selfformation and curriculum as genealogy and teaching as the fostering of the disposition of curiosity before addressing the problem of the teacher and the teacher learner relation as form of a parrhesiatic contract the sections intertwine and overlap in various ways overall in educational studies there is a tendency to interpret and use foucault as a philosopher of oppressions drawing primarily on the work of his middle period and its focus on the problem of power and in particular on discipline and punish from this the means of correct training the panopticon normalisation etc are deployed to explore or more often redescribe the processes of schooling or the experience of teaching and learning in terms of surveillance classification and exclusion 2 in this vein some refer to foucaults bleak and onesided vision of modernity or his analysis as revealing the grim truth of the education processnamely that it is a core element in the mechanics of modern disciplinarity those are right and proper readings of and uses of foucault and ones that he acknowledged but they are also partial what is missing from such renditions is a proper sense of the purpose and thrust of foucaults analytical endeavours that is his intention to destabilise to make things not as necessary as all that foucault as a philosopher of contestation and difference seeks to undermine selfevidences and open up spaces for acting and thinking differently about our relation to ourselves and to others and identify and refuse and transgress the horizon of silent objectification within which we are articulated such critique enables us to recognise that the things values and events that make up our present experience have been constituted historically discursively practically and indeed that the self our subjectivity is historically produced in and through technologies and relations of power see below the point here for foucault is not simply to record mundane processes of ways in which we are made subject to rather it is a means of opening up possibilities of self formation foucault does not intend that his analyses produce an horizon of absolute subjection and domination but rather the opposite an horizon of freedom that is as he put it my role and that is too emphatic a word is to show people that they are much freer than they feel that people accept as truth as evidence some themes which have been built up at a certain moment during history and that this socalled evidence can be criticized and destroyed critique and freedom the essence of foucaults critique is a curiosity towards the arts of being governed and all of those practices and discourses that seek to homogenise subjectivity to make it uniform and narrow the spoke of freedom of which schooling would be a case in point this is a permanent orientation of skepticism a mode of relating to contemporary reality this requires not just a gesture of rejection rather we have to move beyond the outsideinside alternative we have to be at the frontiers these possibilities of freedom are more directly and clearly explored in the later foucault more precisely around 1980 he began to articulate a politics of the care of the self what i want to explore here is some ways this later work enables us to think education differently in particular in relation to the concept of self formation that is education as the production of a subject capable of turning back upon itself of critically studying the processes of its own constitution but also subverting them and effecting changes in them self formation in this sense is a starting point for experiments with an education or educations that do not simply reconstitute what has failed in the past starting with self formation enables and requires us to dismantle the tired and constraining imaginary architecture of schooling curriculum pedagogy and assessment and their very particular grammar or meanings and concomitant social arrangements of space and timethat we call an education here drawing on and using ideas and propositions adumbrated by a small group of foucauldian constructivists i will sketch out what a foucauldian education might look like in practice and consider some of the challenges paradoxes and impossibilities with which it would face us and indicate some of the cherished conceits and reiterated necessities that we must give up if we take seriously the possibility an education that fosters a permanent orientation to curiosity however to reiterate if we wish to take up the later foucault as a starting point for thinking education differently there is no template to follow no guidelines for an educational programme rather some poorly marked tracks and vague signposts that are starting points following foucaults style and method what is offered is not a programmatic account of some alternative to what is as he suggests we cannot conceive of alternatives within the discursive possibilities we current inhabit we are bound by epistemic rules and closures that enable and constrain us to think within certain versions of what is and might be truethe conditions of possibility of modern thought established practices of remembering and forgetting an exteriority that is prior to any conscious activity of a meaningful subjectivity as he explained i think that to imagine another system is to extend our participation in the present system furthermore in seeking to think differently we must leave behind any desire to find a foundational metaphysics for critical action and strive to escape the overused colonised lexicon of critical education rather we must embrace the power of strangeness and the inevitability of failure and resist the obscuring clarity of rational philosophical discourse and thus make both our present and our past alien to us we must struggle with the idea of ourselves as both a discursively produced effect and a viable site of resistance this is ethics as a practice rather than a plan as the kind of relationship you ought to have with yourself… a question of how we govern our own conduct both our behaviour and our purposes and the possibility of unending change both to ourselves and to the arrangements in which we contingently find ourselves authoring ones ethical self foucault was adamant that there is no simple relationship between critique and action the main task is as much or perhaps even more one of refusal as it is resistance maybe the target nowadays is not to discover what we are but to refuse what we are this is a negative ethics not a matter of asserting ideals but rather an aestheticisman imaginative creativity this is a form of ethicopolitics that is visceral rather than abstract rooted as much in the physical and emotional as it is in logic it rests on a refusal to accept the grounds on which subjectivity is proposed within dominant discourses and a willingness to subvert thema subversion that is transformative rather than just disruptive this creativity focuses on the care of the self and of others and involves both the techne of the self and the techne of life it is the cultivation of a self that is on the one hand a product of and a disruption of various discourses and on the other the practice of the art of living well living differently relating to others in different ways this is the construction of a heterotopia both intellectual and practical in which space and time are are somehow other disturbing intense incompatible contradictory or transforming and within which it is possible to make oneself thinkable in a different wayto become other than how you find yourself that is a search for other experiences 3 in these respects selfformation is an active and engaged process based on questioning and learning from the immediate and quoditian on forming and testing at the same time an exercise of oneself in the activity of thought all of this would involve a plurality of refusals resistances and struggles against local fixations of power in specific sites in part through counterconducts and creative strategies of noncompliance that then open up possibilities of autonomous and independent subjectivation that is possibilities for the constitution of oneself counter conducts are active interventions in the ethical domain refusals to be governed this way the cultivation of the arts of voluntary insubordination and a practice of reflective intractability such practices of refusal show us that the production of something new in the world might be possible they are vehicles or opportunities for exploring new forms of existence of being otherwise refusal offers the potential for a repoliticisation of everyday life by reopening to question the taken for granted and naturalised concepts practices relations and social arrangements through which we relate to ourselves and to others however by denaturalising the categories that organise and define our experience and make us what we are we enter into a worrying indeed frightening space in which we must unthink our common sense and recognise as fragile and contingent many of our modernist certainties in this way be might begin to recognise that all knowledge is uncertain that truth is unstably linked to power and that our intelligibility is constantly in question the task is to eschew certainty in order to become an ironic hero of our own life by tak oneself as object of a complex and difficult elaboration we engage in unmaking our selves and what we have become and thus at the same time make intolerable the institutions and experiences within which our intelligibility is constructed in other words our subjectivity becomes a site of political struggle to sum up what is involved here is a creative and aesthetic politics that is not reliant on the pregiven tainted moral principles that we take to define humanity or which require us to search for and link our essential qualities to inherent abstract principles instead one is set the challenge of creatively and courageously authoring ones ethical self … it is a question of searching for another kind of critical philosophy not a critical philosophy that seeks to determine the conditions and the limits of our possible knowledge of the object but a critical philosophy that seeks the conditions and indefinite possibilities of transforming the subject transforming ourselves what is at stake here is the arrangements that have created the modern subject the point is to make these arrangements untenable and unacceptable and to begin to establish the conditions for the creation of new modes of subjectivity and in this case one of the main political problems nowadays would be in the strict sense of the word the politics of ourselves the question is then how might this translate into something we might conceive of as an education education as selfformation leask argues that if we take seriously the focus on the practices of education in the later foucault then … instead of being rendered into factories of obedient behaviour schools or colleges can be the locus for a critically informed oppositional micropolitics in other words the powerrelations that constitute education can now be regarded on foucaults own terms as being creative enabling and positive that is we can rethink education in ways that respond to foucaults question how could it be possible to elaborate new kinds of relationships to ourselves indeed butin suggests that there is a seemingly natural affinity between foucaults insightsinto for example power knowledge resistance subjectificationand educational research and practice and leask argues that in foucaults later work there are possibilities which indicate that pedagogy can be reconsidered not simply as a technique for the manufacture of imposition but as the theatre of subject creation of new practices of the self new kinds of relationsespecially via continued resistance to domination leask also suggests that teachers and students alike can now be regarded as creative agents capable of voluntary and intentional counterpractices… this is what infinito calls a political pedagogy she identifies from foucaults essay what is enlightenment spaces of education as a framework for educational practice the first precept suggests the need to attend to the form and nature of the spaces of education the setting its frames and practices and its architecture selfformation here in the very immediate sense requires spaces where our actions as learners are attended to carefully considered and taken seriously enough to merit a response this would be a space in which agonism would be valued and failure would be a constructive opportunity to learn and to changeboth of which take time the pace of education would need to slow down in such a space it would always be possible to start again and who one is and what one thinks and to what one is committed to would remain tentative open to revision 5 youdell suggests that this means intervening in the intolerable present to make thatwhichis no longer thatwhichis inviting us to imagine becomings that disrupt the intolerable … offering instead moments of the haecceity 6 of this thing or here is the aim would be to make the past come undone at the seams so that it loses its unity continuity and naturalness so that it does not appear any more as a single past that has already been made but rather as a heterogeneous array of converging and diverging struggles that are still on going and only have the appearance of having been settled in this heterotopic space we must attend to frameworks of knowability and unknowability at the same time always bearing in mind that ignorance is formed by knowledge and vice versa genealogy as curriculum curriculum as curiosity infinitos second condition for a political pedagogy suggests genealogy as curriculum and the centrality of the question of truth in stark contrast to the modernist classroom the concern is not with what is true but with the how of truth knowledge becomes a problem rather than a question as infinito unlearning should encourage students to think deeply and critically about the illusory world of all the ideas notions and beliefs that hem jostle whirl confuse and oppress them and requires of them a reversal of standpoint this would involve a view of knowledge as games of truth and in relation to this the collapse of objective meaning leaving us free to create our own lives and ourselves this is a form of combative or guerrilla pluralism in which there is no epistemic innocence what the guerrilla pluralism of the foucaultian genealogical method can help produce is epistemic insurrections that have to be constantly renewed and remain always ongoing in order to keep producing epistemic friction dislocation and decoding as chokr puts it are necessary to place in abeyance the propositions and assumptions underlying and governing understanding and behaviour to reiterate this is not an abdication of truth but rather a selfconscious engagement in the games of truth destabilising truth rather than learning it historising excellence and beauty rather than appreciating it a commitment to uncertainty this might also involve the recovery of subjugated knowledges and thinking tactically about the multiple effects of texts and classroom engagements and drawing out and making visible subjugated meanings and unsettle and open up to troubling those meanings that inscribe the normative at the same time we must come to see and understand past subjects differently by activating countermemories that is a struggle against collective forgetting particularly in relation to social injustices this might also involve a focus on the writerliness of texts and denaturalizing our habitual economy of reading and the consumerist model of reading rather this is writing and reading as a practical strategy in the constitution of the self two key technologies for the care of the self above all this is a classroom in which the aim is to cultivate an orientation of curiosity a readiness to find what surrounds us strange and odd a certain determination to throw off familiar ways of thought and to look at the same things in a different way … a lack of respect for the traditional hierarchies of what is important and fundamental 7 however this is not the curiosity that seeks to assimilate what it is proper for one to know but that enables one to get free of oneself it relies on the knowers straying afield of himself curiosity is one means of loosening our relation to a fixed identity creating the possibility of erring of no longer being doing or thinking what we are do or think curiosity is indeed what enables the student to resist the powerful lure of ideological complacency and to challenge and disrupt the economy of the same a disposition of critique the third task and dimension of a political pedagogy is the cultivation of an attitude or disposition to critique and in relation to this there are certain qualities of character like courage which might be formed and might be needed here not as abstract or selfmanaging dispositions as currently intended by socalled character education but as the basis for action and interaction in the spaces of learning however infinito warns lest we think this a radical notion we must remember that education is practiced at producing desirable dispositions a history of the hidden curriculum reveals specific attitudes infusing education at various times deemed part of its responsibility the point here would be to encourage ethical teacherlearners who have a healthy suspicion of the present but who are also able to acknowledge their own fallibility that is teachers and learners who are open to infinite possibilities for change and are willing to critique their own commitments this would mean adopting a critical stance that oscillates between attempts to recreate ourselves and the world and in doing so make ourselves vulnerable to the past and open ourselves up to interrogation the learning processes involved here may be part of what zembylas and others call a pedagogy of discomfort drawing on what foucault termed the ethic of discomfort that is students and teachers are challenged to embrace their vulnerability and accept the ambiguity of self and their dependence on others and are constantly jarred from their habitual everydayness teachinglearning thus becomes a series of crises disruptions and impasses part of the pedagogical challenge for the teacher is to create a social and ethical environment within which discomfort is productive as felman argues if teaching does not hit upon some sort of crisis if it does not encounter either the vulnerable unpredictable dimension it has perhaps not truly taught i therefore think that my job as a teacher paradoxical as it may sound was that of creating in the class the highest state of crisis that it could withstand… infinito discusses this in an explanation of the use of the blueeyedbrowneyed classroom event and writes of a struggle with the propriety of subjecting students unknowingly to ridicule and discomfort at the same time perhaps the most profound education is always discomforting the goal is to create a space within which it is possible to begin to confront and reimagine the historically sedimented questions and problem through which we address the world that is a curriculum within which we can reconstitute our presentopening up a room understood as a room of concrete freedom that is possible transformation conceived and practiced in this way education becomes an exploration and mapping of limits and testing and crossing them when possiblea set of multiple transgressions that allow individuals to peer over the edge of their limits but also confirms the impossibility of removing them such experiences have the function of wrenching the subject from itself of seeing to it that the subject is no longer itself or that it is brought to its annihilation or its dissolution this is a project of desubjectivation this is a sequence of moments openings spaces in which unlearning is possiblean exploration of ethical heterotopias real and unreal where difference is affirmed a sort of simultaneously mythic and real contestation of the space in which we live 8 in relation to this first and foremost students must be recognized as ethical beings capable of reflection decisionmaking and responsibility for their identity and their social relations that is to say ethical self formation as moral pedagogy allows for the maintenance and production of the learners freedom in a similar way siciliacamacho fernándezbalboa recast critical pedagogy in foucauldian terms and assert that our version of cp seeks the construction of personalpedagogicalpolitical ethics while acknowledging the legitimacy of different pedagogical games and regimes of truth 9 in these ways education and pedagogy are articulated not as bundles of skills and knowledges but as the formation of moral subjectivity a form of practical politics a struggle to become selfgoverning this is not liberation but activation an enduring engagement in the travails and failures of selffashioning experimenting with and choosing what we might be and how we might relate to others it is ethics as a social praxis experiments with forms modes and styles of life and new social and political forms it is driven by failure and the need to fail again but better rather than the expectation of success or closure it values the pluralisation and agonism of voices and contestation over consensus and resolution it recognises that solutions give rise to new problems and rests of what wenham calls the tragic view of the world according to which conflict suffering and strife are inevitable phenomena of social and political life and may never be ultimately overcome teaching here becomes a process of asking questions without providing answers the goal is to explore to what extent it might be possible to think differently it is education as epistemological suspicion education and unlearning become both enabling and destructive and what is at stake is the production of a certain kind of experience a reconfiguring of experience itself this is different from cp this is a morality as action recognizing individuals capacity to develop alternative subjectivities and make appropriate decisions as distinct from cp as a moral process whose goal is the emancipation of others the problem of the teacher one always needs the help of others in the souls labour upon itself all of this as youdell aptly puts it is fraught and begs difficult questions about what a learner and a teacher are foucault sees no objection to those who know more in a given game of truth telling another what he must do teach him the problem in this relationship and interaction is to avoid the effects of dominance in relation to which biesta usefully distinguishes between learning from and being taught by there is a mutuality to the relations of power here and in self writing 10 foucault quotes seneca saying the process is mutual for men learn while they teach the bond between master and disciple as foucault puts it is always provisional and circumstantial a dialogue based on respect and mutual care and mutual development a relationship open to constant scrutiny and revision the teacher here is a genuine interlocutor some one who takes risks and relishes challenges in order to create a public space where fearless speech is encouraged all of this must rest on the relationship for the teacher as much as the student between care of the self and the care of others and as foucault points out in his survey of greek political thought there is a fundamental relation between governing others and governing the self one will not be able to rule if one is not oneself ruled the exercise of political power demands the practice and cultivation of personal virtues it is the power over self which will regulate the power over others … if you care for yourself correctly ie if you know ontologically what you are … then you cannot abuse your power over others this can be transposed into the problem of pedagogical power and would reenvisage teaching as an ethical practice and would mean constructing ones relation to the learner differently with a primary focus on attending to and facilitating their impulse of curiousity and making the classroom as site of ethicoaesthetic selffashioning organised and reorganised in relation to the problem of what kind of self am i going to be as foucault remarks in order to care for the self one needs a master of care a guide a counsellor a friend and he counsels the need to offset the dangers of solitude and as olssen makes clear ethical action is not for foucault an individual affair but presupposes a certain political and social structure with respect to liberty self formation is not a lonely narcissism but is only possible within what falzon calls the fundamental encounter with the other within which our narcissistic reveries are shattered the circle of our solipsism is burst here the life we live among other subjects as infinito puts it is the stuff of ethics it is the fashioning of a mode of being which emerges from our own history and thinking clearly refusing to be a proper teacher means that the teacher is also vulnerable in the classroom putting their subjectivity at risk as deacon points out practices of liberty in the classroom are inextricably intertwined with pedagogical effects of guilt obligation and verification and assumptions about degrees of ignorance dependence on others legitimate compulsion and achievement here teaching and learning are a set of experiments that are both exciting and frightening based on the parrhesiatic contractin which both parties speak frankly the teacher has the task of establishing a vital vibrant public space for truthtelling to occur this is necessarily a very concrete palpable experience it is the art of living dangerously emotions intellectual risks and trust become intermingled in complex and difficult ways nonetheless in these ways teaching might become a site of delight in oneself in greek politics the ability to govern was not defined as if it were a question of a profession with its particular skills and techniques which is how we have come to conceive of the work of the teacherbut rather depended on ethical work of the self on the selfthat is the work of self formation the point is not to accept but to experiment to create to think critically to imagine to make judgments about what it is we do not want to be and what it is we might want to be this is both negative a disavowal of the contingently normal and positive thinking differently about ourselves a transgression an agonism a struggle that produces us as ethical beings a disposition toward and constant activity of changing and an unending search for autonomy the self becomes autonomous only through concrete possibilities which present themselves as invitations for the practice of liberty from here to there all of this begs many questions about how we get from where we are nowwedded to an education system that is absurd and oppressive and that conflates education with schooling to the possibility of education as something different how do we move from a system of education that rests on an assumption of ignorance and a reverence to the past and that can only function through practices of exclusion and humiliation to a form of education that eschews system altogether and offers no privilege to the past and rather consists of a process of creative self fashioning the opening up of vulnerability unruly curiosity and frank speaking a space of education that is not define defined and limited by an institutional rationale but part of and related to forms of selffashioning carried out elsewhere and to the broader life of the citizen in a constant effort to expand the scope of new modes of subjectivity by creating the space for the flourishing of a multiplicity of arts of living the answer is i do not know what i can offer is some incitements towards the critique of what we are and experiments with the possibility of going beyond that combines outrage with limittesting and careful scholarship and which cultivates the art of voluntary insubordination and a practice of reflective intractability zembylas m pedagogy of discomfort and its ethical implications the tensions of ethical violence in social justice education ethics and education 10 163174 notes 1 i am immensely grateful to patrick bailey matthew clarke jordi collet and donald gillies for their careful insightful and very constructive comments on earlier versions of this paper 2 foucault himself refers to this early middle late periodization or rather signals the changing emphases in his analyses from knowledge to power to subjectivity that is studying each of these three areas in turn as moving from a focus on forms of knowledge to the matrix of forms of behavior to the constitution of the subjects modes of being 3 as tavani argues this involves a reading of the myriads of intermediate spaces hosted between the two poles of confirmation or subversion 4 one of many such developments would be to consider how selfformation might relate to primary and secondary schooling unless of course such a division is rendered redundant by the work of critique as i think it might more challenging might be whether selfformation should be thought about in relation to developmental stages and for example kohlbergs theory of moral development but again we might want to take such a conception of the child subject as needing to be dispensed with entirely

foucauldian education might look like in practice considers some of the challenges paradoxes and impossibilities with which such an education would face us and indicates some of the cherished conceits and reiterated necessities that we must give up if we take seriously the need for an education that fosters an orientation to critique and curiosity three elements of foucaults philosophical ethos that might be translated into educational practices are addressed first fostering a learning environment that encourages experimentation second enabling the development of an awareness of ones current condition as defined and constructed by the given culture and historical moment third encouraging an attitude or disposition to critique a focus on the production of particular sorts of dispositions that would be valued and fostered all of this raises issue about the teacher

19862_0

introduction smoking behavior is a common phenomenon in indonesian society for most indonesians smoking is a behavior pattern that occurs every day smoking is a behavior that is often found in various places and is considered a habit in indonesian society regulation of the minister of health of the republic of indonesia number 40 of 2013 is used as a reference for the government regional governments and the community in making policies and strategies to control the impact of cigarette consumption in indonesia the expected achievement of this road map is the formation and implementation of public policiesregulations that protect the public from the dangers of smoking for example nosmoking area regulations meanwhile the dprri has tried to discuss the tobacco bill since the beginning of its drafting this bill has attracted controversy but it will soon be brought to the plenary session to be ratified as legislation even though there have been these efforts it is evident that efforts to control the number of smokers still require community participation most people view that smoking behavior has many negative impacts however some people think that smoking behavior can have a relaxing and calming effect on them even though strangely enough they understand that the smoking behavior they carry out is a considerable danger for themselves as people who smoke as well as people around them who are not smokers even though the writing on cigarette packaging these smokers already know that cigarettes can negatively impact health including cancer heart attacks impotence pregnancy and fetal disorders strokes cataracts tooth decay osteoporosis and sperm abnormalities even now the writing on cigarette packs reads warning that smoking kills you characteristics of social smoking among students to date there is no standard way to define social smoking however their research described the characteristics of a social smoker as someone who smokes more commonly with other people than alone and smokes in certain social situations such as at parties or when socializing with other people in the kendari nursing campus environment students tend to smoke they smoke due to various factors from trial and error or the influence of friends who smoke the results of the interview with mr a who is a security officer at the kendari nursing campus said that most of the male students at this health campus are info article smokers even mr a noted there were also smokers among female students places often used for smoking are campus canteens parking lots and building lobbies these students tend to smoke when hanging out with friends when they come home from college and during their leisure time when there are no lectures smoking is a habit in society often found in everyday life in various places and occasions smoking behavior is the activity of burning tobacco inhaling and then exhaling the smoke cigarettes are one of the biggest causes of death in the world the world health organization states that around 6 million people die yearly from smoking research conducted by pasco stated that among 165 people with major depressive disorder and 806 controls smoking was associated with increased odds of major depressive disorder 146 95 ci 103207 compared with nonsmokers the odds of major depressive disorder are more than double for heavy smokers among 671 men with no history of depressive illness at baseline 13 of 87 smokers and 38 of 584 nonsmokers developed de novo major depressive disorder during a decade of followup smoking increased the risk of depressive illness by 93 193 95 ci 102369 this was not explained by physical activity or alcohol consumption the condition of smokers in indonesia is also increasingly worrying because cigarette consumption continues to increase rapidly yearly exceeding the population growth rate in 2010 it was known that the prevalence of smoking in indonesia was 342 and increased further in 2013 to 363 daily cigarette consumption per person in indonesia in 2013 was 123 cigarettesday global youth tobacco survey 2014 data states that 203 of school children smoke 573 of school children aged 1315 years are exposed to cigarette smoke at home and 60 are exposed to cigarette smoke in public places or six out of every ten school children aged 1315 years are exposed to cigarette smoke at home and in public places data from the global adult tabacco survey also shows that the prevalence of smoking in indonesia is 348 and as many as 67 of men in indonesia are the most giant smokers in the world according to basic health research 243 of active smokers smoke daily 5 are occasional smokers 4 are former and 666 are nonsmokers nearly 80 of smokers smoke when they start smoking from a young age and do not know the risks regarding the dangers of addictive cigarettes a persons intention to act is related to their health or health care behavioral preferences according to ajzen in hanafiah in general the better the subjects attitudes and norms the greater the control one feels and the stronger a persons intention to carry out that behavior jogiyanto argues that intention is a function of two essential determinants namely the individuals attitude towards behavior and the individuals perception of social pressure to carry out or not to carry out behavior which is called subjective norms in short according to the theory of reasoned action practice or conduct is influenced by intentions while attitudes and subjective norms influence intentions beliefs about the results of previous actions influence attitudes themselves subjective norms are influenced by ideas about other peoples opinions and motivation to comply with those opinions more simply this theory says that a person will do an action if he views it as positive and believes that other people want him to do it smoking behavior is a phenomenal activity meaning that even though many people know the terrible effects of smoking the number of smokers has not decreased it continues to increase currently the age group of smokers is varied and is not just dominated by men current facts show that smoking is becoming a trend there is a tendency for the age to start smoking to be younger efforts to overcome smoking behavior in students include reducing cigarette consumption gradually and with a firm intention and motivation not to smoke therefore a high level of awareness is needed from each student realizing the negative impact of smoking activities carried out by cigarette users for themselves and those around them this needs to be reviewed further so that in the future it can reduce the number of cigarette users and the number of health problems due to smoking activities students also smoke quickly because the regulations are less strict about prohibiting smoking in campus areas and it is easy to see cigarette advertisements with their idols then their models boldly use cigarettes so that from the access they see or get the students imitate their heroes moreover we know that nursing or health students must behave healthily and be free from smoking because they are an example of improving the quality of health especially regarding smoking method the qualitative approach is an approach to building knowledge statements based on a constructive perspective this research was conducted at the ppni akper kendari city the informant is a diii nursing student data processing was performed in the following stages 1 data collection using the fgd technique 2 data reduction the data obtained is focused on the problem being studied 3 presentation of data in the form of narrative text and ensuring the confidentiality of informants 4 concluding from the data presented and then discussing and comparing with the results of previous research and theoretically with health behavior 5 conclusions are drawn using the induction method data obtained from indepth interviews were carried out manually by qualitative data processing instructions and by the objectives of this research and then analyzed using the content analysis method the data collected is nonnumerical so data analysis begins with writing down the results of observations fgd results then classified and interpreted and finally presented in narrative form results the results of fgd activities carried out on students regarding smoking behavior showed that almost all of them had no choice but to smoke and only followed their friends behavior as quoted from the informant as follows initially i started smoking from my friend when i had just registered at this campus i didnt want to smoke but because my friends mostly smoked i joined in i started smoking because of my friend jhi he offered me to smoke because everyone smoked and then i didnt anyway if i started smoking because of my social circle many of my friends used to smoke so i also started smoking but if i had no intention of smoking i didnt have any however some students say different things regarding how they started to know and behave about smoking they have not yet thought about how to stay away from smoking as stated by the following two informants you intend to smoke hi youre just curious and want to try it i started smoking recently not many months ago because i just wanted to try it the same thing was also stated by the informant as follows at that time i started to get to know cigarettes because i was just trying it out discussion according to hanafiah behavioral intentions in general the better the subjects attitudes and norms the greater the perceived control and the stronger a persons intention to carry out the behavior intention is the hearts movement towards what it considers the goal obtaining benefits or preventing harm villas describes intention as setting a plan that estimates behavior conner and norman explained that in social cognitive theory in social psychology regarding health intention is a core construct in understanding behavioral intentions related to health actions or changes in behavior the behavior that will be carried out is behavioral intention which is the intention to carry out regular health actions where there is an increasing possibility of carrying out these health actions according to informants in research that has carried out both moderate and heavy smoking behavior they have no intention of smoking a persons behavior starts from choice so from that intention they can manifest it in the form of actions or behavior but the informants studied stated that their smoking behavior was not based on existing definitions but because of other factors whether from the environment or the relationships they experienced this statement is supported by jogiyanto who believes that intention is a function of two essential determinants namely the individuals attitude towards behavior and the individuals perception of social pressure to carry out or not to carry out behavior which is called subjective norms in short according to the theory of reasoned action practice or conduct is influenced by intentions while attitudes and subjective norms influence preferences beliefs about the results of previous actions influence attitudes themselves subjective norms are influenced by ideas about other peoples opinions and motivation to comply with those opinions more simply this theory says that a person will do an action if he views it as positive and believes that other people want him to do it some informants thought they started smoking based on trial and error and influence from friends until they finally became dependent on cigarettes social impacts and the environment in which they live are some factors that cause them to start smoking this is in line with research by rachmat et al that there is a significant relationship between the influence of friends or peer groups and smoking behavior and the results of research by komalasari that in fact most teenagers start the smoking habit because they follow their friends or because of the influence of the social environment during adolescence several changes can occur including a difference in the things that interest him and his relationships with others new and more mature things replace many exciting items from childhood during adolescence this fact is supported by liem namely that friends influence smoking behavior therefore researchers results regarding smoking behavior with intention were not obtained in the field when conducting indepth interviews with each informant conclusion based on the discussion of the research results regarding the intention to smoke behavior in kendari nursing students it was concluded that intention is the basis for a person to do something manifested through attitudes and actions intention to smoke behavior was not obtained from the results of information related to the research conducted from the data obtained they smoked because of their social interactions and the influence of friends who were smokers so it was from this social interaction that the informants started smoking from trial and error until they have made cigarettes one of the needs they must fulfill daily

this study aims to analyze the smoking behavioral intentions of nursing students in kendari the type of research used is qualitative with a case study design the analysis takes the form of domain analysis using focus group discussion data collection techniques for eight nursing students in kendari the research results show that smoking behavior is not based on intention they start smoking by trial and error and are influenced by social friends the need for an interpersonal communication approach is supported by policies to implement strict and sanctioned nosmoking areas both on campus and in nursing students workplaces to minimize their chances of having the intention to smoke

19863_0

introduction in the 1990s the topic of school coexistence emerged as a promising perspective to address a problem related to shared life in schools the processes of exclusion and school rejection contributed decisively to position coexistence as a central issue in the educational process 12 likewise the delors 3 report states that the process of learning to live together is at the heart of learning and can be seen as the crucial foundation of education therefore learning to live in community is a relevant pillar at the educational level as it implies the discovery understanding of the other and the various forms of interdependence which facilitate the establishment of common projects and objectives from a plural peaceful and respectful perspective the discussion on how school educational processes can contribute to the development of respect for other people their cultures and spiritual values as well as to the construction of capacities to implement common social projects has spread in spanishspeaking countries 4 thus in chile although the meanings of school coexistence are diverse and even contradictory from the national policy of school coexistence of the ministry of education 5 it is understood as a daily dynamic and complex process which involves a set of interactions and relationships that occur between all actors of the educational community covering individuals groups teams courses and internal organizations that are part of the institution including the relationship of the school community with the surrounding organizations based on the above the purpose of this article is to describe the perceptions on school coexistence of education professionals in the ñuble region taking into consideration the central elements of this concept so that these professionals express their perception on how they understand school coexistence in the scope of their professional work also to refer to the main study approaches used in their respective educational establishments to address school coexistence such as coexistence as a study of school climate violence andor its prevention coexistence as socioemotional education coexistence as education for citizenship and democracy coexistence as education for peace coexistence as education for human rights coexistence as moral development and values formation 4 on the other hand it is sought that they visualize in their educational context the dimensions for the operationalization of the concept of school coexistence such as the pedagogicalcurricular field the organizationaladministrative sphere and the sociocommunity sphere of participation and conflict management 4 and finally that they identify how their educational institutions address the areas covered by the school coexistence policy 5 such as school coexistence team learningcurriculum families cultural diversity and inclusion theoretical framework model approach and dimensions of school coexistence since the late 1990s the importance of school coexistence has been recognized as a pillar of educational processes 6 this concept has been discussed on several occasions and by various authors its conceptual scope is broad which has developed a range of definitions and conceptualizations 78 however at the educational level in our country one of the agreed definitions corresponds to the proposal of the ministry of education which conceptualizes it as harmonious coexistence of the members of the educational community which implies a positive interrelation among them and allows the proper fulfillment of educational objectives in a climate that favors the comprehensive development of students 9 from this definition chiles educational policy has echoed the international consensus expressed by unesco on the relevance of learning to live together as an objective of the school system 10 ideas that were also deepened by toledo 11 who pointed out that the laws of each country should deepen around school coexistence policies to contribute to prevent experiences of violence in society in this line public policy issues related to school coexistence have been developed around two approaches that are not only different but seemingly incompatible on the one hand the emphasis is placed on control and sanction while on the other hand the development of conditions that allow democratic school coexistence while respecting the rights of the educational community is also sought 4 however school coexistence tends to be addressed not only from these two approaches but also from various perspectives such as school coexistence as socioemotional education coexistence as school climate violence and prevention as education for citizenship and democracy and around moral development and values formation education for peace and education for human rights among others 4 in conjunction with the dimensions or perspectives from which school coexistence is situated it is also possible to glimpse four major dimensions curricular pedagogical dimension organizational dimension administrative dimension and community dimension 1213 these dimensions are at the same time understood as guiding standards and performance indicators for school management to accommodate educational reform moving towards a school that is capable of reflecting on its own work to transform them into processes of continuous improvement focused on learning and the integral formation of its students conflict in the school context according to the dictionary of the royal spanish academy 14 to coexist means to live in the company of others and to coexist in harmony which confers breadth and complexity to this construct which has therefore been studied at the micro and macro levels the micro level considers the family school and business environment and the macro level the interactions at the societal level as can be expected both levels are closely related to the point of conditioning each other 15 in the school environment coexistence expressed through words gestures or actions evidences the bonds generated within a diverse group a group which from a school coexistence paradigm does not deny or repress the conflict but seeks alternatives to address it peacefully and democratically 16 conflict in the school context reflects family community social and institutional dynamics which shape the beliefs that justify the use of violence when relating to others 1718 this is because violence characterized by physical imposition and domination or as a psychological practice that seeks to marginalize and belittle others in public or private situations 19 stems from an inadequate way of coping with conflict in this sense there are various studies that address school coexistence from the educational institution the studies by yao and enrigh 20 stand out indicating that a positive interaction between teachers and students could increase the possibility of using a positive conflict coping strategy as well as a negative interaction would decrease the possibility of using a positive coping strategy in this study the positive strategy refers to forgiveness as a positive way of coping with conflict versus counterattack which would be the negative way the educational institution needs alternative methods and strategies to address and resolve conflicts 21 mainly due to the increase in expressions of violence in schools 22 in this regard garcíaraga et al 23 garcíaraga et al 24 and moore 25 have proposed mediation as an effective strategy that helps mitigate violence derived from a negative approach to conflicts 2326 school coexistence policies in chile in chile in recent years permanent changes have been made regarding educational policies for school coexistence the first of these changes took place during the nineties where reforms were carried out through fundamental transversal objectives these ideas were the indications about the importance of school coexistence the classroom climate in the educational projects of schools and high schools in the country years later at the beginning of the 2000s the first national policy on school coexistence was published through the ministry of education of the time this national policy sought to generate an orientation and articulation of the values of coexistence to achieve the development of the transversal objectives present in the curriculum 27 years later the preferential school subsidy law sep law was enacted which requires the search for school improvement by managing school coexistence subsequently in 2011 law 20536 on school violence was enacted which seeks that every establishment that is receiving state funds create a program that promulgates and develops good coexistence and the avoidance of attacks physical violence and harassment 28 in a more contemporary era there are various laws that are associated with school coexistence of note are law 20370 contained in law 20536 on school violence and law 20609 on discrimination which seeks to protect the right of people not to suffer any type of discrimination 132829 in all these cases the laws are oriented towards the management of school coexistence in different areas of chilean education from there various studies have been developed that have sought to analyze the perceptions regarding these laws and areas of school coexistence in the country including the perspectives of various educational agents students administrative teachers family etc 2 30 31 32 until today ñuble is considered one of the poorest regions with the highest unemployment rates 33 its emergence as a region is brief which has generated a knowledge gap regarding data or evidence on school coexistence with the simce questionnaires being one of the few studies that confirms the above along these lines the study by cea et al 34 where a participatory intervention was implemented through various workshops this is also highlighted by the study by cisternas 35 who worked based on the management processes in school coexistence in the commune of san carlos ñuble region however in both cases school coexistence is approached from management not considering the perceptions of the various actors who participate in the process it is for this reason that the objective of the present study is to describe the perceptions of school coexistence of various professionals in the ñuble region materials and methods diseño the study is descriptive qualitative and transversal by analyzing data on variables collected in a particular period on a sample of teachers from various public schools in the communes of san carlos san nicolas chillá n bulnes and quillón in the ñuble region participants the study participants correspond to teachers from various public schools in the communes of san carlos san nicolas chillá n bulnes and quillón in the ñuble region of the 51 participants 41 are women while 10 are men the average age is 35 years with an average length of teaching service of 25 years fluctuating between one to more than 30 years the participants are associated with various professions linked to the school environment such as basic general education early childhood educators psychology differential education educational assistant pedagogy etc instruments the instrument used was an open questionnaire in online format under the google forms platform which contains 5 questions that the participants answer online the questions in the questionnaire were developed from a theoretical and empirical analysis of the topic in question in accordance with the specific objectives of the study the questions were subsequently validated through expert judgment the questions applied in the questionnaire were the following how do you understand school coexistence in your professional work what approach to studying school coexistence is used in your establishment what dimensions do you see in the school coexistence program in accordance with the national school coexistence policy 20182021 how does my educational establishment address these areas a school coexistence team b learningcurriculum c families d cultural diversity and f inclusion when have we been faced with a conflict in the school system analysis of data participants were contacted personally invited to participate and informed that this activity is completely voluntary sending them the link to the survey through the whatsapp application those who agreed to respond logged in and answered the questions a thematic content analysis was carried out coding the participants responses and developing axes of analysis analytical diagrams were constructed for the synthesis of the coded information all this through atlas software ti version 844 which allows giving circular meaning to qualitative analysis by granting the possibility of incorporating the data sequentially without the need to collect all the material at the same time 3637 ethical standards we had the approval of the bioethics committee of the universidad del bíobío whose requirements implied complying with the criteria of confidentiality anonymity and voluntariness without granting economic retribution to the participants this was specified in the informed consent that was accepted by the professionals 638 results perception of school coexistence in their professional activities the perception held by education professionals in the ñuble region in relation to school coexistence is understood as a permanent interaction among the various educational agents which should coexist in a peaceful environment conducive to healthy positive and democratic living the values that are evidenced in the meanings attributed to school coexistence correspond to respect empathy active listening solidarity responsibility understanding of emotions and tolerance all the above is framed within the framework of human rights institutional seal diversity mission and vision thus generating an integral development of students and their contribution to deep learning some discursive fragments are school coexistence is where we must respect each other mutually learning to live and accepting different opinions having the ability to understand and comprehend others putting ourselves in the others place school coexistence is the way in which all the actors of the educational community relate to each other based on mutual respect acceptance and respect instance where all the actors participate in the pedagogical work according to the vignettes presented figure 1 has been elaborated to provide a general understanding of the perception of school coexistence study approach is used in your establishment to address school coexistence of the 51 participants in the first place it is observed that the approach most used in the educational establishments of the ñuble region corresponds to coexistence as socioemotional education such education should be understood as a formative process focused on the development of skills that seek to recognize and manage ones own and others emotions trying to generate an educational innovation that responds to social needs not met by formal education 38 secondly coexistence is used as school climate violence and prevention that is a classroom climate that favors personal development is one in which students perceive support from their peers and from teachers feeling respected in their discrepancies and inaccuracies as well as identified with the course and their school 39 in third and fourth place the approaches to coexistence as education for citizenship and democracy and as moral development and formation in values are the approaches that are evident in the responses of the 51 participants the first of these approaches is of relevance since it builds the sense of belonging to society being not only part of the family environment but also of the school environment as they are core axes of citizenship training by allowing human coexistence respect for the members of this and the dignity of people 40 and finally in the fifth and sixth instance there are the approaches to coexistence as education for peace and as education for human rights on the one hand peace education responds to new educational forms and new practices to address social contexts where there are or have been various expressions of conflict and violence 41 while the second alludes to on as education seeks by object of study the full development of the human personality and respect for human rights and fundamental freedoms it will favor understanding tolerance and friendship among all nations and all ethnic and religious groups 42 some vignettes are coexistence is used as socioemotional education in our establishment we try to focus on the development of social skills and interpersonal relationships it is about having an objective vision to be able to give the other the recognition it deserves and this is replicated both with students parents and teachers which helps us to better face the different types of conflicts coexistence as moral development and formation in values the establishment seeks to promote values within the community to maintain a healthy coexistence because we are a catholic school coexistence as education for peace psychosocial duple intervention focusing on the conflict looking for origin participants solutions based on the formative school climate is focused on minimizing the latent risks within the school climate we as an establishment deal with human rights education which creates related activities for prevention and for each student to be clear about their rights as human beings dimensions that you visualize in the school coexistence program pedagogicalcurricular dimension school coexistence in this dimension is visualized as the work and management of social skills for conflict resolution class planning with aspects of school coexistence the most visualized is the pedagogical and curricular area since teachers are always asked to remind them of the rules of coexistence in their classes or to carry out an activity in orientation also in conflict management and participation the educational unit is always involved in addition coordination with the school integration program team roles and functions of the psychosocial teams are observed all these actions are planned in accordance with the crosscutting objectives of the school coexistence plan organizationaladministrative dimension this dimension is the one that is least observed by education professionals they assume that it refers to the financing of human resources ie the payment of salaries associated with sep and pie law professionals human and financial resources dimensions it has to do with colleagues working in the pie and sep participatory dimension and conflict management education professionals in the ñuble region show this dimension associated with the set of activities that promote school coexistence complying with the annual school coexistence plan the dimension of participation since activities are carried out to promote the different areas of school coexistence participation being a rural school everything is very participatory and the school community is involved in the process of developing plans or protocols so later the application of the regulations is easier and all the actors are aware of them national policy on school coexistence school coexistence team according to the participants in the educational establishments of the ñuble region the school coexistence teams are made up of a social worker psychologist guidance counselor and coexistence officer it is important to point out that not all the establishments have all these professionals and they even work in this program on an hourly basis the objective of these teams is to manage and solve conflict situations that arise in schools promoting continuous communication through conflict resolution and mediation apprenticeshipcurricular all subjects participate in this area especially guidance to contribute to a healthy coexistence that allows the emotional stability of students teachers directors education assistants and the educational community in general families this area of school coexistence takes the form of • direct and transparent communication • school for parents or guardians • workshops with psychosocial teams • massive activities of the educational unit • workshops and training for families • followup of cases cultural diversity it is materialized in the crosscutting planning of activities associated with daily living associated with the cultural diversity of the families plan transversal activities that in daily practice articulate with the cultural diversity of each family in this same sense it is associated with the inclusion plan through the reduction of barriers to learning promoting and participating in the community in various celebrations parents day students day school coexistence day no cyber bullying day with surveys directed to the community to see their needs on the other hand and no less important this factor is one of the weakest that each establishment works on according to the national policy of school coexistence as reflected in the following discursive extract cultural diversity is an aspect that as an establishment we are a little weak since there is a lack of instances where the community can be enriched by taking advantage of the same diversity that exists today cultural diversity i believe that this is the least developed area i consider that it is necessary to include more actions in the coexistence plan to address it in a more profound way inclusion inclusion is addressed through appropriate positive language without labels promotion of community participation in various celebrations awareness is fundamental school integration program respect and mutual appreciation discussion school coexistence in professional work is loaded with values associated with respect empathy active listening solidarity responsibility understanding of emotions and tolerance all of this is framed within a socialemotional education approach however there are also cases in which school coexistence is governed under a school climate approach education for citizenship and democracy and as moral development and values formation and even as education for peace and education for human rights according to onetto 43 terms school coexistence is used in so many ways and languages that it leads to confusion presumably this idea was built from a narrative logic where a wide variety of researchers tried to contribute to the topic triggering its extensive use in research lines as dissimilar as psychology education pedagogy etc this idea is also validated by fierroevans and carbajalpadilla 4 who seek to clarify and contribute to the development of a common language in the latin american region regarding the concept of school coexistence another aspect to consider is that in the concept of school coexistence several conditioning factors interact for a clear conceptual definition according there is a personal identity relationship of migrants as their coexistence relationships in the school environment complexify or enrich the adaptation strategies or processes that are necessary to ensure the full wellbeing of students however it is necessary to consider that there is no such thing as migrant school coexistence but that these concepts are understood for the entire educational community even in culturally diverse school contexts 44 in general school coexistence is visualized in several dimensions either from the pedagogicalcurricular the organizationaladministrative or from the participatory and conflict management in the first dimension school coexistence is seen as the development of social skills for conflict resolution through the planning of classroom activities where aspects related to school coexistence are used from this perspective it is necessary to remember that school coexistence is a relevant object not only for national policy but also for educational practice this is revealed after the implementation of a series of initiatives in education such as expert recommendations research and training programs 45 in our country there have been several institutions that have tried to address these problems related to school coexistence 17 however such improvements have not only been carried out by educational institutions but also in the political sphere where mineduc wishing for the year 2022 has proposed the national policy on school coexistence however and despite the efforts made by educational institutions in the search for improvements in school coexistence aravena et al 46 indicates that there is a widespread lack of student participation in school coexistence despite being considered one of the most important strata within the educational environment since any change made in the student curriculum converges on them in another line to highlight the participatory dimension and conflict management related to the set of activities that promote school coexistence in schools emerges this is in line with aravena et al 46 who point out many actions proposed by management teams and school leaders events elaboration of plans manuals and protocols stand out the events are presented as instances of celebration andor promotion of aspects of school coexistence such as family day chilean nationality day or the day of good treatment although it is necessary to include the student body in school coexistence actions should be taken towards initial teacher training as the articulating axis of educational policies of school coexistence and professional teaching practice trying to unveil the challenges and opportunities that this student stage will face in their professional practice 47 however gaete et al 48 indicate that teachers themselves have questioned the capacity of the initial coexistence teacher training of the educational process jointly educational policies should be developed that will govern school coexistence guidelines in the country according to ortizmallegas et al 2 punitive practices are understood within a gradualism where the sanction begins when the formative action does not obtain the expected effect this happens in chilean education when it presses for better school results since its regulated use would allow schools to exclude students who do not achieve good results from the classroom in this sense during the last years in latin america and chile these prescriptions have been taking shape as legal bodies laws decrees and regulationswhose wording has been recognized as contradictory and ambivalent for their full understanding in the school environment since promotionalformative approaches coexist with exclusive and pedagogically restricted punitive approaches 49 conclusion the perception of education professionals in the ñuble region in relation to school coexistence is understood as a permanent interaction among the various educational agents which should coexist in a peaceful environment conducive to a healthy positive and democratic life associated with values such as respect empathy active listening solidarity responsibility understanding of emotions and tolerance and that they carry them out from this same conception in their professional work education professionals use coexistence as school climate violence and prevention ie a classroom climate that favors personal development is one in which students perceive support from their classmates and teachers feeling respected in their discrepancies and inaccuracies the approaches to coexistence as education for citizenship and democracy and as moral development and values formation are the most widely used the approaches to coexistence as education for peace and as education for human rights are the least used in the educational establishments of the ñuble region in chile given the above it is necessary to involve the various educational agents in school coexistence thus it is also important that future research considers mentors and tutors in the framework of the professional teacher education system who can be key informants to diversify the views that contribute to school coexistence at the same time it is necessary to deepen the interactions and links between the different educational strata to favor curricular innovation around school coexistence

the objective of this study was to describe the perceptions of school coexistence in primary and secondary school teachers from establishments in the ñuble region the methodology applied was quantitative descriptive in nature and transectional in nature the sample was made up of 51 participants to whom an openresponse questionnaire was applied in online format under the google forms platform among the results it was found that school coexistence is understood as a permanent interaction between the various educational agents associated with values such as respect empathy active listening solidarity responsibility understanding of emotions and tolerance there is a tendency to use a socioemotional approach over others while the documented dimensions are related to curricular pedagogy organizationaladministrative participatory and conflict management it is essential to implement tools and strategies to promote interpersonal relationships between the various actors of the institution and thus mitigate or correct problems of this nature

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introduction human interaction has changed drastically in the last 20 years not only due to the introduction of the internet but also from social media and online communities these social media options and communities have grown from being simply used to communicate on a private network into a strong culture that almost all individuals are using to communicate with others all over the world we will concentrate on the impact that social media has on human communication and interaction among young adults primarily college students in todays society powerful social media platforms such as myspace facebook twitter instagram and pinterest have been the result of an evolution that is changing how humans communicate with each other the big question we asked ourselves was how much has social media really impacted the way that humans communicate and interact with each other and if so how significant is the change of interpersonal interaction among young adults in the united states today the motivation behind this research has been personal experience with interaction and communication with friends and family it had become difficult sometimes even rare to have a oneonone conversation with them without having them glancing at or interacting with their phone has social interaction changed since the introduction of advanced technology and primarily social media in correlation with the research data collected in this study it was concluded that many participants personal communication has decreased due social media influence encouraging them to have online conversations as opposed to facetoface inperson conversations related work the question of how social media affects social and human interaction in our society is being actively researched and studied a literature review highlights the positive and negative aspects of social media interaction as researchers battle to understand the current and future effects of social media interaction a study done by keith oatley an emeritus professor of cognitive psychology at the university of toronto suggests that the brain may interpret digital interaction in the same manner as inperson interaction while others maintain that differences are growing between how we perceive one another online as opposed to in reality 1 this means that young adults can interpret online communication as being real oneonone communication because the brain will process that information as a reality another study revealed that online interaction helps with the ability to relate to others tolerate differing viewpoints and express thoughts and feeling in a healthy way 23 moreover a study executed by the national institutes of health found that youths with strong positive facetoface relationships may be those most frequently using social media as an additional venue to interact with their peers 4 in contrast research reveals that individuals with many friends may appear to be focusing too much on facebook making friends out of desperation rather than popularity spending a great deal of time on their computer ostensibly trying to make connections in a computermediated environment where they feel more comfortable rather than in facetoface social interaction 5 moreover a study among college freshman revealed that social media prevents people from being social and networking in person 6 experimental design this research study was divided into two parts during the academic year 20132014 part one conducted during fall semester 2013 had the purpose of understanding how and why young adults use their mobile devices as well as how the students describe and identify with their mobile devices this was done by distributing an online survey to several kean university student communities various majors fraternity and sorority groups sports groups etc the data revealed that users primarily used their mobile devices for social media and entertainment purposes the surveyed individuals indicated that they mainly accessed mobile apps like facebook pinterest twitter and instagram to communicate interact and share many parts of their daily life with their friends and peers based on the data collected during part one a different approach and purpose was used for part two with the goal being to understand how social media activities shape the communication skills of individuals and reflects their attitudes attention interests and activities additionally research included how young adult communication needs change through the use of different social media platforms and if a pattern can be predicted from the users behavior on the social media platforms part two of this research was conducted by having 30 oneonone interviews with young adults who are college students during this interview key questions were asked in order to understand if there is a significant amount of interpersonal interaction between users and their peers interpersonal interaction is a communication process that involves the exchange of information feelings and meaning by means of verbal or nonverbal messages for the purposes of this paper only the data collected during spring 2014 is presented data collection through interviews accurate results of the interaction of young adults with social media were collected these interviews involved 30 oneonone conversations with kean university students having oneonone interviews with participants allowed for individual results first responses from the participant without permitting responses being skewed or influenced by other participants such as might occur in group interviews it also allows users to give truthful answers in contrast to an online or paper survey as they might have second thoughts about an answer and change it the oneonone interviews consisted of ten openended questions which were aimed to answer and ultimately determine how social media interaction involuntarily influences positively or negatively an individuals attitude attention interests and socialpersonal activities the largest motive behind the questions was to determine how individual communication skills formally and informally have changed from interacting with various social media platforms the interviews along with being recorded on paper were also video and audiorecorded the average time for each interview was between two to ten minutes these interviews were held in quiet labs and during offtimes so that the responses could be given and recorded clearly and without distraction a total of 19 females and 11 males participated with ages ranging from 19 to 28 years old after conducting the interviews and analyzing the data collected it was determined that the age when participants both male and female first began to use social media ranged between 9 to 17 years it was found that generally males began to use social media around the age of 13 whereas females started around the age of 12 the average age for males starting to use social media is about 12909 with a standard deviation of 2343 for females the average age is 12263 with a standard deviation of 1627 from this we can determine that males generally begin to use social media around the age of 13 whereas females begin around the age of 12 after determining the average age of when participants started using social media it was necessary to find which social media platforms they had as a basis meaning which social media platform they first used myspace was the first social media used by twentythree participants followed by facebook with three users and mi gente by only one user with two participants not using social media at all it was interesting to find that all of the participants who started using myspace migrated to facebook the reasoning provided was that everyone they knew started to use facebook according to the participants facebook was more interactive and was extremely easy to use the participants also stated that myspace was becoming suitable for a younger user base and it got boring because they needed to keep changing their profile backgrounds and modifying their top friends which caused rifts or popularity issues between friends after finding out which platform they started from it was also essential to find out which platform they currently use however one platform that seemed to be used by all participants to keep uptodate with their friends and acquaintances was instagram a picture and videobased social media platform another surprising finding was that many users did not use pinterest at all or had not even heard of the platform after determining which social media platforms the users migrated to it was essential to identify what caused the users to move from one platform to another what are the merits of a certain platform that caused the users to migrate to it and what are the drawbacks of another platform that caused users to migrate from it or simply not use it all social interaction changes for some participants social interaction had a chance for a positive outcome while others viewed it in a more negative aspect the participants were asked if their social interactions have changed since they were first exposed to social media one participant stated that it is easier to just look at a social media page to see how friends and family are doing rather than have a oneonone interaction as for peoples attitudes they would rather comment or like a picture than stop and have a quick conversation on the other hand another participant felt that social media helped them when talking and expressing opinions on topics that they generally would not have discussed in person moreover the participants are aware of the actions and thing that they are doing but continue to do it because they feel comfortable and did not desire to have oneonone interactions with people the participants were also asked to explain how social media changed their communication and interactions during the years of using social media the data shows that participants interact less in person because they are relating more via online pictures and status for other participants it made them more cautious and even afraid of putting any personal information online because it might cause problems or rifts in their life on the contrary some participants stated that their communication and interaction is the same however they were able to see how it had changed for the people that are around them a participant stated that internetsocial media is a power tool that allows people to be whatever they want and in a way it creates popularity but once again they walk around acting like they do not know you and like your pictures the next day discussion the data illustrated in this paper shows how much the introduction and usage of social media has impacted the interaction and communication of young adults the future of interaction and communication was also presented as a possibility if the current trend continues with young adults and social media or online communities this raises the notion of possibly not having any social inperson interaction and having all communication or interaction online and virtually with all family and friends has your social interaction changed since your first exposure to social media participant x i have been interacting more on social media to see how my friends and family are doing it easier to see their status and pictures than actually call them or have a facetoface conversation personally i think that peoples attitudes have changed because when people see you around school they act like they do not know you but online they like all your pictures and comment participant x1 it made me more open with people i feel comfortable sharing information and discussing topics that i wouldnt have mentioned in person participant x2 using social media makes it easy to start a conversation however most of the time you will never have the same conversation because people are scared of actually saying something face to face online you do not have to deal with the stress of seeing that other persons gestures or body language participant x3 i text 247 and i ignore people around me while i am texting sometimes i cannot control myself table 2 communication and interaction changed how has your communication changed since social media participant x i interact less because i can simply see that everyone is doing good by looking at their online pictures and status participant x1 it made me more cautious afraid to put my personal information up participant x2 my communication is the same however people have changed a lot the internet creates their popularity but they walk around and act like they now know you but they cannot say hi and act like they do not know you if people dont not learn how to separate the two then there will not be any more onetoone interaction between people participant x3 yes i look at their pictures and i try to understand them just by their pictureswithout speaking to them in other words i judging by looking conclusion referring back to the question asked during the introduction how much has social media impacted the way we communicate and interact with each other after reviewing all the findings seeing the relationship individuals have with their mobile phones and comparing social media platforms it is clear that many young adults have an emotional attachment with their mobile device and want interaction that is quick and to the point with minimal inperson contact many young adults prefer to use their mobile device to send a text message or interact via social media this is due to their comfort level being higher while posting via social media applications as opposed to inperson interaction to successfully and accurately answer the question yes social media has had a very positive and negative effect on the way we communicate and interact with each other however how effective is this method of virtual communication and interaction in the real world

this research paper presents the findings of a research project that investigated how young adult interpersonal communications have changed since using social media specifically the research focused on determining if using social media had a beneficial or an adverse effect on the development of interaction and communication skills of young adults results from interviews reveal a negative impact in young adult communications and social skills in this paper young adult preferences in social media are also explored to answer the question does social media usage affect the development of interaction and communication skills for young adults and set a basis for future adult communication behaviors

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introduction this article looks at religiosity among older jewish israelis we examine the extent of religious practice among older jewish adults in israel and the role of religiosity in relation to well being in late life the main purpose of the inquiry is to estimate just how important the jewish religion is in the lives of older israeli jews and to derive from the analysis a better understanding of why this may be important in order to address these questions the study makes use of a significant new data base namely the israeli sample in the survey of health ageing and retirement in europe aging is clearly a multifaceted phenomenon the understanding of which requires a broad base of knowledge and information the share survey which operates in some 20 european countries and in israel provides just such a data base it is a multidisciplinary crossnationally harmonized panel study of older adults the wide range of topics covered in the survey including many variables that reflect the key economic healthrelated and social aspects of late life provides a unique opportunity to view religiosity in relation to a plethora of relevant factors in the study that is described in the following pages we look at the literature on the nature and the extent of religiosity within the jewish population in the state of israel we also execute a multivariate statistical analysis that seeks to provide answers to the research questions that stand at the heart of the inquiry our goal is to provide new insights regarding what it means to be jewish in israel to reach a better understanding of for whom religion constitutes a central part of their lives and to get an idea as to the dynamics of religiosity that is the ways in which religious practice and spirituality seem to affect the aging process literature review religiosity among jews in israel reflects not only spirituality but also social and political attitudes a survey conducted in 2009 found that the level of religiosity was connected to sociodemographic factors particularly income and education to different attitudes towards democracy and to the definition of who is a jew as well as to the status of women in society smooha argues that the jewish religion itself does not stand in the center of israeli consciousness but rather the tight connection to jewish culture its legacy language and customs thus many jews living in israel developed a jewish identity without being religious which may cause tension between secular traditional and ultraorthodox jews according to data from the israeli central bureau of statistics 44 percent of jewishisraeli adults define themselves as secular 23 percent as nonreligious traditional jews 14 percent as traditionalreligious and 19 percent as religious a similar division reigns among jews aged 65 and older so that 45 percent define themselves as secular 26 percent as nonreligious traditional 15 percent as traditionalreligious and 15 percent as religious thus most of the older jewish population living in israel is not religious per se older israeli jews may be considered as a special group when talking about religiosity they differ from the younger population because they constitute part of the founding generation that is a zionist pioneers who immigrated in 19241939 b holocaust survivors who arrived after the second world war or c those born in the early years of the state the founders rejected the religious jewish identity of the diaspora and sought to create a new jew reflective of a strong and irreligious people this trend was especially dominant among the holocaust survivors many of whom had abandoned religion and faith in god it should also be noted that immigrants who arrived after the establishment of the state of israel many of whom came from asia and north africa differed widely from the pioneers who were already in israel in regard to socioeconomic factors and religiosity levels for these and other reasons older israeli jews tend to differ more among themselves in terms of religiosity than their jewish counterparts in the diaspora differences in religiosity can also be seen when comparing israeli jews to american jews the latter tend to define themselves more often than the former as religious or traditional and less often as secular one possible explanation for this difference is the prevalence of the conservative and reform movements among american jews this stands in contrast to israel in which the conservative and reform movements are not officially acknowledged by religious authorities thus being religious in israel is mainly in relation to the orthodox movement possibly limiting the affiliation of israeli jews with religion religion health and mental health the relationship between religion and mental health has been studied extensively with findings pointing to a positive relationship religion is related to positive emotions wellbeing selfesteem and social support and it has an inverse relationship to depression and substance abuse in addition studies show that in many countries religion can be a powerful coping mechanism in the face of stress and hardship a metaanalysis of the relevant literature concluded that religious coping strategies lead to positive psychological adjustment in the face of stressful events for example experiencing stressrelated growth spiritual growth life satisfaction positive affect and higher selfesteem religion also has an important role for coping with a wide array of serious medical conditions and encouraging psychological growth from these experiences koenig hypothesizes a number of mechanisms through which this positive influence is achieved one is that religion provides resources for dealing with negative life situations and gives the believer a sense of meaning and purpose an optimistic worldview hope and control religious beliefs can also influence the cognitive appraisals of difficult situations so they will seem less stressful this is especially relevant to people with medical conditions since such conditions might make it difficult for them to rely on other more healthdependent resources such as hobbies another mechanism of note is that most religions encourage social gatherings for worship and encourage family life which can in turn provide social support when facing difficult times old age religion health and mental health the association between religion and mental health is particularly important for older people as they face increasing stressors in the form of deteriorating health studies have found a positive association in this population using different measurements of religiosity and mental health for example higher levels of religiosity were related to better mental health in two residential communities in massachusetts greater church attendance was related to less depressive symptoms in samples of older people in north carolina and alabama and higher intrinsic religiosity was related to a decline in depressive symptoms over a fouryear period among adults aged 65 and older in alabama krause found that older christian whites and african americans who derive a sense of meaning in life from religion have higher selfesteem optimism and life satisfaction some studies report a negative association between religion and mental health among older persons for instance that prayer frequency is associated with poorer wellbeing and higher odds of depression however these particular findings may actually support the studies mentioned above insofar as they reflect the use of religion for coping that is older people who face stress turn to religion and prayer for comfort this contention is supported by several other studies which show that older people cope better in difficult situations when they utilize religion therefore higher religiosity level is associated with fewer depressive symptoms among elderly persons coping in different stressful situations such as hospitalization psychiatric conditions and disabilities high religiosity also buffers the effect of poor physical health on the sense of control but only for women in addition to aiding in the face of physical hardship religion helps to cope with financial difficulties according to krause and hayward older adults who faced financial hardship experienced better health and wellbeing when they had greater trust in god jews and mental health most of the studies in the field of religion and mental health are based on christian populations but different religions may be related to different associations between the two phenomena a recent body of work indicates that for jews both in israel and elsewhere religion is also related to better wellbeing for diaspora jews affirming the importance of god in ones life and attendance at synagogue were both found to be associated with greater happiness moreover using religion and trust in god for coping with difficult events were related to lower depression and anxiety research on the jewishisraeli population found that religiosity measured with different indicators is linked to better life satisfaction less stress and a healthier life style better wellbeing and happiness while there is a growing interest in the relation between judaism and mental health among israelijews few studies have looked specifically at older israeli jews two such analyses based on the first wave of the survey of health aging and retirement in europe found that synagogue attendance was related to less depression better life quality more optimism and better health while higher prayer frequency had inverse associations that is more depression poorer life quality less optimism and worse health the investigator suggested that prayer is used as a coping mechanism in the face of poorer mental health and deteriorating health while synagogue attendance might serve as a protective factor or might confound with functional health however as both studies only examined main effects the mechanism through which religion is actually related to mental health can only be speculated other studies on israelijews and mental health have also focused on the main effects of religion in the current study therefore we would like to examine these effects more deeply in order to see if religiosity indeed acts as a coping mechanism for the older population protecting the practitioners from the influence of harsh situations a similar approach was used by pirutinsky et al who looked at intrinsic religiosity measured by means of an intrinsic religiosity subscale assessing the presence of religion in ones life the study showed that among jews with low intrinsic religiosity lower physical health was related to more depression while this relationship did not exist for those with high intrinsic religiosity this indicates that religion may be helpful in buffering the negative effects of deteriorating health but the findings are limited to the measurements of intrinsic religiosity and depression and mainly to the population of american jews common measures in the study of religion and mental health include depression anxiety selfesteem and wellbeing in the current research we focus on the positive potential of old age as older people enjoy healthier and longer lives than ever before with more free time and more disposable income they can continue to develop themselves and pursue their interests this active side of old age can be measured with the casp scale of quality of life in old age the scales creators claim that quality of life consists of four domains control autonomy selfrealization and pleasure while the first two reflect the conditions that need to be fulfilled for someone to be able to participate freely in society the latter two reflect the active side of old age which can be pursued once these requirements have been met accordingly selfrealization and pleasure have been found to load on a single factor in a factor analysis of the casp scale this active part is a meaningful element of wellbeing in old age and its maintenance is important in times of stress based upon this review the current study has several aims first we wish to describe the current state of religiosity among older israeli jews second we aim to examine the factors that are related to religiosity in this population third we seek to clarify the role of religiosity vis a vis the mental health of older jews in israel particularly in states of poor health toward this end we hypothesize that in the face of deteriorating physical health religiosity is associated with somewhat better mental health methods data and sampling the present study is based on data from the survey of health ageing and retirement in europe in which israel has participated since 2005 the survey interviews respondents aged 50 years and older as well as their partners of any age the current analysis used data from the second wave of the survey in israel collected in the years 20092010 we limited most of the analysis to the respondents who were interviewed in hebrew most of whom were assumed to be jewish we excluded recent immigrants from the former soviet union who were interviewed in russian insofar as some of them are not jewish according to strict jewish law and several are only partly jewish or their jewish identity is of a nonreligious character the arabic speaking israeli respondents all of whom are muslim or christian were also excluded finally we focused on respondents aged 50 and over and excluded younger spouses as the former were drawn through probability sampling and the findings related to them may be generalized to the larger population the final study sample thus consisted of 1637 respondents study variables the main variable of interest in the study was a measure of religiosity operationalized as prayer frequency this variable served as the outcome of interest in the first part of the analysis and as a key independent variable in the second part participants were asked thinking about the present how often do you pray and they could choose one of six response options never less than once a week once a week a couple of times a week once daily more than once a day thus a higher score means a higher prayer frequency a second major independent variable was ill health measured as the number of health conditions from which the respondent suffered in the 12 months prior to the interview respondents were asked to cite the health conditions that they had experienced from among a list of 12 possible conditions such as swollen legs sleeping problems and falling down the ill health variable was calculated as a count of the cited conditions and its score ranged from 012 with a higher score indicating more such conditions the study also controlled for five background socioeconomic variables these were age gender years of education marital status and subjective economic status age and years of education were both entered as continuous variables gender was a dichotomous variable marital status was also a dichotomous variable in which the score of 1 reflected respondents with a partner that is they were either married and living with their partner or in a partner relationship respondents classified as 0 were divorced widowed never married or married but not living with their partner economic status was taken into account using a subjective indicator respondents were asked thinking of your households total monthly income would you say that your household is able to make ends meet they answered with one of the following four response options with great difficulty with some difficulty fairly easily easily the dependent variable in the second part of the analysis wellbeing was a calculated selfrealizationpleasure score drawn from part of the 12item casp scale which measures quality of life the casp scale is made up of twelve statements divided into four subscales autonomy control selfrealization and pleasure each statement is measured on a 4point likert scale showing how often it is relevant in the respondents life often sometimes not often or never the casp is a validated scale with a good level of internal consistency the selfrealizationpleasure score that was used in the current analysis is the average of the selfrealization and pleasure subscale scores combined the items were recoded such that a higher score reflects a greater frequency of selfrealization and pleasure examples of items from the scale include i feel that life is full of opportunities and on balance i look back on my life with a sense of happiness we considered cases as missing if they had three or more missing items on the 6item measure the selfrealizationpleasure subscale obtained a good level of internal consistency in order to test whether the selfrealizationpleasure score does consist of a separate subscale in the study population we carried out a factor analysis with an orthogonal rotation our results point to a different subscale for selfrealizationpleasure similarly to previous findings in other populations using casp12 in the analysis three extracted components were retained having met the criteria of an eigenvalue greater than one the three factors were 1 selfrealizationpleasure 2 a control subscale with one variable from the autonomy subscale 3 two variables from the autonomy subscale the three retained factors accounted for a cumulative 56 of the variance in the dataset further results are available upon request statistical analysis the analysis proceeds in several stages first the sample is described showing sample means and standard deviations for continuous variables and percentages for categorical variables we also note the average prayer frequency among israeli jews aged 50 and above and compare it to the same in several european countries we then execute two multivariate analyses the first seeks to identify the variables associated with religiosity it employs an ols regression in which prayer frequency is regressed on the background and sociodemographic variables the second multivariate analysis attempts to understand the factors related to well being among older israeli jews and specifically the association of religiosity with selfrealizationpleasure toward this end we undertake a hierarchical ols regression using three models to find the associations between religiosity and selfrealizationpleasure controlling for the other study variables as well as for the interaction between prayer frequency and ill health results sample description the description of the study sample can be seen in table 1 the sample consists of a majority of women and of respondents who have a partner the average age among respondents is 67 years and the average of years of education is 12 years the respondents report on average two health conditions and rate only minor difficulty regarding the households ability to make ends meet their average score on the selfrealizationpleasure subscale is 34 indicating a relatively high appraisal of selfrealization pleasure turning to religiosity we note that the average frequency of prayer is less than weekly specifically of the 1567 participants who described their prayer frequency 49 never pray 16 pray less than once a week 12 pray once a week 3 pray a couple of times a week 10 pray once daily and 10 pray more than once a day comparison with europe figure 1 presents the average prayer frequency for jewish israeli respondents aged 50 and above in comparison with the same in the european countries that participated in wave 2 of share the graph reveals that the hebrew speaking israeli respondents have low prayer frequency relative to many of their counterparts in the european countries the israeli jews pray less often on average than everyone except the respondents in denmark sweden and the czech republic this may be because such a large percentage do not pray at all lowering the overall average the highest prayer frequency among the share countries is reported by respondents from ireland followed by those from poland and greece comparing the three language groups within israelhebrew arabic and russianturns up additional differences a one way analysis of variance showed that there are significant differences between the three groups in regard to prayer frequency 40401 p 001 and a post hoc test with a bonferroni correction showed that all three groups were different from each other among the arabic speaking israeli respondents 70 pray more than once a day and only 7 never pray in addition arabisraelis pray more frequently on average than respondents in all the share countries in stark contrast among the russian speaking israeli respondents 68 never pray and only 4 pray more than once a day on average the recent immigrants to israel from the former soviet union are the least religious of all the share respondents the hebrew speaking respondents in israel fall between these two extremes with an average rate of prayer closer to the lower end of the frequency distribution in europe multivariate analyses the first multivariate analysis regressed religiosity on the background and sociodemographic variables using an ols regression model the results are presented in table 2 they show that higher frequency of prayer is associated with having fewer years of education being male married having more health conditions and more trouble making ends meet there was no significant association of prayer frequency with age however we should note that the variables in the model explain only 5 of the variance in the second multivariate analysis the selfrealizationpleasure outcome was regressed on the study variables using a hierarchical ols regression model the results are presented in table 3 in model 1 selfrealizationpleasure was regressed exclusively on prayer frequency as may be seen the association between the two variables was not significant initially in model 2 we added the background and sociodemographic controls to the regression after taking the control variables into account the association between religiosity and selfrealizationpleasure became significant and positive that is a higher frequency of prayer was associated with greater selfrealizationpleasure all the control variables had significant associations with selfrealizationpleasure as well such that greater selfrealizationpleasure was linked with having more years of education lower age being female having a partner fewer health conditions and finding it easier to make ends meet the variables in the model accounted for 32 of the explained variance in the selfrealizationpleasure outcome in model 3 we entered a variable measuring the interaction between prayer frequency and the number of health conditions as may be seen in table 3 the association with the interaction was significant indicating that for people who pray more often there is a weaker negative association between detrimental health conditions and selfrealizationpleasure the graph of this interaction is presented in figure 2 it shows that the negative relationship between ill health and selfrealizationpleasure is mitigated by the more often one prays the addition of this interaction term clarified the association but added only a minor amount to the explained variance we note also that the association between prayer frequency and selfrealizationpleasure independent of its interaction with ill health is no longer significant in model 3 after entering the interaction term this indicates that for older people with no ill health conditions prayer frequency is not related to selfrealizationpleasure this is in contrast to the associations with the control variables which remain significant in order to compare our results to those that may be seen among nonjewish respondents in europe we conducted the same ols regression for the sample of european countries the analysis revealed a quite different pattern of results compared to those obtained in the jewishisraeli sample in the first model in which selfrealizationpleasure was regressed on prayer frequency alone the association was significant it remained significant in the next two models even after adding the sociodemographic variables and the interaction with health conditions however in contrast to the results obtained in the jewishisraeli sample the interaction variable was not significant discussion the current study focused on older jewishisraeli adults and found them to be quite varied in their praying habits while almost half of them never pray the rest range from praying less than once a week to praying more than once a day those who pray more often appear to be in a worse state in terms of health conditions and financial wellbeing and they have fewer years of education they are also more likely to be male and to be married however prayer frequency is not related to well being per se measured here as selfrealizationpleasure the results also showed that older jewishisraelis are less religiously observant on average than most of their nonjewish counterparts in europe the findings also indicate that when facing hardship in the form of detrimental health conditions older jewishisraelis who pray more often have a relatively lesser decline in selfrealizationpleasure this implies according to higgs et al that they might be better able to enjoy their lives and to continue developing their interests despite their health limitations compared to their secular counterparts this aspect of life quality is particularly important to maintain when facing deteriorating physical conditions as the latter has a potentially devastating influence on emotional wellbeing the lesser decline may also stem from greater social support which is encouraged by religion for instance the jewish requirement for a quorum of at least ten adults for certain religious obligations called a minyan religion can also assist in dealing with hardship by providing the believer a sense of meaning and purpose the findings in our study are in accordance with the empirical literature on the same phenomenon among older christians elsewhere in the world the general literature shows that among those facing physical or financial adversities religion is related to better mental health either through a relatively moderate decline in mental health or through a complete lack of such a decline the current study added to this field of inquiry with additional evidence that religion may be a helpful coping mechanism in the jewishisraeli older population as well moreover while previous studies have demonstrated this association in regard to depression life satisfaction and a sense of control the current study showed such an effect on selfrealizationpleasure a key factor of quality of late life the results from the current analysis indicate that religion is of particular importance for older jewish israelis who face detrimental health conditions and that those who use prayer as a coping mechanism may be better able to maintain their quality of life and their ability to enjoy life this is highly relevant information for those who are responsible for the care of older people when physical decline comes on as a result of debilitating illness caregivers can help maintain a sense of active living by encouraging their religiously observant care recipients to pray however we must not forget that the majority of older jewishisraeli are not religiously observant and they are unlikely to adopt a religious perspective so late in life even when facing illness for them therefore the efficacy and the potential of prayer to mitigate the effects of illness in old age would seem to be quite minimal a few limitations of the current study should be acknowledged one limitation is the crosssectional nature of the analysis which does not allow for making causal explanations a future study should use longitudinal data to examine the chain of events that link between jewish religiosity health and quality of life another limitation might be our exclusive use of a single indicator for measuring religiosity that is prayer frequency religion is a multidimensional construct that includes beliefs practices and behaviors and there are other aspects of the phenomenon that can be measured however prayer frequency is the main variable in the share survey which relates to religiosity leading to our somewhat focused operationalization of the construct moreover the advantages of having a diverse variable set that reflects a wide range of control variables along with the very large sample that share offers for analysis outweigh the limitations inherent in the use of a single variable to capture religiosity future studies may address this shortcoming by utilizing a different data base perhaps one with more religionoriented content such as the international social survey programme future research may also examine the mediating variables of the religionhealth interaction in the spirit of the study by pirutinsky et al they found social support to be a mediating factor for the influence of religiosity and physical health on depression but only among nonorthodox jews in sum this inquiry sheds new light on the nature and the concomitants of religiosity among older jews in israel in the current era we found that religiosity may indeed have an ameliorative role in the face of illness but only among the observant given that most of the older jews of israel belong to the less observant cohort of the founding generation of the state the potential trials and tribulations of very old age may not be lessened for most of them by religious practice or spirituality the interaction of prayer frequency and health conditions in relation to the selfrealization pleasure score

this study examined the correlates of religiosity among jewish israelis aged 50 and older based on the second wave of survey of health ageing and retirement in europe the findings show that almost half the jewish respondents never pray and that on average prayer frequency is lower among jewish israelis than it is among most of their european counterparts multivariate logistic analyses revealed that those who pray more often have more health conditions are less able to make ends meet financially and have fewer years of education however when facing ill health those who pray more often display a relatively lesser decline in their sense of well being

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background smoking prevalence has been declining over time in many western countries but it remains a leading cause of mortality and morbidity 12 this decline has been greatest among individuals with a high socioeconomic position making tobacco a major contributor to health inequalities 34 some tobacco control policies and interventions are reported to be less effective among sociallydisadvantaged individuals which might contribute to the widening of inequalities with regard to smoking 5 therefore the effect of tobacco control measures on equity should be systematically examined france has one of the highest smoking prevalence rates in the western world 6 after decades of stagnation at high smoking rates the country amplified tobacco control policies and introduced comprehensive measures in 2016 these measured consisted of the implementation of plain tobacco packaging an increase in graphic health warnings on tobacco products massive public health campaigns encouraging smoking cessation and a planned increase in tobacco price 7 these measures were followed by an unprecedented decrease in smoking rates among adults in 2 years there were 16 million fewer smokers among the french adult population 89 auspiciously these policies did not seem to widen socioeconomic inequalities in this area until the covid19 epidemic the decrease in smoking rates was comparable in individuals with low and high socioeconomic status as defined by educational level 910 however there is mounting evidence that marginalized social status due to an immigrant background could drive health inequalities independently of education and income especially due to marginalization and interpersonal and structural discrimination 1112 being an immigrant or having an immigrant background are now considered social determinants of health 13 immigrants and their offspring are often disadvantaged healthwise compared to the general population they are more likely to experience mental health problems and steeper rates of health decline in older age 1415 several theories such as the acculturative stress that is stress due to living in a foreign culture and the cumulative disadvantage theory have been advanced to explain these differences 1617 further migrants usually have low or inadequate health literacy compared to the general population 18 in france immigrants born in africa and the middle east make up the majority of the immigrant population 19 and are reported to have worse health compared to individuals born in france 20 despite significantly lower smoking rates 21 therefore public health campaigns and tobacco control policies as other preventive interventions could have distinct impacts according to immigrant status due to different cultural backgrounds and social norms 22 understanding the impact of specific tobacco control measures on health inequalities is therefore important for developing and evaluating populationlevel public health policy interventions in this study we investigated tobaccorelated behaviors in france before and after the implementation of specific tobacco control measures according to immigrant status as determined by the geographical region of birth methods we conducted depict a nationwide telephone survey of residents of mainland france that took place in two waves one year apart between the end of august and midnovember in 2016 and 2017 therefore the first wave took place before the implementation of several tobacco control measures such as plain packaging and smoking cessation media campaigns the target population consisted of all french speakers aged 18 to 64 years interviews were conducted via landline or mobile telephones by trained interviewers working for a polling institute located in the south of paris randomly generated telephone lists were used to call participants up to 30 times using a computerassisted telephone interviewing system in households reached by landline one participant was randomly selected by the cati system 23 ethical approval and informed consent depict was approved by the ethical review committee of the french national institute of health and medical research all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standard informed consent was obtained from all individual participants included in the study measures smoking status intentions to quit and quit attempts in the preceding year participants were asked about their lifetime tobacco use and their current smoking status current smokers were asked about the daily number of cigarettes smoked and whether they wished or tried to quit in the preceding 12 months former smokers were asked about time since the last smoking cessation geographical region of birth participants not born in france were asked about their geographical region of birth we also asked participants about their parents geographic region of birth we then classified individuals in four categories depending on whether they or their parents were born in a france b another european country c an african or a middle eastern country or d another region this categorization was motivated by previous research we conducted where we showed that first and secondgeneration immigrants to france from africa andor the middle east have different smoking patterns individuals born elsewhere 2425 it was also motivated by the low number of smoking individuals from these minority groups in our study due to french regulations 26 we were unable to ask more direct questions about perceived ethnicity ethnic origin or the country of birth due to their small effect size first and second generation immigrants were grouped together sociodemographic characteristics and other covariables we collected data on sociodemographic characteristics which have previously been linked to smoking sex age educational level and household situation 8 further we also collected selfreported data on ever cannabis use and whether a participant lives with a smoker statistical analyses to test the association between participants immigrant status and smoking cessation we proceeded as follows for each study wave data were weighted based on the probability of being selected through the kish method 23 and to match the structure of the french population in 2016 for sex age education region of residency and smoking experimentation rates using data from the national institute of statistics and economic studies and the national health survey 2728 we used the sas raking macro to estimate a weight value to each participant such that the weighted distribution of the overall sample is comparable to that with the listed variables in the 2016 french population 29 in weighted descriptive analyses we estimated smoking rates according to the study wave and the geographic region of birth we also carried out two distinct multivariable regression models to examine the adjusted association between the geographic region of birth and two different outcomes among smokers or former smokers the first model was used to determine the adjusted association between the geographic region of birth and the intention or attempt to quit in the preceding year among smokers adjusting for covariates which included characteristics previously linked to smoking which were significantly associated with the study outcome in bivariate analyses the second multivariable logistic regression model was limited to smokers who intended to or attempted to quit smoking in the preceding year and former smokers who quit in the preceding year we therefore examined factors associated with an unsuccessful quit attempt in the preceding year all statistical analyses were conducted using sas version 94 statistical significance was set to 005 results smoking rates we recruited a total of 8470 participants with an unweighted mean age of 44 sd 13 weighted mean 42 more than half of the participants were women and people with no high school diploma were underrepresented in the original sample overall the percentage of smokers significantly decreased between the first and second wave however among individuals born in subsaharan africa north africa or in the middle east the percentage of smokers significantly increased by 62 between the two study waves there were more former smokers in the general population in the second study wave compared to the first while the proportion of former smokers among participants of afrmeorigin significantly decreased smoking quit attempts in the last year smokers characteristics according to their intention or attempt to quit in the preceding year are presented in table 1 less than half of smokers in our study were women the average age of smokers was 39 years and afrmeorigin individuals constituted 127 of the smokers population quit attempt or desire to quit was especially high among individuals from the afrme group compared to other groups the results of the multivariable analysis show that afrmeorigin smokers were more likely to report the intention or attempt to quit in the preceding year compared to nonimmigrants or direct descendant of immigrants quit attempt in the preceding year for this model the sample consisted of participants who quit smoking in the preceding year and smokers who desired or attempted to quit in the preceding year the results of the multivariable analysis show that afrmeorigin individuals were more likely to have had an unsuccessful smoking attempt in the preceding year compared to participants with france as the region of birth discussion our results based on data from a twowave nationally representative repeated crosssectional study of 8 470 individuals in france in 2016 and 2017 show that despite an overall decrease in smoking rates after the intensification of tobacco control measures smoking rates appear to have increased among individuals with an immigration background in particular individuals born in africa or the middle east who comprise the largest part of immigrants in france reported significantly higher levels of quit attempts but an increased smoking prevalence there is considerable literature on the association between migrant status and unhealthy behaviors in highincome countries generally migrant groups have lower levels of some healthy behaviors such as access to preventative health services and physical activity compared to the general population 3031 further longer durations of residence are linked with the acquisition of unhealthy behaviors such as unhealthy diet and smoking among migrants 3233 in france premigration prevalence of smoking is generally lower among african migrants arriving in the country however this prevalence tends to increase with time up to levels beyond those of the nativeborn for certain male migrant groups while migrant women tend to have significantly lower smoking prevalence compared to the french female general population 34 this increase in unhealthy behaviors with time among migrants is likely exacerbated by low socioeconomic disadvantage cumulative exposure to racism and low health literacy 3135 there is also evidence that some public health interventions which improve overall population health could lead to intervention generated inequalities 3637 however there is very little data on effective interventions to improve immigrant health especially from europe with experts calling for more data from natural experiments like changes in policy 38 we advance this literature by describing how comprehensive tobacco control policies in france which were successful in decreasing overall smoking rates did not lower smoking rates among migrants and descendant of immigrants tobacco control measures may have had comparableif not bettereffects on the desire to quit among immigrants however even if smokers born in africa or the middle east reported a higher desire and quit attempts their success rates seem to be lower compared to the general population lower quit rates among immigrants could be explained by low access to smoking cessation services which is common among individuals with low socioeconomic status 39 it could also be explained by a poorer mental health and lower health literacy other mechanisms could also explain our results such as a surge in illicit cigarettes from african and middle eastern countries being sold on the streets however little data is available on this subject these findings could imply that the prevalence of smoking among some immigrants and descendants of immigrants in france increases with time this is in accordance with other european studies which also found disparities in smoking rates according to migrant status and acculturation 40 table 1 characteristics of smokers participating in the depict study according to their intention or attempt to quit smoking in the preceding year our findings suggest that tobacco control strategies should provide specific measures to increase successful quit attempts rates among marginalized populations prevention and smoking cessation interventions tailored specifically to first and generation immigrantssuch as neighborhoodbased andor culturally tailored programsare needed the evaluation of public health interventions should also systematically include effects on migrants and other minority populations limitations our study is one of the first to examine the change in smoking rates among immigrants after the implementation of new tobacco control measures however some limitations need to be noted first selective nonresponse to our repeated survey could have resulted in selection bias especially if smokers were less inclined to participate it is possible that smokers were more reluctant to participate in the second wave compared to the first because of a perceived increase in the stigmatisation of smoking nevertheless we did weigh study data to limit such bias second as in most other epidemiological studies we use selfreported data on smoking which may have resulted in underestimating smoking rates further language barrier could also be a limitation in this survey targeting solely the frenchspeaking population moreover merging immigrants and descendant of immigrants due to small effect size is likely to conceal differential subgroups trends we also did not stratify analysis by sex due to small effect size conclusions smoking rates appear to have increased among individuals with an immigration background in france despite the intensification of tobacco control measures and a decrease in smoking rates among the general population our study provides evidence suggesting that the effect of tobacco control measures could have different effects depending on the smokers migrant status abbreviations competing interests the authors declare that they have no conflict of interest • fast convenient online submission • thorough peer 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background the evolution of smoking rates according to migrant status has not been examined in france despite a recent reduction in overall smoking ratesdepict is a two waves 2016 n 4356 2017 n 4114 nationwide telephone survey representative of the french adult population we compared smokingrelated behaviors before and after implementation of tobaccocontrol measures 2017 according to the geographical region of birthcompared to 2016 individuals originating from africa or the middle east had a slightly higher smoking prevalence in 2017 347 vs 313 despite a higher intention to quit or attempt in the preceding year adjusted or ora 272 190 390 compared to nonimmigrants they were also less likely to experience an unsuccessful quit attempt ora 176 118 262 tobaccocontrol measures could have widened smoking inequalities related to migrant status the evolution of smokingrelated behaviors among immigrants should be examined when studying the longterm effects of such policies

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introduction in some jurisdictions in the world chiropractors can gain licensure to prescribe medications from a limited formulary of overthecounter andor prescriptionbased medications for common musculoskeletal conditions such as nonsteroidal antiinflammatory drugs analgesics and muscle relaxants 12 some within the profession feel that such prescribing rights are necessary if chiropractors are to assume the role of primary spine care providers within the healthcare system 34 prescribing drugs in chiropractic nevertheless remains a contentious issue and continued incorporation of these rights into the scope of chiropractic practice has major implications for the profession to date several published surveys 5 6 7 8 9 have shown that chiropractors are generally split in their opinions regarding the right to prescribe drugs in chiropractic practice this split in opinions is most pronounced in countries where chiropractors are not currently licensed to prescribe medications conversely in jurisdictions where chiropractors are licensed to prescribe from a limited formulary such as in switzerland the majority perceive this right as an advantage for the profession 110 moreover continuing education in pharmacology is viewed by swiss chiropractors as a necessary component of this privilege 10 yet despite being divided over prescribing rights in general there is evidence to suggest that many chiropractors often recommend otc medications to patients in practice for example while just over half of respondent chiropractors from surveys in australia 5 and oklahoma usa 6 were supportive of prescribing rights between 66 and 87 indicated they recommend nonprescription analgesics and antiinflammatories with variable frequency to their patients this would suggest that chiropractors that are against prescribing rights for the profession may not be entirely averse to relevant pharmaceutical use by their patients in clinical practice as such further investigation into the frequency of otc drug recommendation by practising chiropractors would be informative contention also exists over the scope of prescriptionbased drug use in chiropractic practice in new mexico usa for example chiropractors can gain licensure to prescribe from a limited formulary of musculoskeletal medications 2 however chiropractors in this state have also made recent attempts to expand their current formulary to include additional prescription drugs as well as drugs to be administered by injection 11 in order for chiropractors to operate as primary care physicians 12 concerning the issue of full prescribing rights however evidence from the literature suggests that chiropractors are generally opposed 568 in canada the current knowledge and attitudes of chiropractors toward full prescribing rights is unknown and research concerning limited prescribing rights is scarce questions also remain as to why the chiropractic profession is split toward prescribing rights in the first place some evidence suggests that this division in attitudes may be reflective of differences in philosophical orientation with socalled mixer chiropractors being in favour and straight chiropractors being opposed 8 however further research is needed in order to validate these findings particularly within the current environment of the chiropractic profession 1314 several of the aforementioned surveys 1 5 6 7 8 9 have also been limited by low response rates leaving the generalizability of their findings open to question as such further surveys andor qualitative research studies are warranted in order to clarify the general attitude of chiropractors toward drug prescription in chiropractic the aim of this study was therefore to ascertain the general attitude of chiropractors from ontario canada toward the inclusion of drug prescription rights in their scope of practice in doing so three main areas were investigated ontario chiropractors attitudes and opinions to drug prescription rights the frequency of otc drug recommendation by ontario chiropractors and ontario chiropractors current knowledge of drug prescription this study also sought to determine if there was a relationship between ontario chiropractors attitudes toward drug prescription rights and the number of years in chiropractic practice or employment and philosophical orientationpreferred style of practice methods study design a survey of all 2900 chiropractors in active chiropractic practice registered through the 20142015 electronic directory of the college of chiropractors of ontario 15 was carried out using an online anonymous 14item selfadministered questionnaire ontario chiropractors who were retired andor who did not have an email address listed with the cco at the time of the survey were excluded the current questionnaire was partially based on questionnaires previously used in assessing chiropractors opinions toward drug prescription rights 58 all qualified participants in this study were contacted via email messages at oneweek intervals up to six times over the course of six weeks the first email was a prenotification message containing an introduction to the survey and its purpose as well as a link to a review article on the topic of prescribing rights in chiropractic 13 the next four email messages which included up to three reminder notifications for nonresponders were distributed through surveymonkey® and included a cover letter a link to the survey instrument as well as optout instructions a final email reminder was sent to nonresponders on the final day before the survey was closed survey instrument the questionnaire was divided into four sections section 1 consisted of four questions recorded on a 5point likert scale ranging from strongly agree to strongly disagree that focused on chiropractors attitudes to drug prescription rights section 2 consisted of two questions regarding otc drug recommendations in chiropractic practice responses to both questions were recorded on a 5point scale ranging from never to routinely section 3 contained three questions asking about the chiropractors current knowledge of drug prescription responses to the first two questions were recorded on a 5point likert scale ranging from very high to very low responses to the third question were recorded on a 3point yes no or dont know verbal scale section 4 asked demographic questions including age gender chiropractic college of graduation number of years in chiropractic practice or employment and chiropractic philosophical orientationscope of practice for this last item respondents were asked to choose between one of three categories as defined by mcdonald et al 8 which best described their philosophical orientation preferred scope of practice the three categories included broad scope middle scope and focused scope pilot testing an assessment of the questionnaires face validity 1617 was undertaken through peer review and a pilot study for the pilot study a random sample of 20 chiropractors registered with the waterloo regional chiropractic society a diverse group of currently 39 chiropractors practising within the region of waterloo ontario canada was used the names of each of the 39 registered chiropractors were entered into a computerbased random number generator and the first 20 listed after randomization were selected each pilot study participant was asked to complete the questionnaire online using surveymonkey® and to give feedback concerning its face validity as well as general feedback regarding the time to complete the survey individual item comprehension and issues of ambiguity there were 12 responses to the pilot study and feedback primarily consisted of comments relating to wording and clarity all respondents affirmed the questionnaires face validity this feedback was used to further revise the questionnaire and the final survey instrument was created online and administered through surveymonkey® data analysis responses to all questions were analyzed using descriptive statistics central tendencies were measured as means and standard deviations for continuous data while medians were used for ordinal data 18 categorical data were presented as proportions inferential statistics were used to investigate any differences in opinion between chiropractors who had been in practice or employed for different amounts of time and had differing views regarding chiropractic philosophyscope of practice it was hypothesized a priori that chiropractors with a higher number of years in practice andor who preferred a focused chiropractic scope of practice would hold more negative views toward drug prescription rights relationships between these two grouping variables and the various attitudinal response variables from section 1 of the questionnaire were explored using the chisquare test of independence for nominalcategorical data 18 in order to evaluate differences between these groups responses to the four likert scale items in section 1 which provided ordinal data on chiropractors attitudes to drug prescription rights were collapsed and recoded as categorical data statistical significance was set at p 005 and all data analysis was carried out using spss ethical considerations prior to data collection ethics approval was obtained through the angloeuropean college of chiropractic research ethics subcommittee the research ethics board secretariat for health canada was also contacted and further ethics review in canada was deemed not necessary due to the nature of the research being undertaken in this study all data collected for this study was recorded anonymously and stored securely in a password protected electronic database results after removing duplicate and invalid email addresses from the 20142015 cco directory the questionnaire was sent to 2847 chiropractors in ontario representing more than twothirds of all chiropractors in active practice registered with the cco at the time of the survey one hundred and seventy questionnaires were automatically returned as undeliverable due to change of recipient email addresses or those previously having opted out of receiving surveymonkey® surveys of the remaining 2677 questionnaires that were sent completed questionnaires were received from 960 respondents representing the views of nearly onequarter of the profession in ontario at the time table 1 provides demographic comparisons between the study sample and the general population of ontario chiropractors with respect to philosophical orientation nearly onethird of respondents classified themselves as practising within a broad scope of chiropractic practice over half were middle scope and the remaining 134 of respondents identified themselves as focused scope chiropractors ontario chiropractors attitudes to drug prescription rights obtained from section 1 of the questionnaire are summarized in fig 1 the majority of respondents were in favour of incorporating limited drug prescription rights within their scope of practice nearly twothirds were in agreement that chiropractors should be able to gain an expanded scope to allow for prescription of otc medications for common musculoskeletal conditions similarly the majority agreed that chiropractors should be able to gain an expanded scope of practice to allow for the prescription of a limited number of prescriptionbased musculoskeletal medications respondents were not in favour of chiropractors having full prescribing rights with a large majority disagreeing that chiropractors should be able to gain an expanded scope to allow for the prescription of any and all medications including controlled substances finally a majority of respondents agreed that if given limited prescriptive authority chiropractors could play a role in counselling patients against overuse and overreliance on medications for musculoskeletal conditions responses to section 2 of the questionnaire asking about the frequency of otc drug recommendation are shown in fig 2 overall the majority of respondents indicated that they recommend otc drugs to patients to some extent in clinical practice respondents also suggested otc medications more frequently to acute patients than chronic patients responses to section 3 of the questionnaire exploring current knowledge of drug prescription are summarized in fig 3 respondents were generally confident regarding their perceived knowledge towards prescribing musculoskeletal medications but less so for drugs used in treating nonmusculoskeletal conditions a large majority of respondents also felt that completion of a formal postgraduate certificate program in pharmacologydrug administration should be required for those in the profession wishing to prescribe medications comparisons between ontario chiropractors attitudes to drug prescription rights and the number of years in practice are displayed in table 2 a statistically significant greater proportion of respondents with less than 15 years experience agreed that ontario chiropractors should be able to prescribe otc and prescriptionbased musculoskeletal medications compared to those with more than 15 years experience respondents with more than 15 years experience also disagreed significantly more so than those with less than 15 years experience regarding the idea that chiropractors with limited prescriptive authority could counsel patients on musculoskeletal medication use with respect to the issue of full prescribing rights no statistically significant difference in opinion was found between chiropractors who had been in practice or employed for different amounts of time comparisons between ontario chiropractors attitudes to drug prescription rights and differences in philosophical orientation are displayed in table 3 among broad scope respondents an overwhelming majority were in agreement that ontario chiropractors should be able to gain an expanded scope to allow for prescription of otc and prescriptionbased analgesics nsaids and muscle relaxants relatively few of the focused group respondents held the same opinion middle scope chiropractors were also in favour of limited prescribing rights although to a lesser extent than their broad scope colleagues supporting the idea of being able to prescribe otc and prescriptionbased musculoskeletal medications similarly a large majority of broad scope and middle scope respondents agreed that if given limited prescriptive authority chiropractors could play a role in counselling patients against overuse and overreliance on drugs commonly prescribed for musculoskeletal conditions in contrast less than onequarter of focused scope respondents supported this idea regarding full prescribing rights nearly onequarter of the broad scope group agreed that ontario chiropractors should be able to gain an expanded scope allowing for the prescription of any and all medications including controlled substances however the proportion of middle scope and focused scope chiropractors who similarly agreed was considerably lower discussion the main finding of this study was that the majority of ontario chiropractors who responded to this survey were in favour of incorporating limited drug prescription rights into their scope of practice nearly twothirds agreed that chiropractors should be permitted to prescribe otc and prescriptionbased analgesics nsaids and muscle relaxants almost 70 also felt that with limited prescriptive authority chiropractors could help counsel patients against overuse and overreliance on in spite of this evidence from two of the aforementioned surveys including that in the present study indicate that there may be a growing interest among ontario chiropractors towards limited chiropractic prescribing rights for instance in surveys involving members of the ontario chiropractic association from 2007 and 2011 increasing majorities of respondents respectively were in favour of chiropractors prescribing antiinflammatory andor analgesic medications an even greater majority favouring limited prescribing rights in the present study suggests that there may be a possible shift in chiropractors attitudes toward drug prescription rights occurring within the profession in ontario in switzerland where chiropractors already have limited prescribing rights the profession is more united regarding drug prescription in chiropractic 110 and is strongly integrated and accepted by the medical community 22 as such swiss chiropractors have cultural authority within the musculoskeletal domain for instance chiropractic is among one of five governmentrecognized medical professions in switzerland and chiropractic treatment is fully covered under the swiss national health insurance program 22 if chiropractors in other countries wish to gain drug prescription privileges however there are numerous implications to consider these would include but are not limited to the need for additional education and training for chiropractors in pharmacology and toxicology necessary regulatory and legislative changes consideration of legal and ethical issues and increases to chiropractic malpracticeliability insurance coverage 1323 concerning the issue of pharmacology education the current study found that ontario chiropractors were quite confident regarding their perceived knowledge towards prescribing musculoskeletal medications in fact nearly twothirds of respondents indicated that their current knowledge of these drugs was high or very high interestingly nearly equal numbers perceived their current knowledge of drugs for nonmusculoskeletal conditions as low or very low the first finding is surprising given that the basic chiropractic educational curriculum contains only 12 h of coursework in pharmacology 24 a possible explanation is that over 72 of respondents in the current study graduated from the canadian memorial chiropractic college where students presently receive 30 h of training in pharmacology and toxicology 25 although this number of hours in pharmacology education is above the world health organization standards for chiropractic students in other healthcare professions such as dentistry complete an average of almost 70 h 26 and chiropractic students in switzerland take over 80 h in pharmacology at the university of zürich regardless of how confident ontario chiropractors might be regarding their perceived knowledge towards musculoskeletal medications further undergraduate andor postgraduate education and training would be necessary in order to competently prescribe these types of medications in clinical practice in fact this view was supported by a large majority of respondents in the current study as over threequarters felt that completion of a formal postgraduate certificate program in pharmacologydrug administration should be required for those in the profession wishing to prescribe medications currently chiropractors in new mexico usa must complete a twoyear postgraduate master of science degree in advanced clinical practice 427 before they can obtain a license to prescribe from the limited chiropractic formulary in that state 2 this postgraduate program offers further training in pharmacology 27 and could serve as a model for the profession particularly in other jurisdictions where chiropractic prescribing rights are being considered despite evidence to suggest that chiropractors in ontario and elsewhere are interested in gaining limited prescriptive privileges a large majority of respondents in the current study did not favour the idea of chiropractors having full prescribing rights more than threequarters disagreed that chiropractors should be able to gain an expanded scope to allow for the prescription of any and all medications including controlled substances this finding is consistent with those of previous surveys of chiropractors from australia 5 the united states 6 and north america 8 where respondents were generally opposed to chiropractors writing drug prescriptions for nonmusculoskeletal conditions this is also in accordance with the views of those in the medical profession whose members would likely oppose such an expansion to the chiropractic scope of practice as well 23 on the other hand if chiropractors would focus their scope to treating spinerelatedmusculoskeletal conditions there is evidence to suggest that medical doctors would support limited prescription privileges for the chiropractic profession 222328 some chiropractors in new mexico usa have nevertheless attempted to expand their existing formulary to beyond a limited number of medications and this has been met by opposition from both the medical and chiropractic professions in that state 11 another finding of the current study was that a large number of ontario chiropractors in this survey tend to recommend otc drugs to their patients for instance when asked how often they suggested nonprescription analgesic and nsaid medications to acute and chronic patients in clinical practice 81 and 67 of respondents indicated that they did so to some extent respectively these nonprescription drug utilization rates are comparable to those of other published studies of practising chiropractors 1561022 and are congruent with current evidencebased guidelines 29 30 31 this nevertheless suggests that several chiropractors in ontario are making treatment recommendations that are outside of their current legislative scope of practice 32 arguably however this studys findings indicate the need to align the chiropractic scope of practice with current scientific evidence as well as individual practitioner behaviour the findings of this study also suggest that many chiropractors support otc drug use in clinical practice no matter what their personal stance is on prescribing rights for the profession for at least some of these chiropractors this points to a disconnect between traditional chiropractic philosophy and once again actual practice behaviour interestingly the remaining respondents in the present study indicated that they would never recommend otc analgesics and nsaids to their patients it is unclear if these participant responses were based on individual chiropractic philosophical orientation or simply that these clinicians felt that otc drug recommendation was outside the scope of chiropractic practice when exploring possible reasons for why some chiropractors have differing views toward drug prescription an association was found in this study between respondents opinions and the number of years in practice for instance chiropractors who had practised for 15 years or less were significantly more in favour of musculoskeletal drug prescription rights versus those with greater than 15 years experience this difference in opinion between the two groups could possibly reflect slightly differing views toward evidencebased practice for example several clinical guidelines endorse the use of mild analgesics andor antiinflammatories in the management of various musculoskeletal conditions 29 30 31 yet some literature suggests that more experienced practitioners are less likely to view research evidence as valuable or necessary in their daytoday clinical practice 33 34 35 the current study did not directly inquire about respondents attitudes to evidencebased practice so it is unclear whether this characteristic actually influenced respondent opinions toward drug prescription in the survey the differences may have once again been based more on respondents philosophical orientation andor attitudes toward current chiropractic scope of practice regardless the majority of respondents from both groups still favoured the idea of limited prescribing rights for chiropractors despite their overall practice experience as for philosophical orientation this study showed that there was a strong relationship between this variable and ontario chiropractors attitudes to drug prescription rights for instance almost all of the broad scope respondents in the survey were in favour of ontario chiropractors gaining prescriptive rights for treating musculoskeletal conditions whereas very few of the focused scope group felt the same way these findings are consistent with those from the study by mcdonald et al 8 where more than threequarters of broad scope respondents supported limited prescribing rights compared to less than onefifth of focused scope chiropractors who similarly agreed the majority of middle scope respondents in the current study also favoured musculoskeletal prescribing rights the majority of middle scope respondents in the mcdonald et al 8 survey supported limited chiropractic prescribing rights as well but to a lesser extent than those in the current study where broad and middle scope chiropractors from the present study disagreed was regarding full prescribing rights nearly onequarter of respondents in the broad scope group agreed that chiropractors should be permitted to write prescriptions for any and all medications while virtually none in the middle scope group held a similar view akin to the situation in new mexico usa however this attitude of favouring full prescribing rights for chiropractors by some broad scope respondents is in contrast to the general view held by many others in the profession 568 there may be a middle ground concerning chiropractic prescribing rights where some level of agreement within the profession could be reached for instance evidence from the literature including results from the current study suggest that among chiropractors who hold favourable views toward drug prescription prescription privileges limited to within a musculoskeletal scope of practice would be preferred 568 a large majority of respondents in the current study also agreed that with limited prescriptive authority chiropractors could advise patients against overusing analgesic and antiinflammatory medications evidence to support this notion can be found in switzerland where chiropractors tend to prescribe medications significantly less so than asked for by their patients 10 with the overprescription of drugs such as opioids in countries like the united states 36 the ability of chiropractors to counsel patients on musculoskeletal drug use is something that all members of the profession should be interested in regardless of philosophical orientation in fact a large majority of broad and middle scope chiropractors in the current study supported this potential role for the profession focused scope respondents did not however as less than onequarter similarly agreed as such these findings along with those of others 8 suggest that complete consensus on the topic of chiropractic prescribing rights will likely remain elusive for the profession given the philosophical views traditionally held by this minority group of chiropractors however in light of the fact that physiotherapists are interested in and are gaining limited drug prescription rights in some countries 3738 it is imperative that the remaining majority of the chiropractic profession continues this discussion further surveys andor qualitative studies of chiropractors opinions toward gaining prescription privileges in these and other jurisdictions would be timely in canada the results of the current study may be taken to other provinces in order to complete a nationwide survey if the same findings are confirmed elsewhere it would argue for a national campaign to reform the chiropractic scope of practice acts across the country limitations this study has some limitations first the overall response to the survey was relatively low thus raising the likelihood of nonresponseexclusion bias in the results 18 however the number of responses obtained in this study was higher than those of other published surveys on chiropractic prescribing rights 1 5 6 7 8 9 10 and when comparing demographic characteristics the sample appears to be representative of the general population of practising chiropractors in ontario nevertheless a 64 nonresponse rate suggests that these survey results should be interpreted with caution as respondents views toward drug prescription rights obtained may not be generalizable to those of all ontario chiropractors a second limitation of this study is that it excluded retired chiropractors and those not on the electronic 20142015 directory of the cco as these groups represented the minority of all licensed chiropractors in ontario at the time of the survey this was felt to be less of an issue nonetheless there is a risk that retired chiropractors andor those who did not have an email address listed with the cco may have held systematically different views toward drug prescription rights compared to chiropractors listed on the electronic cco directory thirdly chiropractors attitudes to drug prescription rights were measured in this study using a closedanswer format only although good for aggregating data from large study populations the disadvantage to using this survey method is that it does not allow participants to expand upon responses or offer alternative viewpoints 17 and this would have prevented any richness to the responses in the current study on the other hand openanswer questions take longer to complete which can dissuade participants from responding 17 these questions can also be laborious to analyze qualitatively 17 particularly with large data sets and was beyond the scope of the current study conclusions this study revealed that a majority of ontario chiropractors were in favour of incorporating limited drug prescription rights into their scope of practice were generally confident regarding their knowledge of musculoskeletal medications and tended to recommend otc drugs such as mild analgesics andor antiinflammatories to patients to some extent in clinical practice however respondents did not favour the idea of chiropractors having full prescribing rights were not confident in their knowledge of drugs for nonmusculoskeletal conditions and felt that further education and training in pharmacology should be necessary for those in the profession wishing to prescribe medications those who had been in practice for less than 15 years favoured musculoskeletal prescribing rights more so than chiropractors with more than 15 years experience however the overall majority in both groups still favoured limited prescribing rights for the profession as for philosophical orientation the majority of broad and middle scope respondents in this study also favoured limited chiropractic prescribing rights whereas those in the focused scope group did not further surveys andor qualitative studies of chiropractors in other jurisdictions are needed in order to validate these findings additional file additional file 1 survey instrument competing interests the authors declare that they have no competing interests authors contributions kjs conceived of the study and participated in its design pce was responsible for study design data collection analysis and interpretation and drafted the initial manuscript both authors reviewed the literature and also drafted revised and approved the final manuscript

background several published surveys have shown that chiropractors are generally split in their opinions regarding the right to prescribe drugs in chiropractic practice many of these studies have been limited by low response rates leaving the generalizability of their findings open to question the aim of the current study was to ascertain the general attitudes of chiropractors in ontario canada toward the inclusion of drug prescription rights in their scope of practice relationships between these attitudes and the number of years in practice including differences in philosophical orientation were also explored methods a 14item questionnaire was developed and invitations sent via email to all eligible 2677 chiropractors in active practice registered electronically with the college of chiropractors of ontario in february 2015 data were collected and analyzed using descriptive and inferential statistics results 960 questionnaires were completed for a 36 response rate the majority of respondents agreed that chiropractors should be permitted to prescribe musculoskeletal medications such as overthecounter and prescriptionbased analgesics antiinflammatories and muscle relaxants over twothirds also felt that with limited prescriptive authority chiropractors could help reduce patients reliance on these types of drugs over threequarters were opposed however to chiropractors having full prescribing rights the majority indicated they recommend overthecounter medications to acute and chronic patients to some extent in clinical practice nearly twothirds perceived their knowledge of musculoskeletal medications as high or very high while a similar proportion perceived their knowledge of drugs for nonmusculoskeletal conditions to be low or very low a majority of respondents felt that further education in pharmacology would be necessary for those in the profession wishing to prescribe medications more recent graduates and those who espoused a broad scope of chiropractic practice were most in favour of limited prescribing rights for the profession conclusions a majority of responding ontario chiropractors expressed interest in expanding their scopes of practice to include limited drug prescription these results together with those of other recent surveys could indicate a shift in chiropractors attitudes toward drug prescription rights within the profession further surveys andor qualitative studies of chiropractors in other jurisdictions are still needed

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introduction in recent years nurses in nordic countries have become increasingly interested in involving families in their clinical practice benzein et al found that the majority of swedish nurses have a positive attitude towards involving families in the care of their relatives families were generally seen as a resource in caring although nurses working in hospitals had less supportive attitudes compared to those working in primary health care according to gavois et al nurses can assist the family through the process of experiencing a mental health crisis by being present listening sharing and empowering nurses play an important role by being present in acute situations providing both physical and emotional comfort and security furthermore open communication and participation in planning care help the family to cope with the acute situation the results from nordby et als study show that families have positive experiences with nursing staff their study highlights the importance of participation from the first contact and stresses that the encounters should contain sharing information guidance support and hope to help families become a resource for the patient hultsjö et al investigated the perceptions of psychiatric care among foreignand swedishborn patients with psychotic disorders they found that while family participation was important for the patient some relatives did not wish to participate it is therefore important for nurses to identify the individual needs of families additionally schröder et al argued that family participation is an element of the quality of care in psychiatric settings both lack of and desire for family participation and support in psychiatric settings have been discussed by stjernswärd and östman van der voort et al and wilkinson and mcandrew in ewertzon et als study in which 70 family members participated the results demonstrated that a majority of families had experienced a lack of confirmation and cooperation from professionals and felt alienation in the care being provided nurses play a unique and vital part in encouraging family participation in psychiatric settings at the same time various barriers such as time working conditions and impact of mental illness can impede the implementation of family participation kjellin and östman stjernswärd and östman tranvåg and kristoffersen and van der voort et al demonstrated how the mental illness of a family member can affect the entire family emotionally and family members might develop health problems of their own their findings indicate that families frequently feel distress and a sense of burden and that these feelings can be experienced in different ways the distress that families experience in such situations has been studied both in the nordic countries and internationally according to östman et al the family experiences burden in the situation of acute psychiatric illness despite the diagnoses of the patients additionally according to salzmannkrikson et al mental illness and acute admissions might involve dramatic situations furthermore families concern for children was brought to light while for hedman ahlström et al supporting and guiding the family including children should be seen as a central part of psychiatric mental health nursing the experience of growing up with a parent who has a mental illness has also been studied previously children desire more initiative contact and information from nurses concerning their parents mental illness grownup children with a parent who has a mental illness highlighted the distress they had experienced in their childhood due to the lack of support and information from psychiatric services both during the hospitalization of their parent and afterwards in view of the high levels of stress experienced by families during admissions and acute phases of illness and the nurses decisive role in supporting and facilitating family participation it appears particularly important to investigate family participation in the acute context therefore the aim of this descriptive qualitative study is to describe how nurses experience family participation in the acute psychiatric inpatient settings design ethics the study was approved by the ethical committee at the university of halmstad sweden participants received written and oral information about the aim of the study and the voluntary nature of their participation they were assured that anonymity would be preserved and that the confidential handling of data protected informants from identification written consent was given finally the participants were advised that they could withdraw at any time without consequences the interview guide was tested through two pilot interviews in order to ensure that the nurses understood the questions and felt comfortable with them and to ascertain that the questions were suitable for use in the study since the pilot interviews did not lead to any modifications of the format they were subsequently included in the total material informants the sample of informants consisted of 18 swedishspeaking nurses at the time of the study the nurses were working with both inpatient and outpatient care in different psychiatric clinics and all had experience of acute psychiatric inpatient care the acute psychiatric inpatient wards in sweden are shortterm assessment and treatment units often integrated into general hospitals patients can be admitted to the same locked wards and be cared for on both voluntary and involuntary bases they are mostly admitted in the acute phase of illness the informants had no relationship with the first author nursing managers were first informed and nurses who met the criteria of participation were identified the study aimed to obtain a wide range of variation in conceptions and therefore nurses were selected to represent different backgrounds with respect to age sex marital status mean number of years as a nurse specialist education and mean number of years in psychiatry as a nurse the first author then contacted the nurses by telephone and invited those who wanted to participate eighteen nurses were asked and all were willing to participate the informants themselves arranged a suitable time and place for the interview the location for a personal interview was chosen by the nurses themselves so that they felt comfortable and would not be disturbed the places they selected turned out to be the nurses workplaces a secluded and quiet room in the vicinity of the clinics the participants were assured that the information they provided would be treated confidentially the mean age of the 18 informants was 44 years with a range between 28 and 60 eight were female and 10 were male eight were married five lived with a partner two were divorced and three were single ten nurses were educated in psychiatric nursing six were specializing in psychiatric nursing at the time of the study one had medicalsurgical nursing training and one had basic nursing training none of nurses were educated in family therapy their mean length of time as nurses in the profession was 125 years with a range between 2 and 33 years the mean length of time as nurses in psychiatry was 12 years with a range between 10 months and 30 years data collection in this study a phenomenographical approach was adopted in order to explore qualitative variations in how nurses experience family participation in acute psychiatric inpatient settings over the last 20 years phenomenographical methodology has mainly been applied to learning within higher education as well as the fields of healthcare education and nursing research there are basic differences between phenomenography and phenomenology phenomenography is substance oriented searching for the essence in the form of the underlying structure of variance while phenomenology is methodological and philosophical and searches for the essence in the form of the main common denominator the phenomenographical approach seeks answers to how human beings form their thinking and understanding about phenomena in qualitativelyvarying ways the secondorder perspective and qualitative variations between individuals are unique to phenomenography in phenomenography the characteristics of participants thoughts about a given phenomenon are more important than the number of participants representing a particular attitude the description of conceptions is based on each informants statements about the phenomenon the method allows conceptions of a phenomenon contained in collected data to be explored by means of a successive process of analysis and interpretation and sorted into descriptive categories in the present study an interview guide and semistructured interviews were employed with two opening questions following usual phenomenographical practice the opening questions were first asked and they were then supplemented with closelyrelated followup questions such as how do you consider the significance of the family in your work how do you understand the participation of family when working in acute psychiatric inpatient settings additional questions were also used in order to deepen the interview and to find out more about how nurses had experienced family participation in the context of acute psychiatric care data were collected during the academic year 20042005 in southwest sweden the interviews lasted between 30 and 90 min they were all taperecorded and transcribed verbatim by the first author data analysis the coauthor was well versed in the research approach employed and acted as a coanalyser during the whole categorization process the analysis of the data followed dahlgren and fallsbergs recommendations 1 familiarization we read through the transcripts several times in order to become familiar with the data and to obtain a sense of the whole material the interview transcripts consisted of 146 pages 2 condensation we reduced longer statements to find the core of each dialogue the material contained 648 statements that were directly related to the aim of study comparison the analysis was continued by searching for variations in or agreement with statements and identifying similarities and differences resulting in 20 preliminary conceptions the data were considered saturated after 15 interviews when no new conceptions appeared in the analysis nevertheless all 18 interviews were analysed 4 grouping we brought similar answers together the preliminary conceptions could therefore be grouped into 11 more comprehensive conceptions 5 articulation the 11 conceptions were compared and grouped on the basis of differences and similarities the analysis then moved back and forth between this step of analysis and the preceding one leading to three descriptive categories covering 10 conceptions of the phenomenon family participation in the acute psychiatric inpatient settings 6 labelling we scrutinized the conceptions and named the descriptive categories the content of the conceptions that formed each category was discussed with the coauthor 7 contrasting we compared the categories in order to find the unique characteristics of each category findings we found three descriptive categories that summarized the material with respect to how the nurses perceived family participation in acute psychiatric inpatient settings family participation as a part of the caring process barriers to family participation and nurses resources in family participation family participation as a part of the caring process this descriptive category comprised four conceptions understanding the family at the acute psychiatric ward family as a resource in caring encountering family and seeing the familys own wellbeing understanding the family at the acute psychiatric ward the nurses believed that the concept of family could be defined and described in many different ways as a nuclear family those who are closest to the patient and those with whom the patient is living with many nurses considered it important that the patient was given the opportunity to define hisher family freely by himherself the nurses also stated that the family could include friends some nurses reflected on how the concept of family changed over time along with changes in society those who are the nearest and dearest around those who the patient feels belong i think that it is important to find out which person the patient includes in hisher family and not have a picture of family oneself some nurses reflected that family could signify both the good and bad things of life although the family could be a source of securityconfidence for many patients it might also involve a number of conflicts and therefore could not always be seen as a resource for all patients family as a resource in caring in this conception the nurses described the family as a support in psychiatric caring and as a helper who made their caring easier some nurses found it important that they received a great deal of information concerning the patient by talking with the family they felt that families could increase their understanding about the patient because families have known the person for a long time by talking with the family i can receive much information that helps and explains and gives answers to questions so that it becomes easier to get a picture of the whole encountering family this conception draws attention to the nursing care activities and familynurse interactions which were practised by nurses at the acute psychiatric ward the nurses described many ways in which they met families encounters often took place spontaneously while the family was visiting the patient during the period of admission in some cases the nurses found it important that family participated in care planning from the beginning of hospital treatment other nurses explained that they played down what had happened at the time of admission if it was dramatic as in the following excerpt the family members are very upset and think that it is terrible and scary and that i must somehow neutralize it like calm them down try to when they got very nervous that this is not as dramatic as it may seem these nurses tried to find a quiet time to sit down with the family listen to their stories experiences and thoughts concerning their situation and how they felt and coped over the last few months they gave emotional support in the form of comforting and consoling some nurses stated that families needed a great deal of information in the acute phases they provided educational information about mental illness medication treatment discharge and the early symptoms of recurrence according to these nurses information increased the familys sense of security and therefore influenced the patient positively promoting mental health this type of information sometimes had to be provided several times considering the crisis the family was experiencing some nurses explained that they contacted families by telephone whenever a family member was anxious or concerned about the patient the nurses described the familys role in mental health promotion and how they attached great importance to family in their communication with patients nurses could remind the patient of herhis family on purpose so that the patient had something positive to go back to but also because their family could be connected to reality for the patient however some nurses remarked that family participation in the acute phase of care was not always appropriate because the patient and family are not always in a position to take advantage of it it is noteworthy that nurses did not mention any encounters with children in the patients families during acute admission although they frequently described the concept of family as a nuclear family including children seeing the familys own wellbeing this conception concerned how nurses saw patients families in a crisis and tried to understand how the families reacted when a family member had an acute mental illness the nurses talked about situations where patients might possibly have been in a mental health crisis a very long time before admission to hospital the nurses understood that this crisis affected and influenced the whole family life all families are a system they affect each other if there is one that is not feeling well it therefore becomes like ripples in the water many nurses emphasized the importance of recognizing the families own wellbeing they saw how the patients families were tired and exhausted as a result of the burden before admission and for this reason they recommended that the families should relax sleep and relieve the pressure some nurses described situations where they had advised families to take a vacation as time for themselves or take the opportunity to devote some time to their children if they had been neglected previously some nurses reflected that family should be taken seriously that the family was able to deal with knowledge of what was happening during the admission and should be informed about what treatment was planned some nurses explained how families needed to share their experiences about the acute mental illness and that time needed to be set aside for families to ask any questions they had according to some nurses the family also needed to be given hope concerning the patients chances of recovery barriers to family participation this descriptive category comprised three concepts only the patient is in focus lack of competence and lack of professional autonomy these concepts described how the family was not a primary focus in caring processes the nurses described that they worked under various constraints and found it difficult to involve family when providing care in acute psychiatric care settings only the patient is in focus based on this conception some nurses expressed their thoughts about the history and tradition of psychiatric care as a barrier in family participation an individualistic patientcentred perspective in psychiatric care still had a certain impact the nurses told stories of how family members were not allowed to visit the inpatient and how staff earlier tended to put the blame on parents and families however the nurses also remarked that this individualistic approach has been changing over the past few years some nurses believed that nurses should not have contact with family during the patients acute phase these nurses added that family participation was not constructive in acute care and stated that they did not find any reason to involve family instead they felt that they should wait and see some nurses suggested that family members get support from outpatient care in order to cope while the nurses focused on the patient instead we are here for the patients sake and the family members can take care of themselves or receive their support from outside some nurses explained that children were not allowed to visit the psychiatric ward because there was not any room for family to see each other and that the focus in caring was only on the inpatient himherself statements placed in this category described the acute psychiatric inpatient setting as a place where patients of all ages were admitted immediately at any time of day or night when the patients mental illness was at its worst short hospital treatment periods were typical for inpatients with all kinds of psychiatric diagnoses the psychiatric ward was characterized by these nurses as a messy and sometimes chaotic place where they had difficulties in finding any continuity in the care of patients the nurses worked under considerable stress for certain periods when they were occupied with many caring activities at the same time while they could have relatively peaceful periods after this they often worked in shifts and found that this way of organizing work limited possibilities for family participation some nurses reflected that for these and similar reasons families were sometimes set aside in the steady flow of new patients and in the immediate acute nursing care activities lack of competence this conception illustrated how psychiatric care in acute caring contexts lacked clarity and adequate nursing structures the nurses found it difficult to determine what was enough and what was expected of their psychiatric caring practice they also attempted to strike a balance between family participation and the requirements of professional secrecy in compliance with the swedish public access to information and secrecy act they felt uncertain as to how to handle the patients rights to selfdetermination and autonomy how could they support the inpatient and at the same time meet the family the nurses additionally expressed a lack of time and continuity due to shift work which prevented them from meeting with the families they sometimes had a different approach to family participation than the norm in their working culture nurses observed that the manner and extent to which they met families depended on their personal initiative and motivation in other words family participation was not supported by work structures the nurses represented in this category described their own lack of competence felt great insecurity in encounters with families and found knowing how to communicate with family demanding they also expressed a weakness in personal communications skills suited for work in a group like a family i think that there frequently exists a great insecurity in how to handle this and when more people are involved that there is a fear that you maybe are not able to clear this up and if difficult things crop up the nurses openly admitted that they did not know how to deal with difficult emotions that appeared in connection with collaboration with families and explained how this made them avoid such encounters the nurses said that it required courage to face families emotional expressions such as frustration and fury one nurse said that it was emotionally disturbing to think about the children in families lack of professional autonomy based on this conception the nurses described how family participation in the acute psychiatric caring context was guided by physicians in many cases nurses perceived that the extent to which the patients family was taken into account as well as the manner in which family participation took place depended on which physician was on duty at the time the nurses expressed that approaches informed by physicians significantly influenced and guided their everyday nursing and caring practice with families often it is the chief physician who directs this in my experience it is seldom that the nursing staff pursue this themselves some nurses found that it was hard to influence the standard clinical practice towards a more participatory view concerning families an individualistic patientcentred perspective dominated the working culture of their units nurses resources in family participation this descriptive category comprised three conceptions theoretical knowledge personal life experience and experience from psychiatric care and coaching statements placed in this category described how encounters with family were possible and how it became progressively easier for them to integrate family participation in their clinical practice here nurses explained how they found the courage to interact with families when they had theoretical knowledge life experience caring experience and coaching theoretical knowledge this conception described how nurses found it important to have theoretical knowledge concerning family participation and communication in a group like the family they expressed the importance of education in this area some nurses stated that through education it was possible to change the manner of thinking modify attitudes and also receive new knowledge one nurse observed that education influenced the way of seeing the children in families this i have learnt as time went and this thing about children in families when one of the parents is hospitalized that we have so much we can do for them also this i have understood later read more and was at a conference about this personal life experience and experience from psychiatric care this conception described how nurses found it helpful when they met families in the acute caring context if they had personal lived experiences and insights as a family member themselves they also reflected that this experience provided them with more knowledge and courage to interact with families and was one of the reasons why they preferred family participation during acute inpatient care they also highlighted the importance of professional experiences as a psychiatric nurse which made them feel more secure in their role and made it easier to manage contacts with families i noticed myself that when a family member has fallen ill i will always be there i am more secure myself it is maybe more difficult for a recentlygraduated nurse to talk with family that it is not easy to answer questions when they do not have so much life experience themselves not to see their desperation behind it all coaching this conception described how the nurses reflected on the importance of receiving coaching from colleagues who were engaged and committed to involving families they stressed the necessity of time for reflection together with these colleagues concerning a course of action ways of seeing the situation or clinical practice some nurses stated that they learnt from one another supported each other and found it extremely helpful to work together with another nurse in connection with their contacts with families that i had a colleague who was ardent for families she was coaching me gave information we had many conversations about this her way of thinking provided much knowledge and experience she was very important for me in this time like by helping me in how i was thinking tried to help each other discussion discussion of method according to fridlund and fridlund and hildingh the research process in qualitative studies can be discussed in terms of applicability reasonableness trustworthiness and conscientiousness eighteen informants were chosen according to certain criteria to include a diversity of backgrounds and thereby obtain a wider range of conceptions all had experience in working in acute psychiatric inpatient settings the phenomenographical approach is commonly used in health sciences in order to discuss the different ways nurses think about and understand various phenomena they encounter therefore the approach used in this study and the mode of selection of the informants were both relevant and appropriate with respect to the research aims the first author an experienced psychiatric nurse conducted all of the interviews this enhanced the studys reasonableness by increasing sense of confidence and openness in the interviews trustworthiness was increased by using two pilot interviews the concepts were determined before all of the interviews had been analysed which strengthened the reasonableness an interview guide was used to achieve a clearer delimitation of topics trustworthiness of data collection and analysis were additionally strengthened by the fact that the first author performed and transcribed all of the interviews the coauthor acted independently as a coanalyser during the whole categorization process in order to ensure accuracy in all steps of the analysis interview excerpts were introduced in every descriptive category to ensure transparency and facilitate interpretation although the findings are not intended to be generalized they could be applicable in similar contexts findings primarily aim to serve as a point of departure for discussions concerning practice in acute settings ways of improving practice can be considered based on the nurses perceptions of conditions for and obstacles to family participation in their experience discussion of findings the results indicate that the acute psychiatric caring context limits possibilities for family participation to a certain extent the lack of control over nursing practice and continuity in inpatient settings were also found by fourie et al goodwin and happell had similar results their study identified the systemic barriers to consumer and carer participation in the present study the nurses described their caring activities with families the activities that were mentioned in the interview material essentially corresponded with the activities identified in earlier studies according to sjöblom et al nurses verified the importance of family and observed that family increased their understanding of the inpatient by giving information which was also noted in the present study earlier research additionally suggested that information given and received has great value in psychiatric care and can reduce the families feelings of shame and guilt the findings from the present study indicate that contact with families often took place spontaneously while the family was visiting or by telephone sjöblom et al highlighted that contact was frequently initiated by the family another aspect noted by the nurses was the importance of seeing the familys own health as well this corresponds to the findings of engqvist et al and schröder et al nurses observed that a number of factors constituted barriers to involving the family in the caring process these included work culture and tradition based on an individualistic view of caring handling issues of professional secrecy insufficient competence and work practice directed by physicians the swedish board of health and welfare stresses that health professionals should provide opportunities for families for involvement psychosocial support information and education to reduce the burden however some nurses in the present study felt that family involvement was not always appropriate the nurses described a lack of professional autonomy and difficulties in changing the view of caring towards a more familyfocused approach in addition the nurses found it demanding to attempt to comply with secrecy regulations while providing support for both inpatients and their families this is in line with earlier findings where nurses lacked training and resources however according to the families themselves considerations of confidentiality should not become an obstacle to their participation in the patients care according to goodwin and happell open and clear communication leads to collaborative involvement the findings of the present study showed that the nurses conceptions of family participation varied and that the family was not always a priority in this caring context what are the implications of such attitudes for families in clinical practice in a recent study stjernswärd and östman investigated the experiences of families living close to an individual with depression they reported that families felt that they were not considered and met by healthcare personnel according to wilkinson and mcandrew families frequently felt excluded from acute psychiatric settings and desired greater participation with nurses it is noteworthy that the nurses in the present study did not describe any instances of including children in the contact they had with families this contrasts with the fact that many nurses believe that the children carry an inhuman burden supporting and taking care of a parent with a mental illness östman and hansson confirmed that it is essential in psychiatric care to include children theoretical knowledge personal life experience as well as nurses professional experience all played a vital role when nurses interacted with families in acute psychiatric inpatient settings the nurses found coaching helpful and explained that it facilitated the implementation of family participation in clinical practice benzein et al showed that nurses personal experience of mental illness in the family might make it easier to communicate with families and that newlygraduated nurses had a less positive attitude towards involving families this is supported by korhonen et al who emphasized that nurses personal insights their characteristics and further professional education were significantly related to how they took into consideration the support network of families and to which extent they worked with families the variation in nurses conceptions of family participation and certain contradictions in their conceptions raise the question of whether families can be met equally well by nurses in the different clinics and units when a shared nursing approach and clarity are lacking do families get differing possibilities for working with the nurses depending on the individual nurse or physician in charge and are such differences potentially problematic this is a great challenge for nurses and to the entire nursing leadership and organization in local settings the findings in this study increase the understanding of the various ways nurses experience family participation since nurses are a professional group who have most direct contact with both patients and families a better understanding of their perceptions is needed to improve family participation and professional education in clinical practice limitations the findings in this study pertain only to a limited number of interviews the aim was to get an idea of the range of variations in qualitativelydifferent conceptions about the phenomenon of family participation it goes without saying that generalization of the findings to a broader population should be undertaken the findings of nurses experiences come from a specific area of sweden and therefore the results reflect the working culture healthcare organization and forms of education that are typical of this area conclusion this study showed nurses various ways of experiencing family participation in acute psychiatric inpatient settings and variations in their approaches to family participation in practice investigating a wider range of nurses would be an interesting research project but future research should also investigate the experiences of families in this acute context seen against the background of nurses perceptions it was apparent that family participation in this context depended more on the individual nurses interests and insights rather than being an institutionallybased part of acute psychiatric inpatient care the weaknesses in the implementation of family participation in this caring context was surprising in view of the numerous ways that mental illness affects the whole family as a result of such weaknesses families can still be left in the waiting room additional insights concerning the barriers and resources for improved practice might help nurses to develop active and systematic ways of providing adequate possibilities for familynurse partnerships during acute admissions considering the negative impacts on both patient and family health these issues should be of large scale and central interest for the whole organization and nursing leadership in local settings

family plays an important role in the care provided for patients in all areas of nursing however relatively few studies deal with the focus of the present study the ways that nurses experience family participation in acute psychiatric inpatient settings data were collected by interviewing 18 nurses who had experience working in such settings a phenomenographical approach was used to analyse the interviews three descriptive categories were found family participation as a part of the caring process barriers to family participation and nurses resources in family participation the findings show that the nurses conceptions of family participation varied and that the family was not always a priority in this caring context the implementation of family participation was often only based on the nurses own interests and insights this could mean that family participation differed substantially depending on which nurse a family encountered and which unit the patient was admitted at finally nurses had little professional autonomy and organizational support and education were also lacking

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introduction there has been phenomenal internet penetration in india in recent years from just 4 in 2007 to nearly 50 in 2020 1 this has led to a substantial increase in eretail sale the eretail market itself is estimated to grow from us 24 billion in fy 2019 to us 98 billion in fy 2024 2 the sector is expected to continue growing and attracting attention of eretailers across the globe however at present 80 of the population who shop online are young people while other consumer segments acceptance of eshopping as a purchasing channel is low thus the percentage of online sales in terms of total retail sales was only 16 in india versus over 15 for china and around 14 globally and hence eretail is considered to be still in a nascent stage in india 3 in order to increase the online sales it is important to make middle aged and older population also to shop online ignoring this fact most extant eshopping research studies in india have concentrated on understanding the motivation of young people for eshopping rather than identifying the barriers that prevent others from shopping online 6 7 8 which is the purview of current study perceived risk is considered the most important psychological state that negatively influences ones eshopping behavior as shown by many studies 9 10 11 12 13 14 15 16 17 18 metaanalysis by 19 however most of the earlier studies have been conducted in developed countries 152021 the risk perception towards any new technology is found to be high in developing countries especially in countries like india with a collectivistic culture 91222 people from countries like india are riskaverse and hence are slow in the adoption of any technology hence eshopping researchers have noted that to make these people shop online it is important for retailers to focus on reducing risks rather than concentrating on benefits when setting up their online presence 12 eshopping researchers have emphasized that there exists a knowledge gap on the factors that act as barriers of adoption of eshopping technology in developing countries 59 23 24 25 26 moreover while several studies have highlighted the importance of considering the multidimensionality of perceived risk 1527 few studies have been conducted taking the various dimensions into account 6 7 8 1028 studies that have assumed perceived risk to be a unidimensional construct have observed insignificant effect of perceived risk on behavioral intention in collectivistic countries they have reported that it is important to further disintegrate the risk construct to gain better understanding 1629 hence this study considers risk as a multidimensional construct and studies the impact of various risk perceptions on eshopping behavioral intention in the indian context researchers have noted that to better understand the effect of perceived risk on bi it is crucial to consider the moderating roles of various sociodemographic factors perception towards risk is dependent on an individuals sociodemography culture and traits people with different sociodemographic and cultural backgrounds encounter different situations in life 8 different types of risks are formed with respect to a particular situation encountered by an individual 31 32 33 moreover time and psychological pressures encountered at different situations have been found to have a significant effect on risk perceptions and the corresponding risk aversion levels also differ 3435 past researchers have investigated the effect of various sociodemographic factors on perceived risk however studies that focus on understanding the differences in eshopping behavior based on family life cycle stages are limited 8 36 37 38 there is a strong evidence from past literature that most situational and behavioral changes in life happen due to the flc stages of an individual rather than hisher age changes in flc stages result in differences in an individuals financial time and psychological pressures and involvement with purchases 39 40 41 42 43 44 45 against this backdrop we expect that there would be differences in the perceptions of risk dimensions and their interplay with bi towards eshopping sites as an individual transcends the various flc stages this study addresses two potential segments that are often ignored in eshopping studies first most eshopping studies on perceived risk are conducted among young people while the pattern of risk perception among the middleaged or older adults often considered lucrative market segments with higher disposable incomehas been least explored 46 47 48 for eshopping to expand and prosper it is important to concentrate on people of all ages and at different stages of life 536 given that eshopping is an integral part of todays economy understanding the eshopping behavior across all age groups becomes important as the adoption of technology by older adults plays a vital role in economic development 49 hence to understand the effect of different demographic variables on online behavior a further split agebased research on technology adoption is essential 263150 this study acknowledges that there are barriers that hinder people of different ages from shopping online and explores this further another potential segment is women eshoppers fewer women are online in india than in other bric countries the dearth of studies on eshopping behavior among indian women has also been an outcome of the nascency of ecommerce in india 51 women perceive higher risks in eshopping than men 162652 especially in developing countries like india 2151 given that in most cultures women assume the responsibility of household shopping and purchase decisions 53 54 55 and flc stages have a greater effect on women than men 56 there is a need to explore the role of perceived risk in deterring indian women of different flc stages from participating in eshopping activities in addition women are identified to spread word of mouth regarding their shopping experience than men hence the ability of women to attract more customers towards online shopping sites is higher than men in addition at the time of purchase men are more direct and only buy at the time they need something on the other hand women tend to try more items than men and are more likely to make impulse purchases hence by targeting women it is possible to increase online sales inturn profit moreover young women are more inclined towards eshopping and there are many studies that have analyzed the eshopping behavior of this section of the young population our study focuses on married women ie women who are a part of a marital family with and without children and analyses the changes in their perception of eshopping risk which in turn affects their bi to shop online since risk perception toward new technology negatively influences eshopping behavior and the problem is particularly bad in developing countries like india with collectivistic cultures it pays off to try to better understand how risk perceptions influence eshopping behavior to mitigate the problem there are large individual differences in perceived risk and to better understand individual factors behind risk perceptions the current study employs the flc objectives of the study this study as a pioneering effort attempts to fill the knowledge gap in the area of ecommerce adoption identified through a search of literature by understanding the effect of different dimensions of perceived risk on eshopping purchase intention among indian women of different flc stages to operationalize perceived risk the study uses the theory of perceived risk proposed by 57 the theory states that a customer while buying any product would perceive some amount of risk they believe that their purchasing actions would lead to consequences that cannot be anticipated with anything approximating certainty and some of the consequences are likely to be unpleasant hence the consumers choices are divided into riskincreasing or riskdecreasing behavior bauer initially proposed perceived risk but did not include specific types later researchers have considered perceived risk as a combination of several dimensions 58 under the new internet environment as scholars adjusted the model according to the development of technology economy and society more dimensions were identified however there is no agreement on the dimensions of perceived risk researches on perceived risk have divided it into different dimensions according to different situations not all dimensions of perceived risk have been found to have significant effects on consumers behavior 59 thus there is a need to examine the effect of different dimensions of perceived risk on a consumers behavior in sharing economy 27 in this study we have considered ten dimensions of perceived risk financial risk performance risk timeloss risk privacy risk delivery risk social risk aftersales service risk source risk psychological risk and physical risk 60 and have identified the risk dimensions affecting eshopping behavioral intention among women of different flc stages to operationalize the flc stages a customized indian flc stages model comprising nine flc stages proposed by 36 has been used furthermore the researchers that applied tpr to understand eshopping risk perception highlighted that gender plays a crucial role in affecting eshopping risk perception women are identified to be riskaverse than men 6162 hence this study attempts to test how the perceived risk perception influence indian womens eshopping behavior as they transcend through different flc stages with this background we arrive at the following research questions jtaer 2020 1 for peer review 5 significant effect on other determinants of eshopping such as the consumers eshopping attitude 126667 trust 24 customer satisfaction 568 and repurchase intention 18 thus perceived risk has been proven to be one of the crucial barriers to eshopping sociodemographics on perceived risk sociodemographics and lifestylerelated changes have been found to play a crucial role in convincing consumers to shift from offline to online stores 7 69 70 71 several studies have found the effect of various sociodemographic factors on eshopping perceived risks such as age 213147 1 among the ten dimensions of perceived risk which dimensions of perceived risks are negatively associated with the purchase intention to shop online among indian women 2 does the effect of these risk dimensions on bi differ as women transcend from one flc stage to the next literature review perceived risk the concept of perceived risk was introduced by 57 in which it was defined as consumers perception of the uncertainty and the possible undesirable consequences of purchasing a product or service in eshopping perceived risk is defined as a belief about possible negative uncertainty from an online commerce transaction 63 perceived risk has been regarded as one of the core motivators in consumer behavior studies have noted that the perception towards risk is much higher when shopping online than in the classical shopping channels 7121828 because of the inability of the consumers to physically examine products before their purchase 64 there is also increasing information asymmetry between buyers and sellers 27 in the eshopping arena studies have emphasized that when converting customers who just search for products andor services on the internet into effective buyers it is important to understand and reduce their risk perception 50 perceived risk has been found to play a crucial role as one of the major determinants in influencing ones bi to shop via internet 14 15 16 25294765 perceived risk has also been to have a significant effect on other determinants of eshopping such as the consumers eshopping attitude 126667 trust 24 customer satisfaction 568 and repurchase intention 18 thus perceived risk has been proven to be one of the crucial barriers to eshopping sociodemographics on perceived risk sociodemographics and lifestylerelated changes have been found to play a crucial role in convincing consumers to shift from offline to online stores 7 69 70 71 several studies have found the effect of various sociodemographic factors on eshopping perceived risks such as age 213147 gender 50 education 2131 etc the observed betweengroup differences of these studies warrant further examination of customer segments based on various sociodemographic factors this would provide more insight into differential behavioral patterns related to eshopping among various sociodemographic factors age has been found to be an important factor that significantly influences risk perceptions of eshopping 31 considering the agebased risk studiesstudies on the effect of perceived risk on eshopping behavior among young and old have given mixed results some studies have shown that perceived risk is an important factor that affects people of all age groups 47 and acts as a crucial factor for consumers in deciding whether to shop online 14 other studies have noted that while young people are aware of the risk in the online atmosphere they are less concerned about risks and could decide to shop online for other reasons whereas older people are more vulnerable to risk perception 50 and hence perceived eshopping risk is a stronger determinant of purchase intentions among older adults 31 although agebased segmentation has remained popular online shopping researchers have noted that people belonging to same agegroup may have different motivations and hence may not behave similarly thus to understand group motivations age cannot be an appropriate way of segmenting people 71 to resolve this studies have focused on segmentation based on generation 69 70 71 instead of age for instance 13 found that perceived risk does not influence gen y eshopping behavior and 71 showed that the capacity to take risk is higher among gen y than gen x and hence these groups are to be treated differently especially when understanding perceived risk 26 recent studies on eshopping adoption have split customers based on flc stages 3672 due to its established significant impact on time pressure and situational changes in families which has been proven to be one of the crucial factors affecting eshopping 5273 family life cycle stages flc differences has been an important topic in consumer behavior studies for many years flc stages was introduced to the marketing domain by 75 the study noted that flc stages have a better predictive ability and explanatory power than the variable age and hence classifying customers according to flc stages is likely to be more meaningful thereafter many studies have been conducted in various areas which have shown flc stages to be a good predictor variable 7476 the flc notion postulates that when a family shifts from one stage of life to the next the roles of its members change as a result of which their financial position 77 lifestyle 7880 situation at home 8182 time pressure and stress level 8384 and leisure behavior 3940 change flc stages have also been found to have significant impact on worklife balance 414584 in an attempt to manage these demanding life changes and new life situations they modify many activities and shopping is no exception 85 several studies have found the influence of flc stages on shopping behavior in the offline context literature shows that as people move from one flc stage to the next the frequency of shopping trips and enjoyment 86 time spent in shopping 8788 purchase involvement and wise buying 89 outshopping behavior 90 shopping styles information use and decision making 91 spending behavior 92 consumer preference 9394 expenditure patterns 95 and brand loyalty 76 change various shoppingrelated issues including arranging money for shopping patronage patterns and preference for proximity and convenience to reach the store have also been found to be affected by flc stages 88 a recent study on the effect of flc stages on women shoppers observed that young mothers visit retail stores not only fulfil the shopping needs but also for recreation and social interaction 89 a study by 96 found how the shopping activities like shopping habits time spent on shopping and mode of shopping differed among mothers of infants with changes in life stages along with constant emphasis from information and communication technology researchers 8 36 37 38 there are also studies emerging in the eshopping arena which have proven the significant impact of flc stages on eshopping behavior for instance 36 the technology acceptance model posited how the perceptions attitudes and bi towards shopping online differed across various life cycle stages among indian women 72 understood the mobile shopping behavior among older adults based on their flc stage 44 found that young parents are more inclined to shop for kids products online their focus is more on convenience and quality than price 43 observed the effect of flc stages in consumer purchase behaviour by including the flc stages in the ecommerce recommendation system the results of all these studies prove that flc stages are better predictors of eshopping behavior while these studies have found the effect of flc stages on motivators of eshopping adoption among eshoppers studies aimed at understanding the effect of flc stages on barriers to eshopping among nonadopters remain scant in order to address this research gap this study attempts to understand the effects of flc stages on eshopping risk perception which is one of the most important barriers to eshopping hypotheses although perceived risk is found to affect people of all age groups preventing them from purchasing online the effect of risk is stronger on bi among people of the older age group as young people are aware of the presence of risk online they are generally less concerned about it but keep shopping online for other reasons 5 on the other hand older adults due to infrequent eshopping behavior 18 develop a lower level of trust towards eshopping sites the utility seeking behavior in shopping the attitude of treating service and security features separately 50 would still increase the risk perception towards eshopping sites moreover studies have noted that development of trust towards an eshopping site does not lead to intended purchase among older adults unless they are ready to overcome the perceived risk 50 thus it can be assumed that later lc stages would perceive a higher level of risk towards eshopping than early lc stages across all risk dimensions financial risk and flc stages concerns about security issues are highlighted predominantly as a major barrier to eshopping adoption 97 older shoppers are not inclined towards discounts and promotions and are sophisticated in their buying behavior 98 furthermore despite being less aware of financial risks involved in eshopping compared to their younger counterparts they tend to generally avoid risk than younger shoppers 99100 hence the financial risk perceived by the later lc stages would be higher than the early lc stages among early lc stages studies have shown that young families once they have children become financially unsteady as compared to families with no children 43101 to balance their financial instability they are found to be more involved in purchases and indulge in wise buying habits 75 studies have shown that risk perception is high when involvement during purchase is high 102 when dealing with online transactions there is a possibility of economic loss due to interception of information by unauthorised parties in such a case families with children would perceive more financial risk than families without children in addition families with young children have time pressure 3993 time pressure has been shown to induce a stronger negative relationship between financial risk and technology adoption 103 hence families with children families with preschool children families with school children are expected to perceive higher level of financial risk from eshopping sites than families without children expecting parents among later lc stages in families with children although dependent children grow older they still undergo higher levels of time and financial pressure 4350104 studies have shown that financial 105 and time pressures 103 aggravate financial risk perception it has also been reported that people looking for utilitarian value during purchase perceive higher levels of financial risk than people looking for hedonism 106 studies have noted that older women with children look more for utilitarian value from eshopping sites than hedonic value 36 families with dependent children families with adult dependents are expected to perceive higher financial risk as compared to families with no children or with independent children empty nest and solitary survivors hypothesis 1 the flc stage to which a woman belongs has a significant impact on perception towards eshopping financial risk which in turn affects ones bi to shop online timeloss risk and flc stages studies have shown that purchasing under time pressure crucially affects the perception of the risks involved in the transaction 35 although timeloss risk is not found to affect young online shoppers 107 with respect to groups for which time is critical time risk maybe an important factor affecting bi towards shopping 25 for women the time pressure increases as they move into the stage of parenthood 4483 and the time spent on leisure activities decrease 3940108 women in these households conserve time by shopping quickly 87 avoid outshopping 90 and prefer convenience during shopping 93 although the lower cost and time of acquiring information about products and services could be helpful for parents with young children who are timeconstrained 3983108 because of the uncertainty involved in eshopping sites the timeloss risk perception may increase 71828 this is because while people with less time pressure can correct mistakes by reordering the goods this is not always possible for timeconstrained customers 35 in addition due to the insufficient time for searching product information with the limited cues displayed online making the purchase would become a challenge to these heuristic decision makers 35 furthermore the timeloss risk involved in waiting time for webpage downloads 109 may make young mothers find eshopping to be a timeconsuming activity hence among early lc stages timeloss risk may be higher among families with children fn fn than families with no children similarly among later lc stages in families that involve children worklife pressures may not decrease but change focus due to frequent combination of teenagerparenting and eldercare 104110 in addition the timefinancial pressure has been found to continue 434450 increased timefinancial pressure difficulty to search and process information with limited product cues available online 3570109 and uncertainty involved in the new shopping channel 1828 could make families of these stages perceive a higher level of timeloss risk however older families with no dependent children do not have the urgency to buy products 90 these people also sometimes experience loneliness 111112 and they enjoy going out to shop 90 hence among later lc stages families with children fn would perceive a higher level of timeloss risk than families with independentno children en ss hypothesis 2 the flc stage to which a woman belongs has a significant impact on perception towards eshopping timeloss risk which in turn affects her bi to shop online performance risk and flc stages performance risk is found to be another dominant factor that acts as a strong barrier among customers to shop online studies have shown that the perception towards performance risk may rely upon the type of product categories chosen as people transcend from one flc stage to the next their needs change and consequently the choice of products 36 thus we expect that product risk towards online shopping site would differ based on the flc stage to which they belong young people are capable of accessing large amount of information and also better understand their technical aspects 113 they usually make purchase decisions after undertaking prior research on the topic which enables them to make faster purchase decisions 114 however the processing of information and the information seeking behavior is less among older people 36 and hence with limited product cues it would be difficult for them to assess the quality of the product 35 hence the perceived product risk would be higher among later lc stages than early lc stages among early lc stages new families with no children being young tend to use technology as an end in itself hence despite risk issues they continue shopping online for various other reasons 115 however flc studies have shown that once children enter families parents get more involved in their purchases and also indulge in wise buying habits to make an efficient purchase 75 for such parents it would be difficult to trust a new medium of shopping that may cause both monetarytimeloss in case of defect these people also rarely focus on price or brand but focus on style and quality 105 hence buying a nonbranded product of high quality without a touch and feel effect becomes difficult for these parents although product information is available online in general consumption situations people under time pressure do not have sufficient time to gather all information about product attributes hence they tend to process information at a faster rate and are more prone to focus on negative product information 35 in such a case the product risk would increase due to the uncertainty involved in online purchases 1828 when the discounts offered are high the risk perception also increases 11116 irrespective of age 23 these young parents are found to buy a lot of product categories which also has significant effect on risk 66 many consumers perceive high correlation between price and quality 24 literature shows that the most attractive fact about eshopping is the large discounts offered by sites 117 this would increase risk perception hence among early lc stages families with children fn fn would possess a higher level of risk than families without children among later lc stages older people are found to prefer branded products for their purchase 118 however the price dispersion online of the branded products and the large discounts on those products in a new shopping medium with high level of uncertainty may make buyers skeptical about the quality 18 moreover as people become older the ability to process information becomes challenging and time consuming especially when combined with time pressure 83 thus families with dependent children who suffer timefinancial pressure may perceive higher levels of performance risk on the other hand once the children become independent andor leave home the older parents have excess spare time 119 this makes them feel lonely and in order to overcome the feeling of loneliness they are found to spend more time on the internet 119 and also show interest in gathering information from websites 39 this may help these older families without children and en ss mitigate product performance risk furthermore these older families are found not to try new productsbrands but stick on to those that they have been using for many years 76120 hence among later lc stages families with dependent children fn would perceive a higher amount of performance risk than families with noindependent children en ss hypothesis 3 the flc stage to which a woman belongs has a significant impact on perception towards eshopping performance risk which in turn affects her bi to shop online social risk and flc stages social aspects have always played a crucial role in enhancing technology adoption in the eshopping domain in particular the effect of social influence on bi has been found to be stronger for women than men 1635 in a collectivistic country like india shopping is considered as a social activity 59 where people usually build relationships make collective purchase decisions and share their shopping experiences for instance 121 showed that accepted retail formats have become popular among indian shoppers social risk is perceived as high when one is not confident with the acceptance of a technology by their peer group in india several studies have noted that eshopping has diffused into younger market segments while not much among older people 5 hence the social risk perceived by the early lc stages may be less than the later lc stages as they are accustomed to traditional shopping formats among the early lc stages as social networks are crucial to young people 122 and most people have already adopted eshopping sites social risk towards eshopping is expected to be less among all segments young families with no children have enough spare time and hence have extensive social networks 82114 these families are more likely to indulge in statusseeking shopping habits in order to showcase their purchasing power 123 as eshopping is popular among these segments social risk perceived by them would be less conversely families with young children who are concerned about managing both their time and financial pressure are found to be least concerned about society 93124125 they are found to avoid social behavior during shopping and these parents are generally less likely to enjoy offline shopping experiences 124 preferring inhome shopping as it is focused and convenient 93125 hence social risk perceived by families of early lc stages withwithout children fn fn would be less once the women grow older they are concerned about societal norms and acceptance 114 they are not confident about their decisions and often look for opinions of others while purchasing products to ensure that their choice of product is correct 1 hence they are most likely to enjoy mingling with other shoppers 124 moreover they look for valueoriented shopping 126 as these women are older very few people in their peer group would have adopted eshopping 5 and hence they may face a lack of social assurance hence all later lc stages fn fn en ss are expected to perceive higher levels of social risk towards osss hypothesis 4 the flc stage to which a woman belongs has a significant impact on perception towards eshopping social risk which in turn affects her bi to shop online psychological risk and flc stages psychological risk is associated with ones mental state to acceptadopt the new shopping medium diffusion of innovation theorybased studies have noted that whenever a technology enters in the market it is the young people who adopt them first while older segments are late adopters 15 in a similar vein the mental acceptance of eshopping is high among young shoppers hence their psychological risk perception would be less however older people are comfortable with traditional shopping formats and hence find eshopping intimidating 67 price fluctuations in eshopping sites may reduce the trust developed towards eshopping sites hence due to the novelty of the activity people belonging to later lc stages may mentally not be prepared to adopt to the new shopping medium and hence would perceive more psychological risk towards eshopping than early lc stages past studies have noted that decision making under time pressure increases consumers psychological pressure anxiety and negative emotions causing a predisposition to avoid risk 34127 families with young children are found to have high levels of time pressure 83108 these mothers are also found to be particular and concerned about their purchases 93 due to their financial pressures 43101 hence families with young children fn fn may perceive higher levels of psychological risk while purchasing online than families without children among later lc stages studies have noted that families with grownup children have high levels of time and financial pressure as compared to families with independent or no children 256990 hence psychological pressure is expected to be high among these families nevertheless as the eshopping medium is new even families with independentno children would possess higher levels of psychological pressure in buying online age can be an additional contributor for their higher level of psychological pressure 67 hence among later lc stages all four stages fn fn en ss would possess higher levels of psychological pressure hypothesis 5 the flc stage to which a woman belongs has significant impact on perception towards eshopping psychological risk which in turn affects her bi to shop online source risk and flc stages familiarity with a website decreases the negative effect of overall perceived source risk on eshopping behavior 94106 people in early lc stages by virtue of being young can get to know better online shopping sites with their friends recommendations thus reducing the source risk on the other hand among older age groups the number of people who shop online is smaller and hence it is difficult to identify the reliable online firms to shop hence we expect source risk to be higher among later lc stages than early lc stages among early lc stages while nm and ep are young and do not have much time and financial pressures they can try different sources and can land on a good site 101107 they may get an idea from the recommendation of their peers and adopt and error method however timefinancial pressures are higher among families with young children when timemoney saving is considered as a major incentive by these young parents 3693 the trial and error method would be considered risky and hence source risk would be perceived as being high by these families fn fn among later lc stages since eshopping has not diffused much into the older market segments getting information through wom also becomes difficult moreover older consumers are incredibly loyal to companies 71 hence later lc stages would find it difficult to identify a credible source to buy online studies have shown that there is technology transfer parents learn using technology from their adolescent children 72 hence families with older children can get ideas from their children to locate credible sites 128 while en ss stages would find it more difficult hence en ss stages would perceive a higher level of source risk than older families with children fn fn hypothesis 6 the flc stage to which a woman belongs has a significant impact on perception towards eshopping source risk which in turn affects her bi to shop online aftersale service risk and flc stages aftersale service risk is found to affect eshopping however not all products require aftersale service and hence it depends more on the type of product bought online flc studies have shown that as people transcend from one flc stage to the next their needs differ and so do the products they purchase 7576 eshopping studies have also shown that the choice of the products differs with different flc stages 3643 hence the aftersale service risk towards eshopping is also expected to differ among early lc stages families with children are found to rely upon various services to take care of their children and hence buy many appliances to keep themselves comfortable 129 in such a case the need for a timely aftersale service becomes essential moreover because of the higher levels of involvement shown by the young parents during product purchase 75 added with their financial and time stress 50104 it is expected that families with young children would perceive higher level of aftersale service risk than families without children similarly among later lc stages families with children continue to have time and financial pressures 43 44 45 the electrical and electronic appliances used in families with children would be more compared to en ss stages 129 hence fn fn and fn may perceive a higher level of aftersale service risk although en ss do not rely much upon these appliances due to their old age they may require timely home service as they could be staying alone hence the fear of aftersale service risk would be present among all later lc stages hypothesis 7 the flc stage to which a woman belongs has a significant impact on perception towards eshopping aftersale service risk which in turn affects her bi to shop online delivery risk and flc stages delivery risk acts as one of the important challenges to eretailers and has increased consumers perceived risk towards eshopping among early lc stages nm and ep stages have enough discretionary time 107 and also do not face as much financial pressure 101 as families with children however in familial stages with young children although delivery charges may not be a big burden as saving time is a major incentive that these young mothers seek from online shopping sites 93 loss of goods and wrong delivery of goods may add to the existing financial and time pressures 5099 hence among early lc stages families with children fn fn would perceive more delivery risk than families without children during later lc stages as the online shopping medium is new the perception of risk related to the delivery of products would be higher than early lc stages among them families with children who experience considerable time and financial pressure 4344 would perceive a higher level of delivery risk moreover their familial needs are higher than en ss and wornwrong delivery would be very expensive in terms of both time and money hence fn fn are found to perceive higher levels of delivery risk than en ss stages hypothesis 8 the flc stage to which a woman belongs has a significant impact on perception towards eshopping delivery risk which in turn affects her bi to shop online privacy risk and flc stages privacy concerns are major inhibitors to eshopping acceptance among both new and experienced users 130 especially among women as they are technophobic and less susceptible to use digital technology 100 studies have shown that people with online shopping experience may be aware of privacy risk 29 hence women of early lc stages who are aware of eshopping may perceive less privacy risk than later lc stages however young people have been found to buy private products online than older people 131 hence they may also perceive privacy risk online hence we expect privacy risk to be perceived by both early and later lc stages hypothesis 9 the flc stage to which a woman belongs has a significant impact on perception towards eshopping privacy risk which in turn affects her bi to shop online physical risk and flc stages physical risk is the risk caused to the body due to the usage of a product studies have shown that young people are tech savvy and technology is their first hand and second brain 70 hence early lc stages who use internet not only for eshopping but also for other purposes 115 may not find physical risks to be problematic however women of later lc stages are older they are neither familiar with computers nor are they tech savvy 5 hence usage of computer for the purpose of shopping may cause adverse effect on their health adding to their already existing physical issues due to age 132 hence physical risk is expected to be higher among later lc stages than the early lc stages hypothesis 10 the flc stage to which a woman belongs has a significant impact on perception towards eshopping physical risk which in turn affects her bi to shop online research methodology • who have never shopped online as that would exactly replicate the risks hinder them from shopping online • residing in selected metropolitan cities of india and • living in nuclear families since the nuclear family system predominantly exists in metropolitan cities of india 133 furthermore it is believed that time and work pressures are higher in nuclear families than in extendedjoint families which would affect eshopping behavior • who have remained in that particular flc stage for the past 6 months to ensure buying behavior of that particular stage data collection instrument this study is nonexperimental and quantitative in nature the study used offline mode for data collection standardized selfreport questionnaires were used to collect data which had two sections it began with the administration of screening question to respondents to ascertain if they have had any prior eshopping experience if the answer was no the respondent proceeded with the questionnaire section 1 focused on the demographic profile of the respondent and collected details about familyrelated information including respondents age spouses age and employment status age of children information on children living with them or not to understand the flc stage to which they belonged section 2 captured the perception towards eshopping perceived risk dimensions and bi the 134 scale was used to measure performance risk financial risk timeloss risk psychological risk source risk physical risk and 60 scale was used to measure social risk privacy risk delivery risk aftersale risk which consisted of a total of 33 scale items measured on a seven point likert scale anchored by strongly disagree to strongly agree 135 as the questionnaire has not been tested in india a pilot study was conducted by collecting data from 10 samples across all segments following this fullfledged data collection was made data collection procedure data is gathered via offline mode we met respondents directly at home we preferred societyapartments as it is easy to meet many respondents at a time the societyapartment head is contacted and explained with the data collection process and with their support the hard copies of the samples are distributed to all the houses in the apartments gifts and rewards are announced to encourage participation we requested the samples to participate in the survey staying at home the questionnaires are collected from their homes after three days data collection was made over a period of four months in five metrocities ie chennai bangalore hyderabad mumbai and pune in order to have a wider variety of population the study sought 100 filled questionnaires from each flc stage respondents were met directly at homeapartments and requested to participate in the survey the homes and apartments were chosen in such a way that it covered the major areas of the cities gifts worth rs a total of 30 were announced to all participants additionally a lucky prize worth rs 1000 was announced for three participants to improve the participation rate respondents were given a time of three days to complete the questionnaire two rounds of data collection were carried out the first round was based on the convenience sampling method homesapartments located in different parts of the five metrocities were chosen and around 3500 respondents meeting the study criteria were requested to participate in the survey finally 725 respondents agreed to participate in the survey in round 1 after excluding incomplete questionnaires and treating responses with a few missing values using the amos maximum likelihood method 673 usable responses were obtained of the received responses 53 of the respondents were in early lc stages and 47 were there in later lc stages to obtain an adequate number of required samples a second round of data collection was carried out the second round was based on both convenience and snowball sampling a total of 1685 participants were identified through snowball sampling with the help of the respondents who participated in round 1 along with convenience sampling all participants in round 1 were requested to suggest potential respondents from nearby areas after they completed the survey with the information received data was collected from these participants and also through our own search this resulted in 349 responses out of which 240 were usable among them 56 belonged to early lc stages and 44 belonged to later lc stages a total of 913 usable responses were received 500 were in early lc stage and 413 were in later lc stage when split based on flc stages there were 103 nm 87 ep 103 fn 102 fn 105 fn 105 fn 105 fn 104 fn 99 en ss this sample size is larger than that used in previous studies 42 we then proceeded with data analysis sample demographics table 3 shows the sample demographics the respondents were in the ages of 2162 years the average age of respondents was about 43 years in terms of employment status 34 of women were employed full time 25 were part time or workfromhome employees and 41 were housewives a total of 28 of women had completed their postgraduation 35 had undergraduation degree 27 had higher secondary education and the remaining 10 had below higher secondary education level this is similar to the observation of previous studies that women who have not shopped online are unemployed and less educated 53136 data analysis as recommended by 137 a threestep approach was adopted to analyze the collected data • preliminary tests first all measurement models were checked for their psychometric propertiesthe reliability and validity to do this smart pls 30 software package was used as it is an extensively accepted variancebased descriptive and predictionoriented approach in structural equation modelling 138 to ensure the data were free from common method bias harmans single factor test was conducted using spss 210 • structural model to measure the relationship among the perceived risk dimensions and bi across flc stages partial least square structural equation modelling was used as it is an appropriate technique for studies with small sample sizes and models with multiple relationships 139 • multigroup analysis to know if there were significant group differences across flc stages in the dimensions of perceived risk and bi relationship plsmga was carried out as it is considered to be the simple but robust method 138 results and discussion preliminary tests to assess the measurement model the data were checked for reliability and validity reliability was checked with composite reliability values all the cr values were above 07 meeting the threshold requirement thus fulfilling the reliability test 140 after the reliability test the data was tested for its validityboth in terms of convergent and discriminant properties convergent validity of the constructs were tested with two values 141 factor loadings and average variance extracted the factor analysis results showed factor loadings of items on the constructs all items had factor loadings above the recommended level of 070 on their corresponding constructs thus indicating good convergent validity similarly all the aves ranged from 0676 to 0807 which exceeded the recommended level of 050 this shows that more than one half of the variances observed in the items were accounted for by their hypothesized constructs thus both conditions for convergent validity were satisfied following this to check discriminant validity of the data the shared variances between factors were compared with the ave of the individual factors 141 the result showed that the ave of the individual factors were higher than the shared variances between factors confirming discriminant validity further the factor analysis result showed that factor loading on the respective construct was larger than its loadings on all other constructs and there was no crossfactor loadings indicating good discriminant validity 142 thus the measurement model demonstrated adequate reliability convergent validity and discriminant validity then the harmans onefactor common method bias test was conducted the unrotated principal component analysis including eleven factors counts for 37 of the total variance lower than the cutoff value of 50 indicating that the data is free from common method bias structural model once the data satisfied the reliability and validity tests the structural model was tested to confirm the hypothesized causal relationships among the constructs under study this study proceeded to test the path significances using a biascorrected bootstrapping resampling technique with 5000 subsamples 139 the path coefficients indicated the strengths of the relationships between constructs paths with tvalues greater than or equal to 196 with a significance level of 005 16 was considered to be significant relationship r 2 value indicates the overall predictability of the model baseline model testing overall results as shown in figure 2 the results of pls analysis showed that of the ten dimensions of perceived risk only five dimensions have significant negative effect on bi to shop online the directions of the relationships are in accordance with the findings observed in other studies 9 10 11 12 13 14 15 16 17 18 and the metaanalysis by 19 factors in order of relative importance affecting bi to shop online were performance risk social risk timeloss risk psychological risk and source risk while financial risk aftersale risk physical risk delivery risk and privacy risk were found to have insignificant effects 60 checking r 2 values perceived risk predicted 757 of intention thus it confirmed the model validity by meeting the reasonable criteria to confirm the model validity 143 across all relationships performance risk was more influential in affecting bi to shop online than any other risk dimensions this is similar to the results observed in several previous studies 242894 following this social risk and timeloss risk were found to play dominant roles this is also in line with the results observed in past studies 24252833 however some studies have also shown that social risk and timeloss risk had insignificant effect on bi to shop online in certain developing countries 60140 however as far as eshopping in india is concerned social risk and timeloss risk continue to play an important role in affecting eshopping behavior among women the reason for social risk to show a significant effect may be that women in india buy in groups and enjoy group memberships when one shops online one may feel insecure that she may be separated from the group in a similar vein the significant effect of timeloss risk on eshopping bi may be due to the time constraints that indian women have due to excessive time spent on taking care of children and household responsibilities than men hence losing time may be of great concern to them psychological risk was found to play a dominant effect this may be attributed to the fact that eshopping is in nascent stage in india and most women are used to traditional shopping formats financial risk was also found to be an important barrier for eshopping 1294106 the results of this study showed insignificant effect a similar result was also observed in a previous study conducted in china 144 the reason for financial risk being insignificant maybe because customers prefer the cash on delivery mode of payment to online payments in india 2 due to poor internet security studies have noted that the perception towards financial risks differed widely with culture and eshopping adoption rate 60 privacy risk was found in earlier studies to be a major deterrent affecting eshopping bi particularly in collectivist cultures 145 however our study showed an insignificant effect of privacy risk on eshopping bi studies have shown that except for expensive products privacy risk did not have a significant effect on others 29 as purchase of lowticket items is more popular in india than the purchase of expensive goods privacy risk would not have shown a positive effect moreover earlier studies have shown that women are concerned about privacy and hence take all necessary measures to protect their privacy 130 hence women would be proactive in protecting their privacy while other risks which are beyond their control would show a stronger effect alternately just mitigating privacy and security risk on eshopping would not make one shop online privacy and security maybe the basic things expected by eshoppers it may be a hygienic factor as noted by herzbergs theory the absence of which would affect adoption of eshopping while its presence may not contribute to buying behavior physical and delivery risks were found to have insignificant effect in our study similar to the result observed in previous studies 2560 flc stagewise model testing across early lc stages of the ten dimensions of risk only three dimensions were found to affect people of early lc stagesperformance timeloss and aftersale for nm women no other risk except performance was found to affect eshopping purchase intention ep families avoid shopping online due to their strong perception of performance and aftersale service risk once children enter into the family it could be observed that timeloss risk starts to play a much more crucial role than aftersale service risk in affecting bi to shop online in 36 the authors noted that time saving acted as an important reason for these young families with children to shop online with this result it is noted that the same factor also acts as a great hindrance to adopt eshopping hence it could be inferred that timeloss risk may act as a barrier before adoption but once adopted eshopping offers timesaving benefit that the same acts as a strong reason to shop online however other risk dimensions like financial privacy social source psychological physical delivery were found to be insignificant in affecting early lc stages bi to shop online 4 as women reach later lc stages of the 10 risk dimensions 5 dimensionsperformance social source psychological and aftersale were found to affect eshopping bi performance risk continued to be a strong barrier to bi among all later lc stages however the timeloss risk has been found to lose its effect while psychological risk source risk and social risk starts gaining importance 2528 as expected since these older families are not used to eshopping psychological risk of adopting a new channel and if at all adopting confusions about the reliable site source risk all act as hindrances among these later lc stages however this was not applicable to all later lc stages only 2 groupsfn and en ss were found to be affected by source risk while it was insignificant among groups fn and fn en ss stages perceived aftersale service risk as these people are new to eshopping and also stay alone hence they have the most need for them security risk privacy risk timeloss risk delivery risk physical risk had insignificant effect on eshopping bi among these older segments multigroup analysis analyzing the plsmga considering the significant factors in sem analysis it could be noted that there were not many group differences between early and later lc stages while performance risk was expected to be higher among later lc stages than early results were to the contrary early lc stages were found to perceive a higher level of performance risk than the later lc stages fn and fn were particularly found to perceive a low level of performance risk time loss risk as expected is one dominant factor that was found to affect families with young children families fn showed a significantly higher timeloss risk than families without children fn was also found to differ with certain later lc stages fn and en ss in a similar vein though not so rigorous fn and fn perceived very high timeloss risk that it 4 as women reach later lc stages of the 10 risk dimensions 5 dimensionsperformance social source psychological and aftersale were found to affect eshopping bi performance risk continued to be a strong barrier to bi among all later lc stages however the timeloss risk has been found to lose its effect while psychological risk source risk and social risk starts gaining importance 2528 as expected since these older families are not used to eshopping psychological risk of adopting a new channel and if at all adopting confusions about the reliable site source risk all act as hindrances among these later lc stages however this was not applicable to all later lc stages only 2 groupsfn and en ss were found to be affected by source risk while it was insignificant among groups fn and fn en ss stages perceived aftersale service risk as these people are new to eshopping and also stay alone hence they have the most need for them security risk privacy risk timeloss risk delivery risk physical risk had insignificant effect on eshopping bi among these older segments multigroup analysis analyzing the plsmga considering the significant factors in sem analysis it could be noted that there were not many group differences between early and later lc stages while performance risk was expected to be higher among later lc stages than early results were to the contrary early lc stages were found to perceive a higher level of performance risk than the later lc stages fn and fn were particularly found to perceive a low level of performance risk time loss risk as expected is one dominant factor that was found to affect families with young children families fn showed a significantly higher timeloss risk than families without children fn was also found to differ with certain later lc stages fn and en ss in a similar vein though not so rigorous fn and fn perceived very high timeloss risk that it also differed with some later lc stages contradicting expectation the aftersale risk perceived by early lc stages was higher than the later lc stagesfn and en ss that they differed significantly with all early lc stages except fn groups ep and fn perceived higher levels of aftersale service risk as expected perception of psychological risk was found to be much higher among later lc stages especially fn and en ss that it differed with all early lc stages en ss differed with later lc stages fn and fn as well in that people belonging to this stage perceived a high level of psychological risk with regard to social risk among later lc stages fn perceived a higher level of social risk than any other group that it differed with fn and fn en ss also perceived a higher level of social risk but not as high as fn however among other later lc stages fn or fn did not differ significantly from the early lc stages hence their perceived social risk was small source risk was found to be perceived highly by en ss stages and it differed with ep and fn stages fn and fn also differed with ep stages however fn did not show a significant difference with any early lc stage implications theoretical contributions this study contributes to a relatively unexplored field and hence it is a pioneering effort to understand the role of flc stages on eshopping perceived risk among indian women additionally the study is focused on indian women across all lc stages which is hardly available in the literature this paper has made contributions to eretail research in the following ways first this study considered the ten dimensions of perceived risk and analyzed their direct effects on eshopping bi among indian women the results empirically proved that perceived risk dimensions have negative effects on eshopping bi in india while dimensions like performance social timeloss psychological source security and aftersale service risks were found to have significant impacts on eshopping bi among indian women dimensions like physical privacy and delivery were not found to play any role hence this study emphasizes on understanding the multidimensionality of perceived risk as some dimensions of perceived risk may prove more useful than others 6710 second using the indian flc stages model this study examined how various risk dimensions affected bi towards eshopping as women transcended from one flc stage to the next for this we critically examined the ten dimensions of perceived risk across nine flc stages results showed that not all the risks affected people of all flc stages certain risks were perceived more strongly than other risks at different stages of life for instance timeloss risk and aftersale risk acted as important hindrances in early lc stages while social or source risk did not have a significant effect as women reached the later lc stages timeloss and aftersale risk were found to become insignificant and social and source risk became dominant the observations of the effects of perceived risk on women shoppers across varied flc stages showed as women transcend from one flc stage to the next their situations vary based on which their perceptions of the risks of eshopping also vary by testing the relevance of each dimension to each flc stage we extend our knowledge on how to decrease the perceived risk of buying online among women across each flc stage hence this study proves that flc basedsegmentation is useful in eshopping studies managerial implications this study has the following managerial implications performance risk is found to be dominantly hindering women from shopping online across all flc stages hence measures must be taken to mitigate this risk detailed and complete product information clarity regarding product guarantee and warranty policies free returns etc may help to some extent 22 however as eshopping lacks the touch and feel effect offering additional features like multidimensional view of the products with zoom functions and product comparison features can aid consumers in making better purchase decisions higher performance risk is found to increase the online search behavior 146 hence facilitating quick search of products is essential eshopping sites may provide the right amount and quality of information at the right time to the customer at the site to promote purchase decision furthermore the young generation is found to be more comfortable with brands than previous generations 147 hence ensuring availability of branded items with appropriate product information may help them mitigate risk 1370 in addition studies have noted that at times of purchases that involve relatively high product performance risk along with product information customers check the sources trustworthiness 148 hence providing such information would also be helpful timeloss risk is found to affect families with young children among early lc stages studies have already noted that these women are hard pressed for time and look to save time by shopping online to reduce timeloss risk a website that is light and also easy to navigate must be provided 36 when subjected to time pressure people opt for choosing branded goods to avoid risk hence for these groups more branded goods may be offered rather than local brands 35 this would increase the time shoppers remain on the webpage that may end up in a purchase aftersale risk is also found to affect early lc stages hence eretailers must guarantee aftersale service for young parents who are constrained in both time and money these segments are found to buy more number of products from eshopping sites thus by guaranteeing and offering good aftersale service a large segment of consumers could be captured social risk source risk and psychological risk play significant roles among later lc stages in eshopping adoption as discussed shopping is considered a social activity in a collectivistic country like india hence to make eshopping an accepted retail format indian women must be made to understand that they are not shopping online in isolation in general women tend to share their shopping experiences with others hence actual eshoppers can be projected as role models to potential buyers a positive wordofmouth strategy could help to advance and promote the benefits and awareness of the services of online shopping providers 733 which would build a trust towards the company providing clear information based on comparison of reviews along with pictures may reduce risk and increase source credibility among consumers 17 women are more open to social influence than men and often look for opinion of friends before making a purchase decision 11 hence eretail firms must encourage customers to create wom recommendation and actively participate in social forums that would reduce eshopping risk perceptions 71 with regard to security and privacy risk issues both have insignificant effects on eshopping bi among indian women 149 this does not mean the ecustomers do not look for a secure transaction system when ideas like digital india is gaining momentum cod option will gradually be eliminated from online e shopping systems in such a case without a secure system no customer will shop online hence eretailers must adopt superior encryption technology and implement buyerfriendly online security and privacy protection measures 22 limitations and future research directions this study is not free from limitations that offer avenues for future studies with regard to the methodology the risk dimensions and their effect on eshopping adoption could be different for different product categories 29 hence understanding how it differs across various product segments would be helpful 20 moreover perceived risk has been found to be considerably more when purchasing services than for goods 24 hence a study of variations in risk perception across flc stages when purchasing services would be informative this study dealt with perceptions of online shopping risks by studying the nonadopters of eshopping however the actual risks perceived by eshoppers may be different and these differences must be understood studies have shown that when there are huge discounts the risk perception is high in such a case at times of sale the risk dimensions affecting bi may differ this aspect must be tested 66 while this study concentrated on one of the online activities ie eshopping future studies could focus on activities like ebanking in order to understand ecommerce more effectively finally risks are a function of involvement with the decisionmaking process if this model is analyzed according to categories due to its implication these results could be modified future research can test this variable in the model appendix a questionnaire item no texts of items source ten dimensions of perceived risk perceived financial risk i am concerned that my financial records might not be adequately protected if i shop online 134 it is not safe to give my credit card number when i order online i am concerned about the ultimate price of the online product because there might be hidden costs perceived performance risk it is difficult to ascertain the characteristics of the products such as quality size colour and style by just looking at pictures on the web 134 it is difficult to feel try or land experience the product prior to purchase during online shopping i am concerned that the product delivered may not be exactly as it appeared when displayed on the computer screen perceived timeloss risk i would have to spend much time if i want to return online merchandise 134 i am afraid that products purchased from online vendors will not be delivered on time i am concerned for the time lost between ordering and receiving products bought over the web perceived psychological risk the thought of online shopping makes me feel uncomfortable 134 the thought of online shopping causes me to experience unnecessary tension online shopping will lead to too much social isolation perceived source risk it is difficult to ascertain the reliability and expertise of some online companies 134 it is difficult to ascertain the reputation of some online companies i am concerned about the trustworthiness and believability of some online companies perceived physical risk i am concerned about experiencing eyestrain because of frequent exposure to computer screen during online shopping 134 i am concerned about viruses infecting my computer while i shop online i am concerned about getting carpal tunnel syndrome while shopping online perceived social risk online shopping may affect the image of people around me 60 online products may not be recognized by relatives or friends online shopping may make others reduce their evaluation of me item no texts of items source perceived privacy risk my personal information may not be kept safe 60 my email address may be abused by others my personal information may be disclosed to others companies perceived delivery risk an additional fee will be charged for express delivery 60 after shopping goods are easily lost express delivery may be sent to the wrong place perceived aftersale service risk if i have problem with a product it will be hard to contact the seller 60 it is difficult to solve commercial disputes in online shopping products purchased online may lack an aftersales service guarantee behavioural intention given a chance in the next six months the likelihood of shopping online is high 60 i would consider shopping online my willingness to shop online is high author contributions conceptualization methodology software validation formal analysis investigation resources data curation writingoriginal draft preparation writingreview and editingra visualization supervision funding acquisitionvjs project administrationyh all authors have read and agreed to the published version of the manuscript funding this research received no external funding

the relationship between perceived risk and behavioral intention bi in eshopping based on family life cycle flc stages has been analyzed in this work although flc stages are considered to have a better predictive ability than age few eshopping studies have concentrated on understanding its effects this study as a pioneering effort has divided indian women based on nine flc stages and has studied the role of ten dimensions of perceived risk on bi to shop online across each life cycle stage results show that different facets of risks had distinct effects on purchase behavior among women belonging to different flc stages in effect this study shows the importance of splitting people based on flc stages in emarketing and its value in making marketing decisions

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1 introduction in each community the development of the community is greatly influenced by the involvement of its citizens in the form of participation the participation is manifested in the form of community participation through social action related to a community program which contains planning identification decision making and responsibilities that are consciously chosen to benefit 1 4 the maiwa ethnic lives in maiwa subdistrict of south sulawesi the maiwa population is estimated about 320000 people the ethnic is one of the bugis subethnic they have a high social sense this is shown in the pattern of mutual cooperation in every activity and daily life of this maiwa ethnic 5 moreover they are predominantly followers of islam but assimilated with local beliefs islamic life is very thick in the daily life of the maiwa people it can be seen in several traditions and cultures that contain many islamic elements islam entered here since the 17 th century even though they embraced islam some of the animist traditions are still carried out here some shamanic practices are still carried out as well as trusting sacred places that are considered to be able to have catastrophic effects for those who do not respect it 6 in their daily lives this community works as farmers they planted a number of hard plants such as coconut coffee and cloves as the source of livelihood for the maiwa people while some others choose the profession as a trader and other professions in carrying out these daily lives the maiwa society is very thick with traditional leaders there is a subtribe of maiwa called the matajang society has a traditional leader called tau appa the traditional leaders were formed in a traditional institution that has been going on for generations the traditional institution is also believed to be a manifestation of gods representative who was sent down to earth to help people realize lives that are in harmony with nature and god this situation is also suitable to main characteristic of community in bergers perspective 7 that they tend to create a harmony and balancing lifes all human actions in daily life are aimed at creating mutual understanding for the sake of mutual peace gradually the actions that the community feels in them there is peace will experience repetition and patterning until they become a habit to secure this the community then accepts the good habit as a custom that is strengthened by custom institution in the custom institution ruler of republik indonesia number 1 year of 2009 custom institution is a social organization that is intentionally formed or that has naturally grown and developed in the history of the community or in certain customary law communities with jurisdiction and rights to assets within the customary law area that has the right and authority to regulate administer and settle various life issues related to local customs and customary law within the territory of the republic of indonesia definition of custom institution according to directorate of village government development of directorate general of the ministry of home affairs 9 is an institution that contains values views of life ideals knowledge beliefs and norms that are interrelated with one another it functions as the highest guideline for people to behave this means also the local institution maintains harmonization of its people based on the description above it is important for researchers to reveal the existence of the tau appa traditional or custom institution in relation to the participation of the community in maiwa enrekang regency research methods this research descriptives the role of custom institution of tau appa qualitatively 13 15 the roles is about directing and instructing people in involving to all of societys activity so this research uses also institutional approach the tau appa custom institution is located in mata kali village maiwa district enrekang regency research informants consisted of 4 leaders in tau appa custom institution 1 village head 2 community leaders and 2 local people those informants know much about the custom institutions role in driving peoples participation data collection used interview techniques observation and literature study data analysis technique used threeflow model namely data reduction categorization and conclusions 16 this model describes the way in data analyzing that in the same time there could be reduction and data categorization together 3 result and discussion 31 profile of custom institution in mata kali society the costum institution is called tau appa that means the four men of leader the four men are tomatoa means the old man he is the leader of of this costum institution leads all of rituals in this society and opens and closes all rituals imang or sarak officer this imang ensure the action of society in accordance with local custom especially in ritual ceremony dulung as the responsible person for livelihood in this society he drives people to work based on local costum not work by modern knowledge livelihood relates the local peoples job as farmer and gardener sanro or shaman this person is in charge of health protection physically sanro protect also local people from demonic interference through his ritual rejecting reinforcements the urgent of custom institution existence 321 organizing traditional activities as a community guide in this section what is said by the top leaders of custom institution must be carried out because there is a place for information about their customs for examples they may not go home immediately after friday prayers because there is usually important information to be conveyed because these four elements of custom institution meeting and talking about the afterlife in the time before friday and at the end of the friday prayers they again meeting to talk about worldly problems this custom leader also gave instructions to the other three custom leaders and always reminded each other in various matters including worldly duties another task is to lead the meeting on friday after prayer because at that time each of tau appa took turns talking to convey information to the community including always leading and organizing and distributing tasks to other leaders for example giving directions to livelihood officials to always do their work the other most important task is to give prior approval of what is carried out in the community that is before a public and traditional event must be known and give its approval because the smooth celebration in a village is all customary responsibilities whatever celebration will be carried out in both the rambu solo and the rambu tuka regulate and understand this the person in charge of sarak this person responsible for sarak or imang is tasked with discussing the afterlife in front of the congregation the time before friday which includes not being able to go to an event when no community comes to call him all that relates to the problem of the afterlife is the duty of the imang to distinguish between good and bad what needs to be done so that we do not sin so that our lives in the good afterlife are sarak duties in essence imang is in charge and ensures that all community activities are always related to customs and religion the person in charge of agriculture dulung this person has more work because it is directly related to community livelihoods one of his tasks is to provide information to the public about plants on friday after friday prayers are finished in addition he also determines the time when farmers start planting again both in the fields and in the fields in carrying out activities the person in charge must ask permission from the almighty when the work is about to begin because essentially all places are occupied by gods creation we must ask permission from him including gods creations in the form of supernatural beings the person in charge of health protection sanro this custom leader is known as the protector of the village he is responsible for human safety the health protection officer also plays a very important role in protecting the community because he can know supernaturally when things are about to enter the village to protect the village he instructed the community to jointly perform the mattulak bala reinforcements ritual on friday nights participation of community in matakali village 331 custom participation when there are ritual activities all of tau apa must attend both the rambu solo and rambu tuka events rambu solo related to grief such as death rambu tuka is related to joy party such as marriage harvest party thanksgiving marriage and so on the task of tomatua is to arrange everything will do their job if there is permission and order from tomatua so it is a tomatua who knows all of positions of sanro dulung and imang including the sitting position during the rambu solo ritual or the rambu tuka ritual the tupoksi tau apa to tau ega is to carry out all forms of rituals the assumption is that there is almost no time for tau apa to take care of his own world life because their time is up in the matters of ritual afterlife participation of development 341 participation in mind inviting people to get involved in various activities is not difficult this condition is seen by various community meetings or tudangsipulung especially in the lead up to family and community rituals during the meeting residents wholeheartedly flocked to follow it only with one delivery through the mosque in fact during the meeting they also expressed a lot of their thoughts participation in labor in matakali village the involvement of residents in almost all activities has always been the main thing especially when it comes to traditional activities all traditional activities such as the rambu solo ritual rambu tuka ritual maccera manurung ritual andulang ritual and so on are almost certainly able to take place due to community involvement the same thing also happened to the construction of facilities and infrastructure such as road construction construction of houses of worship village offices and schools although the work requires professional staff citizen involvement in some parts of it is still very much needed for example when villagers work on village roads all men are involved in completing them starting from cleaning the road leveling mixing cement mixture and so on however in some parts of the work such as the supply of sand and cement mixing machines they still use graders participation of goods and money reality shows that citizens are so eager to donate not only mind and energy but also goods and money some people bought cement some donated sand some also rented moleng machines soil compacting machines and the rest contributed food this continued until the street they could pass analyzing community participation in matakali it can be said that they have a high level of participation this is caused by their emotional ties to the traditional leaders of tau apa who they believe to be the incarnation of god dewata seuwwae that is their participation is both a belief and a form of obedience to god obey to god then their lives will be harmonious and harmonious the existence of traditional institutions in maiwa is very urgent in the life with the people it was much influenced by the homogeneity of the community towards their beliefs about the custom institution as a society that relies heavily on figures relies on charismatics relies on offspring matakali villagers place high trust in the tau appa custom institution this aspect is then strengthened by the strengths possessed and demonstrated by the tau appa figure as it is emphasized that one of the strengths of a leader is to have the strengths displayed above the ability of the community 17 18 considering the sociocultural characteristics a number of steps have been taken to strengthen the existence of custom institutions in the matakali village area namely collaborating with the village administration in various activities empowering the potential roles and functions of the tau apa as custom institution to assist village government objectives maintains the existing autonomy and authority of traditional institutions strengthen the existence of custom institutions through village ruler provision of benefits involvement in government activities as a form of government appreciation increasing the role and function of the tau apa as custom institution to be wider not only in rituals but in joint villagelevel decisionmaking for development facilitating community interests in development through the provision of facilities and infrastructure strengthening ritual symbols through improvement of facilities and infrastructure such as repairing roads to andulang and repairing mosques thus the existence of custom institutions indirectly experiences strengthening and at the same time becomes a container for controlling the sociocultural life of local communities through various rituals and other values that have been integrated within them conclusion the traditional institution in maiwa is believed to be a representation of to manurung as local belief as well as a source of the highest norms for people who guide their daily lives the forms of community participation in matakali village consist of two parts custom participation and participation in development custom participation related to custom ritual meanwhile the participation for development related to build and repair highways build schools build houses of worship and other public facilities there are three types of citizen participation namely mind participation labor participation and goods and money participation custom institutions collaborate with village government in mobilizing community participation where traditional institutions are functionally cultural while village governments are structural 4

the existence of custom institution is associated with traditional community entities that are generally located in inland areas traditional society is a term that is attached because almost all the daily activities is simple of many people use local resources and the nature the livelihoods of people are still dependent on agricultural land plantations and forest products in this context custom institutions exist that ensures all kinds of community relations between them the environment and god to keep them in harmony this paper intends to reveal the existence of custom institutions as a special community that called tau appa in maiwa subdistrict so that explorative research is conducted by interviews and documentation studies interviews conducted with local community leaders and community members the results of the research obtained as follows 1 custom institution tau appa is a manifestation of local trust of to manurung 2 tau appa present to maintain life harmonization of local community 3 people participation is divided into 2 types namely custom participation and development participation 4 it needs the government support in strengthening the existence of custom institution observing that results it can be concluded the following things custom institution is the source of custom and social norms for the matakali people custom institution as the mobilizer of all people activities custom institution need to be supported the existence role and function by government

19871_0

background ensuring universal access to family planning services is a priority in the 2030 sustainable development goals 1 removing barriers to access fp services as well as making sure women have the information and support they need to seek reproductive health services receive respectful care and be able to effectively use contraception when desired will allow women to exercise their reproductive autonomy 2 meeting womens fp needs has been shown to help reduce maternal mortality which is particularly high in subsaharan african countries such as madagascar 34 while there is growing research showing that womens social networks that is their ties with family members friends and health care providers and the nature of these ties affects their contraceptive use 5 6 7 8 9 10 11 12 13 14 male partners can also influence whether women use contraception 15 studies have shown that perceptions of whether male partners are supportive of contraceptive use can influence whether women use contraception 16 17 18 19 20 21 22 for example concern about opposition to contraceptive use mainly from male partners was identified as a barrier to contraceptive use among women in madagascar 23 additional research has found that involving men in contraceptive counseling was associated with increased contraceptive use 24 25 26 27 though other studies have found negative or no effects 2829 most research on the role of men in contraceptive decisionmaking has focused on their individual characteristics such as age education urbanicity as well as social and cultural factors such as religious beliefs desired family size gender roles and male identity 30 31 32 33 34 however very few studies have moved beyond looking at mens individual characteristics to consider whether mens social networks influence womens contraceptive use insofar as womens contraceptive use may be influenced by their male partners womens contraceptive use may also be influenced by the networks of their male partners ie the ties that men have with their partner family members friends and health providers 3536 based on the nature of these ties networks can provide informational emotional and financial support offer opportunities for peer learning andor social engagement while being influenced by the sociocultural context within which they exist whereas researchers have increasingly used social network theory and analysis to explore how womens reproductive health decisions are tied to others in their networks 37 38 39 very little research exists examining how the composition of mens social networks may influence in part female partners contraceptive use a longitudinal network study in kenya found that couples were significantly more likely to use contraception if the male partner had at least 1 contraceptive user in their own network adjusting for unmeasured confounding and the tendency for individuals to have ties to other individuals with similar characteristics 9 another longitudinal study found that men in ghana who received positive encouragement from their social network to use contraception were more likely to report using contraception with their partners 40 men may differ in the types of social ties they rely on for seeking information and advice about fp including contraceptive use some men may rely on health providers for fp and contraceptive information and advice while others may rely on social ties such as friends partners and family members men may also rely on a combination of both of these or on no one at all indepth interviews among married men in uganda found that men preferred to rely on partners for contraceptive information as opposed to health providers peers or mass media 41 focus group discussions with men in kenya revealed that men did not trust either their health providers or their partners for fp information 33 the extent to which the type and composition of ties in mens fp networks impacts contraceptive use among couples is unknown while relying on health providers for advice is expected to be positively associated with couples contraceptive use the influence of other kinds of ties within mens social networks on couples contraceptive use is more ambiguous a study among women in the united states showed that women tend to hear negative or incorrect information about contraception from their social relations compared to providers but it is unclear if this might be the case for men as well 42 however this association has not been studies among men especially within a resourcelimited setting additionally networks can constrain individual autonomy in reproductive health decisions by inducing individuals to align their behaviors with other network members 4344 information about the extent to which the composition of mens networks for fp information and advice may be associated with couples contraceptive use is limited addressing this gap in the literature could inform the design of fp interventions that leverage mens social networks to foster their engagement in contraceptive decisionmaking support their partners choices in relation to contraception use and facilitate the goal of universal access to fp for all women in this egocentric network study among men in madagascar we collected data from men about who they turn to for information and advice regarding fp and how these fp ties are associated with their female partners contraceptive use we assessed 1 whether men were more likely to report that their partner was using modern contraception if they personally had at least one fp tie to turn to for information and advice about fp 2 whether the composition of mens networks was differentially associated with couples contraceptive use 3 whether men who knew other individuals using contraception were more likely to report that their partner was using modern contraception and 4 whether the characteristics of mens ties such as type of interpersonal relationship and the perceived support of contraceptive use by that person was associated with couples contraceptive use methods study participants and design the study sample was recruited from 27 villages randomly selected from the 80 villages within a 5 km radius of the semiurban town of ambalavao in fianarantsoa province madagascar data collectors enumerated all households by village and then used random number draws to identify households for study participation the total sample chosen from each village was proportionate to the number of households in the village with a minimum of 5 households per village within each selected household the data collector enumerated all men ages 18 years and older who were willing to answer questions about fp and then randomly selected one man surveys were conducted in the local language by male data collectors in order to facilitate study recruitment and elicit candid answers about reproductive health topics prior to data collection written informed consent was obtained with verbal informed consent permitted for participants who could not read and write all men who were randomly chosen within a household consented to participate yielding a study sample of 208 men men who were not in partnership and men whose partners were pregnant were excluded from this study thus the final analytical sample included 178 study participants participants were provided with a small gift for their time and participation in the form of a lamba a cloth used locally for multiple purposes the study received approval from the national ethics committee in madagascar and the university of california san francisco institutional review board crosssectional data were collected from june to july 2019 measures the primary outcome was a binary measure of whether the participant reported that their partner is currently using modern contraception we hereafter interpret this variable as the couple using modern contraception though it is understood that the measure is based on the male partners perception of his partners contraceptive use we defined modern contraception to include injectables the pill implants intrauterine devices and external condoms participants were also asked if they knew anyone else using these modern methods which was recorded as a dichotomous yes or no male and female sterilization were excluded as forms of modern contraception because of data validity issues in our data 15 of men reported using sterilization for reference in national surveys among reproductive age women in madagascar 4 report using female sterilization and 03 report that men were sterilized 45 this discrepancy was likely due to a misunderstanding of the question so we excluded reports of sterilization as a form of modern contraception participants were also asked about their desire for pregnancy as a couple in the last 4 weeks participants also reported who within the couple made decisions about contraceptive use the number of births that the female partner had experienced was also elicited from participants the number of births was used to reflect fertility given high infant and child mortality in madagascar 46 other data recorded included age whether the participant was married andor living with the partner or has partner but not living together number of household members whether attended school and highest grade attained current occupation estimated household earnings in the past month and whether the household had electricity missingness for these variables is 3 except for pregnancy desires contraceptive use decisionmaking and number of births to collect network data we adapted the people network survey developed by brunson 4748 to ask about fp we asked participants to list the individuals from whom they obtain information advice andor guidance about fp 1 the question was worded as follows the purpose of these next questions is to gather accurate information about your people network in other words the people from whom you obtain information advice andor guidance about your use of family planning please take a moment to think about who these people might be please provide the first names of the people who have influenced your use of family planning interviewers then prompted participants to review if they had forgotten any alters prompting them to consider whether they wished to include their partner siblings parents chws and other health providers to ensure completeness the maximum number of alters elicited from any study participant was 3 for each alter that was listed name interpreter questions elicited alter age and gender nature of the egos relationship with that alter and the egos perception of that alters support of modern contraceptive use several network measures were used as explanatory variables in separate analyses the first explanatory variable was a dichotomous variable for whether the study participant named at least one individual in his fp network the second was a categorical variable that included four mutually exclusive categories to represent network composition 1 having no fp ties and thus no fp network 2 all fp ties were composed of social relations only including partner other family members andor friends 3 all fp ties were composed of providers only including chws health educators nurses midwives or doctors and 4 fp ties were composed of a combination of social and provider ties the size of the fp network was categorized as 0 alters 1 alter or ≥ 2 alters there were no differences in contraceptive use or network composition by missingness of baseline covariates if observations had missing covariates then they were not included in the analysis however missingness of covariates was significant at p 0051 level for differences in fp network composition men with no fp network were more likely to have missing covariates and therefore were not included in the analysis 26 of men with missing covariates had no fp network compared to 16 of men with nonmissing covariates analytical approach we fitted a generalized linear model specifying a poisson distribution with robust standard errors interpreting the estimated incidence rate ratios as relative risk ratios 49 in all analyses the individuallevel characteristics included age number of births by partner living together status primary school completion and household earnings to avoid model overspecification other individual characteristics were not included because of limited variation household size was included instead of number of births because of higher missingness rates models also included fixed effects by subdistricts analyses were conducted at the egolevel using robust standard errors clustered by subdistrict additional analyses were conducted at the alterlevel only using data from men with a fp network to examine the association between alter characteristics and couples use of contraception with robust standard errors clustered by subdistrict alternative specifications included adjusting for 1 couples pregnancy desire and 2 couples contraceptive decisionmaking these covariates were not included in the main model because of higher missingness rates in other specifications we explored 3 including both network composition and knowledge of contraceptive users variables and 4 excluding partners as sources of advice in the network since the outcome simultaneously measures partners use of contraception we also conducted an evalue sensitivity analysis to estimate how large the relative risk ratio of an unobserved confounder would need to be associated with both contraceptive use and mens social networks in order to completely explain the associations in the study 5051 results descriptive statistics of sample the mean age of the men in the study was 31 years 141 were married or living with their partner while 37 were living apart from their partner the mean number of reported births by their partner was 23 and the median was 20 mean household size was 48 almost all the men had attended school with 116 reporting that they had completed primary school almost all men reported that farming was their main occupation only 2 reported having electricity in their home average household monthly earnings were reported to be 29 usd 2 ambivalence about desire for pregnancy as a couple was very common with 150 men reporting that they andor their partners were uncertain about wanting to become pregnant when asked about who in their relationship makes decision about contraception 6 said that the decision was the mans decision 39 said that it was the womans decision and 98 said that it was the couples decision together twothirds of participants reported their partner was using modern contraception the most common methods were injectables the pill and the implant with few using an iud or the external condom threequarters of men knew someone else using modern contraception specifically 93 knew someone using injectables 88 knew someone using the pill and 69 knew someone using the implant most men reported having a fp network with an average network size of 096 alters thirtytwo had no alters 125 had 1 alter 17 had 2 alters and 4 had 3 alters the composition of the fp network varied 46 men had a socialonly fp network 96 men had a provideronly fp network and 4 men had a mixed fp network while 32 men identified no fp network most men who have a fp network nominated only 1 alter among the 170 nominated alters the mean age was 43 years almost all were women and 86 were perceived to be supportive of contraceptive use provider relationships between ego and alter were more prevalent than social relationships among the nominated alters 37 were health educators 18 were health health educator health provider friend partner sibling mother aunt other providers and 15 were chws five percent of alters were friends 12 were partners 9 were mothers and 2 were siblings differences in couples contraceptive use by composition of fp network chisquare testing indicated differences in contraceptive use by composition of the fp network among the 32 men with no fp network 39 were using contraception among the 46 men with a socialonly fp network 79 were using contraception among the 96 men with a provideronly fp network 67 were using contraception association between composition of fp network and couples use of contraception men who reported any kind of fp network were 19 times more likely to use modern contraception as a couple compared to men with no fp network after adjusting for mens individual characteristics the associations between contraceptive use and alter gender or age were not statistically significant compared with men who relied on doctors nurses and midwives men were more likely to use contraception if they relied on their partner or their sibling the estimated relative risks for chws were positive but imprecisely estimated the association with other types of alter relationships was not statistically significant in the second specification being married was positively associated with contraceptive use while completing primary school was negatively associated with contraceptive use in all specifications there were significant differences by subdistricts among the 37 men who did not know someone else using contraception 18 were using contraception as a couple whereas among the 131 men who did know someone else using contraception 91 were using contraception regression analyses confirmed that after adjusting for individuallevel characteristics men who knew someone else using contraception were 14 times more likely to use contraception sensitivity analyses the results were consistent after adjusting for additional covariates including pregnancy desires as a couple compared to men in couples who wanted to become pregnant men in couples who wanted to avoid pregnancy were significantly more likely to use contraception similarly men in couples who were uncertain about wanting to become pregnant were also significantly more likely to use contraception when covariates for couples decisionmaking about contraception were included all coefficients on type of fp network were significant there was no association between who makes contraceptive decisions and contraceptive use while the main analyses showed that individuallevel characteristics were not associated with contraceptive use omitting these variables yielded similar results though the magnitude of the coefficients of interest were slightly smaller suggesting that it was important to adjust for these variables when both the measure for network composition and measures for knowing another contraceptive user were included the coefficients on network composition remained consistent while the coefficient for knowing another contraceptive user was no longer significant when partners were excluded from the definition of fp networks the findings remained consistent though the magnitude of coefficients were smaller having a fp network was associated with 12 times higher use of contraception while the coefficient on provideronly fp networks was no longer significant the coefficients on socialonly fp networks and mixed fp networks remained significant the estimated evalue for the rr of having a fp network was 32 meaning that an unmeasured confounder would need to have a rr greater than 32 associated with both couples contraceptive use and whether men have a fp network in order to explain away the main results the estimated evalues for socialonly network provideronly network and mixed fp network were 36 30 and 41 discussion there exists very little evidence examining mens networks for information and advice about fp and how these networks are associated with womens contraceptive use the findings from this novel egocentric study show that many men report having at least one person who influences their fp use by providing information advice or guidance although men are twice as likely to be influenced by providers by relying on them for information advice and guidance about fp compared to family and friends men having any kind of fp network were 2 times more likely to report their partner using modern contraception compared to men with no fp network having more than one tie was not differentially associated with contraceptive use compared to having just one tie overall the findings demonstrate that having at least one tie who influenced their fp use be it a social relationship or a provider relationship is what differentiates men who report that their partner is using contraception interventions to ensure women can exercise their reproductive autonomy and use contraception if desired should adopt a multipronged approach that includes male partners and their networks to foster their supportive engagement in contraceptive decisionmaking men who reported being influenced by their partner for fp decisionmaking by turning to them for fp information advice and guidance are even more likely to use contraception this finding is consistent with evidence from uganda where married men were less likely to rely on health providers or their peers and they preferred to rely on their partners due to their partners experience with side effects knowledge gained from their own peers and exposure to mass media campaigns and health providers 41 men who nominated their partner as their social tie influencing their fp decisionmaking likely have more open couples communication about contraception a critical factor affecting contraceptive use 5253 the absence of significant coefficients for joint couples roles in decisionmaking about contraception may mean that actual decisionmaking resides with the woman but more work needs to be done to explore these mechanisms in depth in addition future research should also examine concordance within couples regarding perceptions of contraceptive use since this study relied on mens perceptions of their partners contraceptive use which may differ from their actual contraceptive behaviors relying on other social ties specifically siblings was also associated with higher contraceptive use as a couple compared to relying on doctors nurses and midwives similar to the role of womens social ties in madagascar which play a positive role in increasing the likelihood of contraceptive use 14 mens social ties also play a supportive role for contraceptive decisionmaking these results contrast with other research finding that for women they were more likely to receive negative and incorrect information about contraceptives through social ties 42 and that social networks can exert a negative influence on adoption of reproductive behaviors 4344 our findings are consistent with the network study in ghana showing that couples contraceptive use was higher among men who received support through their social networks to use contraception 40 despite the positive influence of social ties only half as many men turned to social ties compared to providers which could point to the more sensitive nature of this topic in these communities there were no differences in the likelihood of contraceptive use depending on the type of health provider men were just as likely to use contraception whether they relied on nurses midwives or doctors for information and advice about fp compared to when they relied on chws and health educators while another study found that women in madagascar were more likely to use contraception if they relied on chws in their fp network compared to relying on nurses midwives and doctors 14 the association in this study was not statistically significant for men in this study the lack of precise estimation is possibly due to a small sample size the findings also demonstrate that men primarily relied on women rather than men for fp information and advice this tendency reflects the high proportion of women who occupy the roles of providers including midwives nurses chws and health educators tend to be women in addition to partners and female siblings similar to past work 8 men in this study were more likely to use contraception if they knew someone else using contraception yet the associations were attenuated when network composition was included having fp network that is supportive of contraceptive use may be more important than having a network that includes contraceptive users 6891112 valente et al show that among women their perceptions of ties approval of contraceptive use was more important than their ties actual use 8 while our data did not allow for a distinction between alters active use versus egos perception of their use future research should explore the role of both actual and perceived contraceptive use by alters on contraceptive use specifically socionetwork studies examining discordance in perceptions between egos and alters would be able to show whether perceptions of contraceptive use matter more than actual contraceptive behaviors research on social norms in subsaharan africa has found that perceptions about whether friends or most people within a local reference group engage in a healthrelated behavior are potentially more important than peers actual behaviors 8135455 there are several study limitations first the relationship between having a fp network including the composition of that network and the decision to use contraception may be endogenous for example the reverse relationship could exist where couples decided to use contraception and men then selectively formed their fp network to validate that decision due to feasibility it was not possible to conduct a complete network study to examine dynamic selection in this study population and establish the causal role of networks on contraceptive use it is plausible that the main findings reflect a combination of selection versus the influence of those networks on contraceptive behaviors as with other egocentric network studies this could not be teased out with the data for this reason we consistently referred to associations rather than using causal language if it was possible to distinguish between selection and influence of networks our estimates are likely to be smaller in magnitude though not zero as put forth by fowler and christakis 56 in addition the opportunity for men to selectively form their fp network may be limited in this particular study context half of the men had a provideronly network and were constrained in selectively forming their fp network in the study area there are typically only 1 health educator or chw per village and 1 nurse at the public health center providing fp men may have more ability to selectively form their socialonly network future research using multiple data waves would facilitate identifying the causal influence of fp network composition on contraceptive use furthermore if there was an omitted variable which influenced couples decision to use contraception and this factor also influenced fp network formation the relationship between that omitted variable and these two variables would need to have a rr of at least 32 based on the evalue sensitivity analyses proposed by vanderweele and ding and oster 5051 to completely explain away our main findings the example of another unobservable did not meet this threshold for ruling out the main findings second mens networks may be closely tied to their female partners social networks by virtue of being in a couple one of the studys limitations is that the data were not collected by couple therefore it is not possible to assess correlations in a couples fp networks the results could be confounded by the female partners fp network which we cannot adjust for due to potential sensitivities of interviewing couples about fp and sexual healthpractices in madagascar it was more feasible to recruit men without their partner there is no study to our knowledge comparing differences by fp networks within couples and future studies examining couples would be beneficial third there may be concern that including female partners within mens networks is problematic because the outcome is simultaneously measuring those female partners contraceptive behaviors yet when female partners were excluded from the definition of mens fp networks the results remained consistent fourth it is not possible to rule out the influence of potential unmeasured confounders such as shared environmental factors that may influence both mens fp networks and contraceptive use one such unmeasured factor might be access to fp services the analyses adjusted for differences by fokontany which were statistically significant and suggest that there may exist differences in ease of access to fp services whether men have a fp network and the composition of that network may vary with their access to fp providers thereby potentially biasing our estimates away from the null however there is no known research demonstrating such an association and the participants in our study were all equidistant from fp providers since they were recruited from the same geographic area one study from madagascar showed that integrating fp services at the community level to improve access resulted in a twofold increase in contraceptive use 57 but the effect size estimated from that study is smaller than our estimated evalue of 32 therefore we believe it is unlikely that failure to account for confounding by access to fp services could completely explain away the main findings fifth as an egocentric study the data did not include alterlevel contraceptive use for comparison to egos perceptions sixth the sample may not be representative of rural populations in madagascar since the villages were within a 5 km radius of a wellresourced semiurban town couples contraceptive use in the sample was higher than reported contraceptive use in madagascar as a whole 45 potentially due to ease of access to providers in the study region lastly while the difference in missingness of covariates just misses statistical significance at the 5 level it suggest that the analysis likely provides conservative estimates of the relationship between fp network and contraceptive use because the men without a fp note this analysis was restricted to men who had a fp network each column presents the findings of a separate regression model covariates included in each of these 4 regression models were age household size marital status primary school completion and household earnings we also included subdistrict fixed effects subdistrict 2 is not included in this analysis due to missing data from the 5 respondents in that subdistrict which had reported an alter but for whom specific alter characteristics are missing likely due to data collection error we used cluster robust standard errors at the subdistrict level rr relative risk ratio network who were not included in some of the analyses may have been more difficult to engage with the survey and thus had missing data and biased the results towards the null conclusions whether men have a fp network distinguishes if couples are using contraception men vary in terms of whether they relied on providers or social ties for fp information and advice yet all men who had a fp network were significantly more likely to use contraception as a couple compared to those with no fp network while men are more likely to rely on providers than social ties these social ties can be just as important in providing support for contraceptive decisionmaking there is very limited research examining whether mens networks influence womens contraceptive use even though existing research has shown that men can play an important role in either facilitating or impeding womens contraceptive use 16 17 18 19 20 21 22 23 24 25 26 27 28 29 this study broadens the examination of mens roles by moving beyond a focus on individuallevel characteristics to examining mens fp networks and their role in contraceptive decisionmaking the studys findings point to several important ways to foster mens positive engagement in contraceptive decisionmaking first reaching men through providers continues to be important there remains a critical need to foster couples open communication about contraception interventions that engage mens broader social network including friends and family members are an untapped avenue for supporting womens access to and use of contraception in pursuit of universal access for all women we used generalized linear model with poisson regression and robust standard errors we reported relative risk ratios each column presents the findings of a separate regression model covariates included in each of these 4 regression models were age household size marital status primary school completion and household earnings we also included subdistrict fixed effects we used cluster robust standard errors at the subdistrict level socialonly fp network included social ties such as partner friend and other family members provideronly fp network included provider ties such as chws health educators nurses midwives and doctors a mixed fp network included both social ties and providers ties appendix abbreviations chw community health worker fp family planning iud intrauterine device rr relative risk authors contributions abc pjk jrr anr and rh designed the study abc pjk ca ms performed the analyses abc pjk ca and ms designed the tables and figures abc pjk cch act jmp jrr anr and jm wrote the manuscript all authors provided critical feedback and helped shape the research analysis and manuscript competing interests dr comfort and dr krezanoski are cofounders and directors of opportunity solutions international which funded the study they receive no salary support from the organization

background ensuring women have information support and access to family planning fp services will allow women to exercise their reproductive autonomy and reduce maternal mortality which remains high in countries such as madagascar research shows that womens social networks their ties with partners family members friends and providers affect their contraceptive use few studies have considered the role of mens social networks on womens contraceptive use insofar as womens contraceptive use may be influenced by their male partners womens contraceptive use may also be affected by their partners social networks men may differ by the types of ties they rely on for information and advice about fp it is unknown whether differences in the composition of mens fp networks matter for couples contraceptive use this study assessed the association between mens fp networks and couples contraceptive use methods this egocentric network study was conducted among marriedpartnered men n 178 in rural madagascar study participants listed who they relied on for fp information and advice including health providers and social ties they provided ties gender age relationship and perceived support of contraceptive use the primary outcome was couples contraceptive use and explanatory variables included fp networks and their composition no fp network socialonly network provideronly network and mixed network of social and provider ties analyses used generalized linear models specifying a poisson distribution with covariate adjustment and cluster robust standard errors results men who had fp networks were 19 times more likely to use modern contraception as a couple compared to men with no fp network 95 confidence interval ci 164252 p ≤ 0001 compared to men with no fp network men were more likely to use modern contraception if they had a socialonly network relative risk rr 210 95 ci 165268 p ≤ 0001 a provideronly network rr 180 95 ci 154211 p ≤ 0001 or a mixed network rr 235 95 ci 197280 p ≤ 0001

19872_0

introduction the emergence of social networking sites is producing a massive impact in the internet usage despite the fastgrowing levels of social networks user adoption it remains to be seen how individual privacy expectations are adjusted the aim of this research in progress is to investigate the following research question do individuals cultural values explain the adoption of privacy threatening features in social networks the paper therefore builds on both the theoretical contribution of it adoption literature and on the role of cultural values in it adoption the model integrates the utaut model and the open cultural orientation construct additionally adhoc variables relevant in social networks research such as attitude and trust have been incorporated in the model in order to study the research question the authors expect to issue a quantitative research based on a structural equation model in this paper the authors propose the model to be validated in the quantitative research this paper is structured as follows first section 2 presents the literature review on social networks it adoption and cultural values frameworks next section 3 describes the research model finally section 4 provides the further steps in this research project literature review social networks a social network is a concept which can be defined as a group of nodes tied with social relationships if this concept is focused on web 20 social networks are a technology which allows people to connect interact work and share opinions videos social networks users disclose all kind of personal information involuntarily allowing third parties to track and study their behavior lack of controls on private information exposure has severely threatened users privacy acceptance theories based on previous models of user acceptance of information technology venkatesh et al proposed a unified model for user acceptance of it the model was called the unified theory of acceptance and use of technology and included most of the items that were proposed by the previous models the model for this researchinprogress work is based on the utaut with some additional items to include the effect of individual cultural values based on dorfman howell andhwang an open cultural orientation construct is used to reflect these individual cultural values in the utaut model culture values and it uses culture values have been a persistent worry to management researchers it adoption and diffusion is one of the areas where cultural values have been used the most a majority of these studies were based on cultural values at a national level in this research in progress work the authors focus on the individual cultural values and their goal is to shed some light on the effects of culture on the usage of social networks research model the research model is depicted in figure 1 the model proposes to combine utaut the open cultural orientation construct and the social network characteristic use to study individual privacy concern levels from the perspective of it adoption and cultural values the presented conceptual model has been enriched with the data obtained via semistructured personal interviews with social network users the participants are last year students in telecommunications and it management programs the interviews provided qualitative data to enrich our model variables and to support the hypothesis formulation based on proposed causal relationships as in most of the it acceptance models the dependent variable is based on use behavior in this model use behavior depicts the different levels of use based on users privacy concerns two levels have been identified high privacy concern usage and low privacy concern usage high privacy concern usage includes those users that take into account the impact of the shared information in their personal privacy in contrast low privacy concern usage would contain profiles whose participation in social networks is not affected by a certain degree of self control on private information sharing in the following sections of this chapter there is a detailed description of the variables that build up the model and the hypotheses that have been formulated from the model webist 2010 6th international conference on web information systems and technologies user acceptance constructs social networks use behavior as presented in the model use behavior is determined by behavioral intention of use in the interviews conducted behavioral intention was observed in both the high privacy concern usage and low privacy concern usage profiles as low privacy concern usage profiles foresee to do a more intensive use while high privacy concern usage profiles expect to get more involved in the network activity hence the authors propose that h1 intention to use social networks is positively related to low privacy concern usage when asked about the devices being used to access the social networks most of the respondents mentioned that they would connect using their home pc also being interested in using other new access devices such as cell phones giving support to the idea that as device connectivity improves lower levels of privacy concern could be expected therefore the authors propose that h2 facilitating conditions are positively related to low privacy concern usage social networks intention of use performance expectancy social networks performance expectancy is based on the perception of the influence that the usage of social networks can have to improve social relationships participants expressed their perception that social networks use would derivate in better social relations quoting one of the respondents they help to sustain improve and make new relationships with different type of people in general consistent social relationship improvement expectancy was observed accordingly the authors introduce the following hypothesis h3 social relationship improvement expectancy is positively related to social network behavioral intention effort expectancy effort expectancy introduced in tam as perceived ease of use directly relates to the individuals intention to use higher intention of use behavior would be expected if there is a lower perceived effort in using the technology therefore this leads to the following hypothesis h4 perceived ease of use is positively related to social network behavioral intention social influence social influence on it user acceptance models is related to users perception about others opinion on using this technology social networks play a relevant role in fostering social relationships social networks by definition have an inherent relation to social influence it seems coherent that if others perceive that being in a social network can be positive the individual would have higher use behavior intention as some of the respondents contextualize as everyone has it and to be in touch with my friends i created a profile consequently the authors propose the following hypotheses h5 others favourable opinion on using social networks is positively related to social network behavioral intention h6 others favourable opinion on using social networks is positively related to social relationship improvement expectancy open cultural orientation individual open cultural orientation is defined by high individualism low power distance and low uncertainty avoidance participants in the interviews have reported different values in their attitudes towards the variables that define the open cultural orientation construct observed outcomes related to the individualism variable would include participants expressions such as i prefer to work with other people as better ideas come out or i rather prefer to work alone it is expected a positive correlation of open cultural orientation with social relationship improvement expectancy ease of use and attitude but negative correlation with others favourable opinion as it is expected less influence of bandwagon effect in high open cultural orientation individuals therefore the authors propose h7 high individual open cultural orientation is positively related to social network behavioral intention h8 high individual open cultural orientation is positively related to attitude h9 high individual open cultural orientation is positively related to social relationship improvement expectancy h10 high individual open cultural orientation is positively related to perceived ease of use h11 high individual open cultural orientation is negatively related to influence of others favourable opinion on using social networks adhoc variables attitude construct in social networks social networks have combined their basic applications with other functionalities that reinforce the attitude of their usage as one of the participants described the time spent in social networks is enjoyable and fun therefore it is expected that attitude influences directly the social relationship improvement expectancy but it is also expected others favourable opinion to directly drive use attitude hence the authors hypothesize h12 others favourable opinion on using social networks is positively related to attitude h13 attitude on social networks is positively related to social relationship improvement expectancy trust construct in social networks trust is defined as the willingness of a party to be vulnerable to the actions of another party based on the expectation that the other will perform a particular action important to the trustor irrespective of the ability to monitor or control that other party based on respondents answers it is expected that trust will be related to behavioral intention thus high levels of trust could encourage high behavioral intention furthermore trust could improve perceived ease of use it also expected that trust will be influenced by individual open cultural orientation hence the authors propose the following hypotheses h14 high individual open cultural orientation is positively related to trust h15 trust is negatively related to perceived ease of use h16 trust is positively related to social networks behavioral intention summary and next steps this research studies the influence of individual cultural values in the use behavior of social networks in this position paper the authors propose a model that hypothesizes a causal relationship between individual cultural values and the use of social networks privacy threatening features the model is built up from previous theories and has been completed using information from social networks users interviews in the following steps of this research project the authors aim to design and build a questionnaire to validate the model hypotheses a structural equation model is going to be issued to assess the support for the causal relationship between the model variables

the effect of cultural values in it adoption has attracted growing interest in the last years researchers posit that cultural values can shed some additional light on the factors that determine it user acceptance and use in this research in progress work the authors propose a model based on previous user acceptance theories to develop a research study to inquire the role that individual cultural values play on the adoption of those social networks features that threat users privacy the most what the authors posit is that adoption of those features that are more critical from the point of view of users privacy can be explained from the perspective of individuals cultural values in this preliminary work the authors have developed the model and have drawn a set of hypotheses in the following steps of the research the authors are going to develop a survey to start the quantitative research

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introduction youth admitted into foster care in the united states are likely to experience a series of investigations and evaluations this constant surveillance often combined with frequent and abrupt shifts in living situations leave a number of lasting socioemotional scars 2748 these scars are moreover not distributed equally in particular significant racial biases exist regarding who enters into foster care 522 these and other issues with the american child welfare system have led to a growing movement to abolish it 11 suggested alternatives from these advocates include reallocating funding to communitybased localized initiatives not run by government actors 11 others have in a more traditional vein for the field of social work instead argued for changing rather than eradicating the system however both abolitionists and reformers generally agree on one point youth are better off with their own families than in the foster care system 6 the most important recent development aimed at keeping youth out of care is the family first prevention services act 32 the ffpsa signed into federal law in 2018 overhauled funding in the american child welfare system in order to providing financial incentives to states to keep youth out of foster care or more formally to 1 reduce unnecessary separation and 2 provide familybased service for removed youth in order to encourage family reunification these incentives include the construction of new benchmarks for numbers of youth in care and additional funding for familybased services aimed specifically at helping the families of youth who are in care to get to a point where the youth can be returned to them efforts to effectively use this funding from the ffpsa to reduce the number of youth in foster care face three formidable challenges first the american child welfare system is heavily decentralized with drastically different policy environments across and often even within states 50 changes that are effective at moving towards the goals of the ffpsa in one county or state may therefore be difficult to enact in others second even in a single jurisdiction the process of placing a youth into the foster care system is complex when a potentially maltreated youth is reported to child protective service a series of decisions made by case workers and judges are carried out to decide the best path for the youth the process is cumbersome and riddled with the potential of both personal and systemic biases 3653 efforts to discharge youth from foster care can face similar challenges finally as with most social policy settings 37 attempts to make progress on one goal can often have unexpected negative impacts on others as we highlight here for example interventions aimed making the system more racially equitable may end up leading to substantially more youth in foster care and not with their families help is needed to tackle these challenges 1 argues that implicit in the ffpsa is the assumption that such help will come from the expansion of data collection the bill enables which will in turn lead to the construction of analytical tools that can serve to ameliorate potential problems indeed the use of such tools is already widespread in child welfare and is only expected to grow with the ffpsa 42 the present work takes a different bend on how computation can serve a role in social change 2 arguing that if used carefully computational models can help us to reason about the best path forward under myriad possible social and policy environments and various potential interventions that is rather than make predictions about youth we can use computation to help us understand the foster care system as a whole and to rethink the potential interventions needed to address new policy goals like those set forth in the ffpsa the present work conducts such an analysis using a twostage pipeline we first take a forensic social science 31 approach to address the following research question how do existing practices within the new york state child welfare system fare in light of the new stated goals introduced by ffpsa and the existing stated goal of racial equity while our methodology generalizes to other contexts we focus on new york because of our policy and practical expertise in the state forensic social science is a methodology in which computational analyses of observational data are conducted in ways that inform and are informed by relevant social theory here using complete data from the child welfare system in new york from 20002017 34 we conducted a computational analysis on 1 entry rates of youth into the foster care system 2 patterns in how long youth stay in care and 3 the rates at which youth are discharged we also consider how these quantities differ for white versus black youth our forensic social science analysis informs the second and focal part of our computational pipeline in which we construct a datadriven system dynamics simulation 1747 to analyze a hypothetical intervention into new yorks foster care system specifically we analyze how the introduction of an automated risk assessment tool currently in practice in other parts of the country 8 would if implemented in new york help to address the goals of the ffpsa while maintaining the existing goal of improving racial equity system dynamics models help formalize how particular entities flow through a system over time conditioned on assumptions about the probability of flowing from one point to another here we model the flow of american youth into and out of foster care in a datadriven system dynamics model some of these patterns of flow and associated probabilities can be informed by data those that cannot be informed by available data can then be set based on assumptions andor theory these assumptions in turn can then be varied to address certain research questions or to perform robustness checks our work makes three primary contributions we provide quantitative evidence supporting earlier work that show that youth stays in foster care in new york can be empirically separated into two classes longterm and shortterm we find further that the duration of longterm but not shortterm stays varies significantly across racial lines for all ages informed by these analyses we develop a datadriven simulation model of the us foster care system and parameterize it for the study of new york as a sign of the models validity we show that the model can reliably forecast patterns in the number of youth admitted into new york states foster care system in 2018 given only data from previous years we use our model to study the impacts of a potential algorithmic intervention in new york our observations resonate with the concerned pointed out by samant et al 42 specifically we find that it is difficult to balance the goals of racial equity and a reduction of youth in care and that proposed algorithmic interventionsencouraged by the ffpsa in order to achieve its goals 1 are not necessarily capable of doing so as with any simulation model our findings rely on modeling assumptions which may be reasonably disagreed with to facilitate such discussions we have made our model publicly available 1 however as we believe our modeling assumptions to be at least within the realm of possibilities our results suggest that shifting policy landscapes impacts both the validity and utility of using historical administrative dataset to build machine learning models in public sectors instead we argue that machine learning and computation writ large may be better served as a tool to facilitate social theory and social policy rather than to act as explicitly as a decisionmaking tool where it is often inserted into the problematic decision loops which expose risks of amplifying existing problems related work computational social scientists have develop a number of ways to formalize and analyze complex sociotechnical systems 172845 careful formalization and analysis can serve to illuminate and identify paths towards addressing societal issues 13 the benefits and drawbacks of computational modeling of social systems are perhaps best summarized by abebe et al 2 who note that computing can act as a synecdoche allowing us to think about problems in new ways and as a rebuttal clarify ing the limits of technical interventions 2 pg 256 our goal in the present work similar in some respects to the arguments made by green 20 but with distinct methods is to use computation as both a synecdoche and as a rebuttal for the blind reapplication of machine learning methods from one context to another here we define computational analysis broadly to include both forensic social science and simulation with respect to the former forensic social science entails the combined use of machine learning and social theory to advance our understanding of social phenomenon where machine learningadvanced statistical analyses are applied an atheoretical approach to agnostic search for potential explanations and social theory is a focusing device that identifies which constructs are to be selected and formed from the millions of possible analyses 31 we briefly touch on related work in the context of quantitative studies of american foster care system that inform our forensic social science analysis and the simulations of sociotechnical systems that compliment andor inform the work presented here quantitative study of the american foster care system quantitative studies of foster care are routinely conducted by and for policy makers case workers and researchers given the rich administrative datasets curated in this context quantitative studies have been carried out to both understand the different aspects of the system and to provide assistance with decision making with respect to quantitative work that assists decision making we direct the reader to a number of recent literature reviews 4244 around algorithms used within the us child welfare system most notably here chouldechova et al 8 build and implement a machine learning model called afst in allegheny county pennsylvania that helps case workers decide whether or not to screen in reported cases of child abuse for further analysis this academic work is complemented by a number of public reports as well a number of other researchers have used quantitative methods to critique existing practices within the us foster care system to better understand associations with service allocation to youth to analyze racial disparities within the system and to criticize the use of automatic decision tools in foster care system our work compliments these efforts both in its use of quantitative methods to explore youth lengths of stay in new ways and to use quantitative methods to critique existing practices social simulation the present work uses a simulation methodology particularly wellsuited for our work datadriven simulation the term datadriven simulation encapsulates a broad range of computing techniques which use relevant data to make educated predictions about what might happen in a situation for which complete data cannot be obtained datadriven simulation has seen increasing use in the facctaligned community 91923243333 as noted above we use a specific form of datadriven simulation system dynamics modeling 47 perhaps most relevant to our work then martin et al 30 argues that instead of focusing on mathematicalbased interventions on opaque algorithms andor models using community based system dynamics modeling to place the algorithmmodel into the social context is a better way to understand the longterm impact of algorithmsmodel while we aspire to communitybased methods our current work relies only on our existing knowledge of and experiences as practitioners within child welfare finally while significantly distinct in focus it is worth noting that there is other work using simulation in the foster care context specifically fowler et al 15 use a system dynamic model to test the impact of scaling up a policy to provide longterm rental subsidies for foster care family and goldhaberfiebert et al 19 use decisionanalytic model in support of child welfare policymakers considering implementing evidencebased interventions a brief overview of how youth enter foster care in america our work assumes a slightly simplified process model of youth trajectories through the us foster care system introduced by sterman 47 and visualized in figure 1 the first step in the process of placing a youth in foster care is a report to child protective services these reports are handled by a cps employee who decides whether or not to screen in the call a decision based on myriad factors eg characteristics of the youth their family and the local policy environment 8 if a call is not screened in the case is dismissed and the youth exits the system if a call is screened in the case is then taken on for further consideration by a cps case worker this phase fig 1 the standard decisionmaking pipeline for a youth reported to child protective services in the united states diamonds represent decision points in the system squares are states that youth may be in at a given time the blue box represents the portion of the decision pipeline informed by afcars data the orange and green boxes represent respectively the decision point for the algorithmic intervention considered in the present work and the proxy variable used to train the proposed model typically includes a more detailed records review of the youth and their family and a visit to the location relevant to the call the cps case worker then decides whether or not the case is substantiated ie whether there is evidence that the concern voiced in the original call is true if a case is substantiated a decision is then made on whether to a remove the youth from their home or b to keep the youth in their home this decision is typically made by a judge if the decision is that the youth should be removed from their family the youth then enters foster care once the youth is in foster care the family is repeatedly reevaluated for a need to be in the system more specifically judges and case workers are expected to return the youth to their family when they are satisfied that it is safe to do so while also making a backup plan according to what is referred to as the permanency plan for that youth when the home is safe again or alternatively another longterm plan such as guardianship or adoption is available the youth is then discharged back to a living placement outside of the foster care system data our analysis uses federal administrative data from the adoption and foster care analysis reporting system 34 a dataset from the national data archive on child abuse and neglect afcars data contains a range of information for all foster youth from all 50 us states the district of columbia and puerto rico this information includes demographic data like race and gender and administrative data like the youths current placement setting however critically such information is only available for youth who are in foster care other relevant data for example the number of youth who are reported but not removed are not in this dataset as we discuss further below we can thus only make assumptions about these youth which we can then vary to emulate different potential realworld settings our analysis uses a particular sample of youth from the full afcars dataset first as noted above we focus our analysis only on data from new york state second our analysis below considers racial disparities in a number of ways due to limited data availability leading to imprecise estimates we focus here only on data for youth who identify white or black this is a significant limitation of the present work that could be alleviated in the future by additional data and more diverse expertise n n table 1 fitted normal distributions for the difference between the number of admitted black or white youth in consecutive months in the afcars dataset forensic social science analysis we conduct a forensic social science analysis to analyze the foster care system in new york with respect to the number of youth in care and racial equity within the system these analyses are useful both in providing a better understanding of how many youth are in care at any time and for how long they remain in foster care for seeing how these quantities vary for black versus white youth and for informing parameters of our datadrive simulation model we conduct an analysis of three quantities how many youth are entering into care how long youth stay in care and the rate at which youth are discharged prior work has analyzed entry rates at the state level finding potential associations with race and age 441 other work analyzing youth in florida also suggest race is a key factor influencing the length of stay 4 motivated by this work we therefore study these quantities split out by youth age in all cases moreover in order to obtain results which are informative for the system dynamics model we aggregate data at a monthly level entry rate to determine entry rates we extract the total number of admitted youth 𝑛 𝑡 𝑟𝑎 where 𝑟 represents the youths race 𝑎 represents the age at which they were admitted and 𝑡 represents the admitted month for each combination of 𝑟 and 𝑎 we calculate the difference of the number of admitted youth between two consecutive months by δ 𝑡 𝑟𝑎 𝑛 𝑡 1 𝑟𝑎 𝑛 𝑡 𝑟𝑎 after confirming that this difference is stationary for the vast majority of combinations2 we fit the resulting data to normal distributions n δ 𝑟𝑎 for each δ 𝑟𝑎 along 𝑡 samples of the estimated distributions for changes in entry rates for white and black youth at various ages are displayed in table 1 across the visualized quantities as well as for all ages not displayed we find no significant differences in the rate of change in the number of black and white youth entering the system however consistent with prior work at a national level 51 we observe that black youth are overrepresented relative to white youth within new york length of stay figure 2a shows the density of the logarithm of the length of stay for white and black youth admitted at ages 1 5 9 and 13 other ages show similar patterns and thus we omit the results here from these plots we notice that the distribution of loglos appears to be readily modeled by a mixture of gaussian distributions in other words there appear to be distinct classes of stay lengths for foster youth that align with different distributions of length of stay to test this observation statistically we fit each individual distribution of loglos for all combinations of 𝑎 and 𝑟 to five different gaussian mixture models with the assumed number of distributions 𝑁 to be either 𝑁 1 2 3 4 5 confirming our intuitions from figure 2a we find that 𝑁 2 best fitted all densities for all age and race combinations according to the aic score the distributions of loglos depending on the youths race from left to right plots correspond to a different age at which the youth was admitted into foster care 1 5 9 and 13 other ages show similar patterns and are not displayed q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q short term youth age percentage q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q q 25 this gaussian mixture model separates stays in foster care into two groupslongterm and shortterm stays longterm stays have longer loglos than shortterm stay for example among white youth at age 10 the median length of a shortterm stay is 10 days while it is 680 days for a longterm stay among black youth at age 10 the median length of a shortterm stay is 9 days and 804 for a longterm stay breaking afcars data down further by longterm youth vs shortterm youth is revealing first as shown in the leftmost plot in figure 2b we find that between 1030 of admitted black and white youth are shortterm with that quantity generally decreasing as youth are older second the middle subplot shows that consistently across age groups longterm stays for black youth are longer than those for white youth similarly the rightmost plot in figure 2b shows that that from ages 02 shortterm stays are also longer for black youth there is some evidence that short term stays are slightly longer for older white youth but this finding is inconsistent at older ages discharge rate we formalize discharge rate as the percentage of youth that are in care after 𝑡 months we again learn this function separately for all combinations of 𝑎 and 𝑟 as well as for longshortterm foster care youth we then extracted the empirical inverse cumulative distribution of los for longshortterm stays for youth of different demographics finally we learn a nonparametric discharge function using a linear interpolation to fit the empirical inverse cumulative fig 3 on the xaxis is youth lengthofstay the yaxis represents the probability that a given youth will still be in foster care after spending the given number of months in foster care the first row shows the results for longterm youth while second row shows the results for shortterm youth cyan lines shows results for white youth red for black youth data are for youth in new york state in the afcars dataset distribution this discharge function d 𝑙 𝑟𝑎 gives us the probability of 𝑙term youth whose race is 𝑟 and admitted age is 𝑎 will still be in foster care after 𝑑 𝑡 months a representative portion of the results from this analysis are presented in figure 3 which shows the expected length of stay for black and white youth separated out into longterm and shortterm stays for youth results mirror findings above namely that longterm stays for black youth and shortterm stays for the youngest black are both longer than for the corresponding white youth summary of findings and linking back to relevant social theory our empirical analysis reveals that 1 there is a relatively constant rate of entry into the nys foster care system 2 that youth can generally be categorized into having a shortterm or a longterm stay in care and that 3 black youth who have longterm stays and the youngest black youth with shortterm stays remain on average for longer in the foster care system than their white counterparts in a forensic social science analysis it is important to not only guide analyses with prior social science research but also to tie back to this work once the analysis has been conducted for our work the most critical observation is the bimodal distribution in length of stay across all ages and races that differentiate youth into what we call longterm youth 40 and shortterm youth 43 rather than social theory however it is practical knowledge that help us to contextualize this finding in particular we understand shortterm stays which are often the result of brief parental incarceration or shortterm concerns about child safety to be a distinct class of events relative to longerterm stays which are often the result of structural factors this link between longterm stays and structural factors can in turn help us to better understand a more novel finding from our work differences in length of longterm stays but not shortterm stays for black vs white youth both critical race theory in general and critical veins of social work research emphasize that race is a socially constructed concept intertwined with structural factors one such factor in particular is poverty and although poverty is not always indicator for removal it is often a proxy for reunification for instance children are not removed due to homelessness but housing is often a requirement for a childs return home if they enter foster care 46 second single motherhood also linked to fewer financial resources also predicts slower reunification 21 third black families have disparate access to supportive services including employment substance use and mental health treatment 26 finally black youth are less likely to move from foster care into alternative plans such as adoption and guardianship 3 these four mechanisms are examples of how structural factors can serve to create longterm barriers to reunification for black youth more so than white youth finally having contextualized our findings within the literature we turn to their policy implications with respect to the goals of the ffpsa and of improving life for foster youth more broadly it is useful to distinguish between youth who are more likely to have short and longterm stays in foster care short term youth are typically in care for less than a month before being returned to their families this makes them likely candidates under the auspice of the ffpsa to never have been removed at all 164349 additionally we note that data useful for policy in child welfare need not be highly coercive or individualized to be useful rather as others have noted 39 even analyses of aggregate rates of shorterterm versus longerterm foster care stays may appraise agencies to needs related to distribution of services and help agencies assess the success of their racial equity efforts in this sense algorithms and simulations like those described below may serve as a policy function precisely via the analysis of aggregate rates and measures of allocation to this end we now turn to how our insights on aggregate measures from this section can be further used to construct a model that simulates the number of youth in foster care in new york state in the federal fiscal year 2018 under current conditions and in response to an algorithmic intervention datadriven simulation analysis informed by the discussion and findings above we proceed to our analysis of a hypothetical algorithmic intervention in the new york state foster care system two aspects in particular from our forensic social science analysis carry over first our simulation model explicitly differentiates between youth with shortterm versus longterm stays second we use a variety of statistics from the work above to inform parameterization of our model in what follows we first provide an overview of our model which simulates the trajectory of youth within the new york state foster care system and show it produces reliable forecasts for the number of youth in foster care we then use this model model to investigate the potential impacts of replacing human decisionmakers in the screening portion of the child welfare decision pipeline with an algorithm model overview the goal of our model is to simulate for each future month 𝑡 in t 𝑓 𝑢𝑡𝑢𝑟𝑒 the number of longand shortterm youth having a select combination of race 𝑟 and age 𝑎 who are still in foster care system we denote this number as 𝑁 𝑙𝑡 𝑟𝑎 and simulate it at at each stage of the decision pipeline outlined in figure 1 to parameterize the portion of the model where youth are in foster care we use data from afcars for each month until the last month of fy 2017 ie each month in t ℎ𝑖𝑠𝑡𝑜𝑟 𝑦 where data is not available to inform the model parameters we model a range of plausible assumptions about decision pipelines of foster care system and assess results across these possible settings more precisely we choose our parameters using the following steps • extract the number of admitted youth 𝑛 𝑡 𝑟𝑎 from afcars where 𝑡 ∈ t ℎ𝑖𝑠𝑡𝑜𝑟 𝑦 • extracted n δ 𝑟𝑎 and use it to simulate the number of admitted youth 𝑛 𝑡 𝑟𝑎 where 𝑡 ∈ t 𝑓 𝑢𝑡𝑢𝑟𝑒 • extract the longshortterm youth proportion p 𝑙 𝑟𝑎 n 𝑠ℎ distribution of feature of shortterm youth • extract the discharge rate d 𝑙 𝑟𝑎 using these parameterizations we simulate the number of youth in care in new york using algorithm 1 for this algorithm we use the fact that the number of youth in foster care in the next month 𝑁 𝑙𝑡 𝑟𝑎 equals the total number of youth who were 1 admitted into foster care during previous months and that 2 remained in the system in turn the number of youth who remained in the system is given by the product between the number of admitted youth in the previous month and the discharge rate finally in addition to modeling how many youth are admitted the proposed intervention we study also requires assumptions about 1 how many youth are not admitted as well as 2 how many youth cases are screened in given the literature discussed above 4043 we assume the following assumption 1 screen in and substantiation decisions only depend on a youths race and whether their stay is designated as one who will have a shortterm or longterm stay assumption 1 says that every reported youth of a given race with a short or longterm stay will have the same probability to be screened in and substantiated as discussed further below this assumption notably assumes that substantiation rate does not vary with screen in rates and vice versa we fixed this value as introduced in table 2 extending the model to investigate the effects of an algorithmic intervention our hypothetical intervention is based on the work of chouldechova et al 8 who develop a model to assist screening decisions in allegheny county pa we stress that chouldechova et al 8 do not intend for their model to replace humans and that there are important effects of maintaining a human in the loop during this decision process 7 however it is nonetheless informative to study the simplified case where the model does in fact fit this role below we detail our implementation of their algorithm and the additional model parameters we vary to explore how the model responds to different potential context in which it is deployed simulating training and deployment of the algorithm to build the machine learning algorithm to identify the youth who need to be screened in chouldechova et al 8 use what we will call the profiles of youth these profiles include demographics behavioral health records and past history in care as features and well as whether or not the youth end up in the foster care as the outcome to be predicted to simulate the training procedure for their model we define the features given to the model to be continuous values drawn from a gaussian distribution given our knowledge above that youth with shortand longterm stays are likely to have distinct reasons for being brought into care we further assume that their profiles are generated from two different distributions profiles of longterm youth are generated from n 𝑙𝑜 while profiles of shortterm youth are generated from n 𝑠ℎ parameters of these two distributions are shown in table 2 we define the label the model is trained on using the decisions at the substantiation phase notably as shown in figure 1 chouldechova et als 2018 model makes predictions at the screenin stage of the child welfare pipeline thus the label used is a downstream proxy assumed to be less racially biased in this setup however 8 therefore assume that if youth end up in foster care at the last decision made in the decision pipeline then the youth should be screened in at the first decision and vice versa we simulate the impact of introducing the model from chouldechova et al 8 as if it was trained using a dataset generated before november 2017 and implemented during the following year to do so we construct the training set by using profiles of admitted youth as positive samples and using profiles of reported but not admitted youth as negative samples after the training dataset is constructed we use it to train a logistic regression model as a screenin recommendation tool 3 in our simulation we model the deployment of this machine learning model as having complete autonomy over decisionmaking to be more specific after deploying the algorithm step in algorithm 1 is changed to send the profiles of 𝑛 𝑙𝑡 𝑟𝑎 reported youth at each month to the deployed algorithms to extract youth screened in and then admitted youth are extracted randomly using the substantiate rate introduced in the table 2 following assumption 1 because substantiation decisions are still made entirely by humans varying assumptions to evaluate the intervention we evaluate the performance of this algorithmic intervention under different assumptions about the underlying foster care system on which it is trained these variations are summarized in table 2 for black youth with shortterm stays the larger the number of black youth reported we vary the screen in rate for shortterm black youth in to represent high reporting bias low reporting bias and no reporting bias leaving other parameters at their defaults results of assessing an algorithmic intervention overall we find that relying on an algorithm trained as suggested by chouldechova et al 8 to make screenin decision would increase the number of youth in foster care contradicting the goals of the ffpsa however the impact of the algorithm varies depending on the assumed separability between profiles of youth with shortterm vs longterm stays figure 5 compares monthly forecasts of the number of black and white youth in foster care with and without using the algorithm for making screenin decisions moreover we distinguish between different algorithmbased screenin decisions by the ease of separability between youth with shortand longterm stays we see that in all conditions of separability we examined the algorithm would increase the number of youth in foster care however perhaps surprisingly the increase is significantly more pronounced when it is easy to separate longfrom shortterm youth that is the greater the assumed differences between youth with long and shortterm stays the more youth the algorithm puts into care figure 6a shows a that aggregating over youth with longand shortterm stays provides a distorted picture of the algorithms benefits and b that depending on the separability assumptions the algorithm has nonobvious sideeffects on racial disparities more specifically as the separability of youth with longand shortterm stays increases the number of youth with longterm stays in foster care increases and so does the racial inequity for these 3 training data was balanced by downsampling negative samples to approximate how machine learning models are trained in real world note that we dont modify hyperparameters of the model because this induces yet another implicit value judgement which is out of the scope of our main focus in the current work q q q q q q q q q q q q q q q q q q q q q q 6000 7000 8000 9000 q q q q q q q q q q q q q q q q q q q q q q 6000 7000 8000 9000 10000 fig 5 the simulated number of black and white youth in foster care by month for different screenin procedures without an algorithm and with an algorithm but different levels of separability between shortterm and longterm youth profiles youth however both the number of youth with shortterm stays and the racial inequity in the number of youth with shortterm stays increase as separability decreases thus under the assumptions of our model when training an algorithm under a situation where youth who end up in care longterm are similar to youth who stay for a short period of time the more short term youth enter foster care overall this is because the screenin algorithm if trained using substantiation as a proxy variable will get better at identifying youth who the current system sees as needing longterm care and these youth will in turn remain in care for longer even under a seemingly better situation where there is high separability between profiles of longterm and shortterm youth algorithms will place more longterm youth into the system contradicting the goal of ffpsa according to our simulation higher levels of bias when reporting youth to cps result in more youth in care and larger racial disparities the explanation for this phenomenon comes from the interplay of the different parts of the system if shortterm youth are more often black then while screenin rates of black youth will decrease overall the algorithm will produce more false positives for black youth this effect is problematic since the reporting of youth is biased 22 and exogenous to the child welfare system so a solution to this issue is needed and difficult to implement discussion and conclusion two major stated goals of the ffpsa are to 1 reduce unnecessary admission of youth into the foster care system and 2 provide more familybased service for youth who are in the foster care system to achieve such goals practitioners have been incentivized to leverage additional data collection and predictive modeling to assist decision making 1 here we construct a simulation model that considers how a particular algorithm can help to address the goals of the ffpsa while maintaining the additional goal of racial equality before reviewing the main resultant claims we find it pertinent to emphasize their limits first as noted above the intervention we consider does not account for the fact that while this may not be true of tomorrows algorithms 36 todays algorithms are often used at best as suggestions for screening in rather than allencompassing decisionmakers 8 second and related our model greatly simplifies facct 22 june 2124 2022 seoul republic of korea yuhao du stefania ionescu melanie sage and kenneth joseph q q q q q q q q q q q q q q q q total youth the first two plots shows the total number of longand shortterm stays while the last two plots shows the disparities between the number of black and white youth for longand shortterm stays q q q q q q q q short term total youth the number of admitted shortterm youth during simulated months for different levels of racial biases in reporting in the original system the first plot shows the total number of short term youth while the second plot shows the disparity of short term black and white youth fig 6 impact of the algorithm under varying assumptions the ways in which algorithmic decisions are made about specific youth in foster care additional complexity eg by creating more realistic youth profiles using advanced machine learning models may lead to distinct conclusions third certain parameterizations may be reasonably disagreed with in particular it is possible that higher levels of screenin rates may lead directly to lower rates of substantiation which violates assumption 1 4 as such we expect and hope that our model is viewed primarily as a starting point for informed debate to this end and with these limitations in mind we use our model here to bring forth the point that implementing a machine learning algorithm to assist in screenin decisions will tend instead to increase the number of youth in foster care and to increase racial disparities in the number of black versus white youth as well importantly this increase of youth in care often comes in the form of better identification of youth that may be in genuine need of longterm foster care as defined by the current system in turn while increasing the total number of youth in care the algorithm actually decreases the number of and racial disparities in shortterm stays in foster care as we interpret the work of chouldechova et al 8 the algorithm in this sense is accomplishing its goalreducing racial inequality and misidentified screen in cases as determined by the current system our findings thus expose a contradiction between the two justifiable goals of ffpsa 1 placing fewer youth in foster care and 2 more accurate identification of families who need more intensive services according to current measures namely improving our ability to differentiate youth with longterm versus shortterm stays in the current system increases the number of overall youth in foster care but does so through the inclusion of youth who the system would likely deem to need care therefore we argue that implementing algorithms that use past historical data under the new directive of the ffpsa will therefore require either 1 that we embed different notions of who needs foster care into our models or 2 that we use variables other than substantiation rates to train them equally as important our simulation make clear that efforts to develop algorithms for screening in youth must provide space for discussion about who if anyone should be placed into foster care proposed algorithms shouldnt be necessarily fitted into the existing problematic loop of the social system but rather provide a new perspective to policy makers that might facilitate more effective decisionmaking about policy and practice at the macro level our work also shows that these decisions must occur with a deeper consideration of assumptions we make about the myriad and sometimes unknowable parameters of the existing system at a fundamental level our work shows that the assumption of substantiation decisions as a proxy for screenin decisions made by chouldechova et al 8 can be problematic less obvious however is that variations in assumptions about parts of the system external to this proxy can still have important effects on model outcomes this variation in our simulation model not simply hypothetical wildly different policy environments across and even within states mean that assumptions in one setting are quite possibly incorrect for others these complex and hierarchical sets of assumptions benefit from the ability to systematically investigate how one change may impact others in nonobvious ways our simulation tool we therefore hope can serve as a kind of testbed as more data becomes available to validate or inform certain assumptions in different jurisdictions including new york state we also hope it will assist practitioners and policymakers in understanding the tradeoffs implicit in different assumptions they are making about decisions made in their own local arena

we introduce an analytic pipeline to model and simulate youth trajectories through the new york state foster care system our goal in doing so is to forecast how proposed interventions may impact the foster care systems ability to achieve its stated goals before these interventions are actually implemented and impact the lives of thousands of youth here we focus on two specific stated goals of the system racial equity and as codified most recently by the 2018 family first prevention services act ffpsa a focus on keeping all youth out of foster care we also focus on one specific potential interventiona predictive model proposed in prior work and implemented elsewhere in the us which aims to determine whether or not a youth is in need of care we use our method to explore how the implementation of this predictive model in new york would impact racial equity and the number of youth in care while our findings as in any simulation model ultimately rely on modeling assumptions we find evidence that the model would not necessarily achieve either goal primarily then we aim to further promote the use of datadriven simulation to help understand the ramifications of algorithmic interventions in public systems ccs concepts • computing methodologies → model verification and validation

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introduction gaokao chinas college entrance examination takes place annually in june with millions of candidates attending every year since clearing the gaokao is required for entrance into most higher education institutions it carries much significance in the lives of chinese youth although its highly pressurepacked nature aroused great controversy the gaokao was hailed by most chinese who hold a strong belief that it is a true and meritocratic examination that offers equal opportunities for students with different social origins while admitting that nepotism plays a relatively insignificant role in gaokao compared to other social competitions the paper argues that the meritocracy and social equalizing effect of gaokao is a false promise indeed not only did gaokao fail to promote an equitable education system as commonly believed but it also reproduced an unequal and oppressive status quo the paper begins by exploring the history of gaokao and how gaokao became the embodiment of a meritocratic ideal following this it briefly discusses how gaokao failed to promote an equitable education system as commonly believed the last section highlights the harmful effects of the failure to realize the inequality and oppression inherent in gaokao conventional sociological research on educational meritocracy examines two significant aspects how social origin affects educational opportunities and success and how educational qualification is related to the social destination this paper focused primarily on examining the former aspect the approaches adopted include examining related literatures and reflecting on the observations and personal experience in the chinese society this study spreads awareness in society on recognizing the flaws of standardized test and will provide valuable information for policymakers to further the educational reforms history of the gaokao the genesis of the gaokao can be traced back to the ancient sui dynasty when keju also known as the civil service examination was first introduced by the central government to select academicians to serve as officials in imperial china for a commoner who aspired to ascend to the elite class the only path seemed to be the keju system after serving imperial china for 1300 years keju was abolished in 1905 in 1952 three years after the birth of the peoples republic of china the gaokao was launched by the communist government as the successor of the keju system 1 during the chaotic cultural revolution public education in china took a complete hiatus and the gaokao was suspended after maos death in 1977 the gaokao was reintroduced by vice premier deng xiaoping regardless of age or background people rushed to attend gaokao and embrace its reinstatement 1 about 57 million candidates registered for the exam in 1977 while only 027 million were admitted making the enrollment rate as low as five percent 2 since then the general enrollment scale has continued to expand bringing increased access to higher education for less privileged students gaokao and meritocracy the fatechanging power of gaokao meritocracy has been an enduring yet controversial theme in modern sociological scholarship a meritocratic social system is where commonly desired opportunities and rewards such as privilege and power are positively associated with merit 3 generally speaking merit refers to ones educational qualification intelligence and effort 4 the concept of meritocracy has its deep root in the confuciuss philosophy that those who govern should do so because of merit not of inherited status the centurieslong keju tradition the first system in the world to select government elites through an open and anonymous examination instituted a modern form of meritocracy in imperial china 5 the social practice of meritocracy in china later inspired european enlightenment thinkers and european colonizers 6 for example britain experimented with a competitive civil service examinations in the chinese style first in its colony india and then at home 7 in 1958 the term meritocracy was formally coined by british sociologist michael young in his book the rise of the meritocracy with rapid changes in economic and occupational domains after world war ii giving rise to its prevalence in postindustrial western societies 8 since it represents a type of social selection that transcends ascriptive boundaries and promotes great mobility the ideology of meritocracy has powerful political attraction and has been incorporated into a variety of political ideologies the ideology of meritocracy was brought into china and used by the communist party of china to address socioeconomic and political hardships in the postmao era of reform chinas rapid economic growth has been accompanied by a sharp increase in social inequalities to hold the society together cpc employed a transformed ideology which involved rejuvenating traditional values and promoting an educationbased meritocracy 9 gaokao was introduced as a meritbased route promising social mobility equality and development the gaokao has played a critical role in reinforcing the impression that people regardless of their social origins can change fate if they are selfdisciplined enough and endure longhour of schoolwork today chinese citizens regard the gaokao as the cornerstone of meritocracy and hold strong faith that the exam rests on a fair foundation most people in china are acutely aware of the prevalent social inequalities and corruptions specifically how ordinary social competitions are determined through social connections they therefore see such competitions as counterfeit and fake by stark contrast they perceive gaokao as true and genuine owing to the fact that gaokao scores are decided during the examination frontstage publicly according to rulesbased and universal measures of merit 10 it is also widely believed that gaokao shields admission decisions from interference by political connections among people and thus it improves equity and credibility of college enrollment 11 deeply convinced of the educational meritocracy and its lifechanging power many chinese teachers and parents tell their children the way of heaven is to reward hard work if there is no pain there is no gain gaokao the false promise of meritocracy despite the commonly held belief that the gaokao is true and fair it actually failed to promote an equitable educational system and reproduced an unequal and oppressive status quo the gaokao is far removed from the meritocratic ideals that ones educational success is weakly related to his or her origin indeed there is a wide chasm in rural and urban childrens access to social resources which pierre bourdieu an educational sociologist refers to as the cultural economic and social capitals that determine educational opportunities and achievement in the gaokao 12 specifically rural children lack the embodied cultural capital to succeed in the gaokao which caters to the nations aspiration for globalization and favors knowledge pertaining to industrial lifestyles to transfer into a knowledgebased economy and prosper in the context of globalization china launched a series of educational reforms in recent years propositioning shifts from the instilment of knowledge to studentcentered knowledge construction 13 at the same time the state reprioritized knowledge skills and competencies to be included in curriculum standards and tested in the gaokao and recontextualized pedagogical discourses as the emphasis shifted to globalization rural cultural capital became further marginalized with the knowledge and competencies to be tested more culturally alienating for both rural children and teachers such alienation is reflected in rural teachers accounts in the book the demoralization of teachers that the knowledge to be learned is so distanced from rural childrens life we cant expect them to understand the word highway without ever having seen one and we didnt know how to teach independent exploration investigation and selfreflection 14 being culturally marginalized and lacking support from teachers rural children are fundamentally disadvantaged in an educational system in which globalization dominates most pedagogical discourses in addition to disadvantages in cultural means the limited access to economic and social capital makes it more challenging for rural children to compete with their urban counterparts in the gaokao urban children have the opportunity to frequent libraries and museums and attend private tutoring sessions to extend knowledge beyond school requirements according to wendy liang a civil servant who bought her son online english classes with a foreign tutor it is quite common for urban parents to sign up for tutoring classes for their children in shanghai 15 in urban cram schools prominent teachers and former test designers can even predict what will be covered in the gaokao and target exam preparation to improve students chances of acing the exam for rural children and families however access to those activities and resources that are common to urban students is unimaginable ms liang migrant worker in shenzhen and mother of a lowersecondary school student said in an interview that she has no idea where to find suitable tutors for her child even they manage to find a suitable tutor it would be impossible for them to afford the tutoring fee indeed the yearly tutoring cost of an urban high school student is around 8000 rmb 16 which exceeds the median household income per capita for a rural household in 2021 17 the divergence in access to a wide range of social and economic capitals results in a starkly different learning experience among rural and urban children rural families are both geographically distanced from urban areas in which educational resources are concentrated and financially incapable of paying for private tutoring or a study tour as a result schools and families are the sole sources of learning for rural students on the contrary children in cities and counties are surrounded by social resources such as teaching professionals and exampreparation institutions which enable a higher chance of success in the gaokao the coronavirus outbreak has put rural schoolchildren at an even greater disadvantage to their urban counterparts according to the china development research foundation nearly half of students in rural villages didnt have access to online classes during the pandemic though the gaokao is a standardized test that disassociates itself from corruption and nepotism it fails to mediate the pronounced ruralurban divide and ensure educational equality owing to the fact that rural children are afforded fewer cultural social and economic capital that fuel academic success in fact geographical origin plays a significant role in predicting test outcomes specifically ye lius multimodal analysis of factors influencing students higher education opportunities in china indicates that students from urban areas and counties generally performed better compared to those from rural areas in the 2006 gaokao 18 other studies have indicated an association between socioeconomic status parents educational levels and students educational outcomes therefore the gaokaobased meritocracy assumption that ones social origin has little impact on educational attainment is disproved with rural children systematically disadvantaged along their learning trajectories the gaokao fails to promote educational inequality and close the ruralurban learning gap despite the false promise of a socially equalizing effect the meritocratic ideal of the gaokao reinforced an inequitable and oppressive status quo by recruiting many into believing in individual merit thus enhancing the societys tolerance towards an unequal educational system despite acutely recognizing the wide social inequalities in china citizens are convinced that success and failure in the gaokao are the outcome of a relatively fair process during which ones origin only plays an insignificant role in fact the effects of education on opinions about meritocracy are greater for relatively disadvantaged social groups who tend to believe that merit plays a more important role than family origin for educational success in the gaokao 18 like many rural parents the father of zeyu a highachieving student from a peripheral rural county saw the gaokao as chinas only relatively fair competition offering ordinary people a chance to fight back against a corrupt and unequal world 10 in xiangs narratives of rural childrens attitudes towards schooling rural children hold strong faith in the tests power to change fate seeing the gaokao as their only hope of escaping a backward village life 19 while being disadvantaged systemically the belief that they can transform their own lives if they are selfdisciplined enough and they only have themselves to blame if they fail is indoctrinated into rural childrens psyche in this way the gaokao rendered moot the contribution of urban upper and middleclass childrens inherited assets making the oppressed more tolerant of an unequal educational system implications the false meritocratic ideal of the gaokao harms chinese students by imposing a public form of shame on low achievers and legitimates the process of social segregation fascinated by the narratives of success without realizing the fact that opportunities to accumulate such merit are unevenly distributed society positions rural lowachieving students as too stupid and idle to move up the social ladder students are discriminated against for simply having low scores 19 and teachers make debasing remarks on low achievers regarding them as junk and coal dusk 14 many children internalize the public humiliation seeing themselves as inferior and having unpromising life prospects during my interviews with vocational school students in guangdong many have low selfesteem describing themselves as losers in the system professor diane reays ethnographic research on british workingclass students resonated with my observation many workingclass children held the belief that a rubbish learner was only fit to go to rubbish schools at the same time the myth of a meritbased gaokao justifies the process of social segregation impairing both losers and winners in the system simply attributing exam success or failure to individual merit not only puts a veil on the fact that people are afforded with uneven opportunities to accumulate merit but also instills a strong sense of individualism among chinese students 10 the meritbased theory also justifies homogenous grouping and social segregation which puts students into different tracks based on their capabilities and chance to enter a prominent college as such it renders a simplistic outlook on the world for chinese youth covering up the social complexity and the fact that people inevitably belong to a social construct at the same time students are deprived of the chance to appreciate diversity learn from people who have different social capitals and thus make sense of relationships and the self in tandem with an overemphasis on textbook knowledge individualism hampers the meaningmaking process of learning for both winners and losers in chinese school settings the youth mental health problem is plaguing chinese society dominating pedagogical discourse a number of research has attributed the skyrocketing mental health problems among chinese youth to the intensive and highly competitive nature of the gaokao however few have ever investigated how the divide between the false promise of meritocracy and the inequityplagued reality is associated with the rise in mental health problems this paper offers an unconventional view on educational meritocracy and has implications for future research on a possible relationship between educational meritocracy and students mental health in contemporary chinese society conclusion in conclusion contrary to the commonly held belief that the gaokao offers fair opportunities for even the most underprivileged students it actually fails to promote an equitable educational system and reproduces an oppressive status quo torn between a false meritocratic promise and an unequal reality between a belief in individual merit and the interconnected society no one is the winner in this grueling contest this paper is subjective to several limitations first the new 3x mode of the gaokao was introduced in 2020 while most literature and personal accounts that i examined are from before 2020 my claims on the gaokao may lack credibility since i did not make a distinction between the new gaokao and the old one in addition my research did not distinguish gaokao from other standardized tests addressing limitations of my research more recent literature and evidence will need to be examined to focus on the new 3x mode of the gaokao and whether the shift to 3x remove the invisible barriers for disadvantaged groups in addition a comparative study on gaokao other forms of standardized selection and holistic admissions could be conducted to examine what makes gaokao different from other selection systems around the world my research builds a foundation for exploring possible visions of better selection mechanisms

this analytical paper examined the role of gaokao chinas college entrance examination in reproducing an unequal and oppressive status quo gaokao has received mounting criticism for requiring so much rote learning and discounting individual creativity though there is also heated debate on the fairness of this highstake test gaokao is widely believed by many chinese students and parents as the relatively fair approach for the nation to select talents the research brings new insights into this topic by analyzing it with pierre bourdieus framework of types of capitals it elucidates why gaokao offers a false promise of a socially equalizing effect moreover through the analysis made by this study it gives awareness to society on how failure to realize the inequality in gaokao will legitimates the process of social segregation and thus calls for exploring possible visions of better selection mechanisms the paper begins by exploring the history of gaokao and how gaokao became the embodiment of a meritocratic ideal following this this paper briefly discusses how gaokao failed to promote an equitable education system as commonly believed the last section highlights the harmful effects of the failure to realize the inequality and oppression inherent in gaokao

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introduction social bots have influenced public opinion about covid19 in social media during the covid19 pandemic the responsible and appropriate use of social media has become a fast and effective way to disseminate critical information during the covid19 pandemic 1 meanwhile the vast spread of misinformation conspiracy theories and fake news on social media is also a pressing question academics have used the infodemic to describe their research on spreading covid19related information online search behavior or spreading misinformation on twitter 2 3 4 5 6 7 the spread of the infodemic not only fuels the rise of racist attitudes and behaviors but also poses a significant global risk by putting both the health of the population and the ability of governments to implement effective preventive measures at risk moreover as computer algorithms social bots can generate content and interact with humans on social media to mimic and possibly manipulate humans and their behavior 89 in the context of the widespread influence of social media on individual opinions and behaviors social bots could be used to massively spread misinformation fake news hate speech and manipulate public opinion 10 11 12 13 we need to reconsider the nature and function of social bots in light of the covid19 outbreak based on the above background this study selected the tweets during the wuhan lableak theory as analysis samples to conduct social network analysis to find out and visualize the role of social bots and the path of humanbot communication literature review covid19 and social networks during the covid19 pandemic information in social networks can influence peoples perceptions attitudes and behaviors regarding health issues the rising popularity of social networks and media increased rapidly when people were forced to be isolated following social distancing norms 1415 the covid19 pandemic has caused extensive disturbance in individuals beliefs and societal structures people turn online for alternative cognitive and social structures when faced with these distractions 16 however governments and public health agencies were slow to disseminate information online and build public trust leaving room for the spread of covid19 misinformation and conspiracy theories 17 social media platforms such as youtube and twitter providing direct access to unprecedented content can amplify rumors and suspicious news 18 for example many fictional stories were popular on twitter the 5g network activates the virus the pandemic is a hoax created by a global conspiracy the virus is a biological weapon intentionally released by the chinese or bill gates is using it as cover to activate a global surveillance system 19 a popular view linked 5g to the spread of covid19 leading to the burning of 5g towers in the uk 20 moreover the spread of stigmatized negative emotional information on social media can create cyber racism covid19 is driving the rise of online sinophobia and the web is being exploited for spreading conspiracy theories targeting chinese and asians as covid19 is believed to have originated in china 21 studies have analyzed sentiment on twitter associated with terms such as chinese virus wuhan virus and chinese coronavirus and have shown that the majority of tweets analyzed were negative and tinged with feelings of fear sadness anger and disgust the use of slander and profane words was high 22 research proved that fake news tends to spread faster than verified news 23 the global epidemic of misinformation on social media platforms poses serious problems for public health 7 more importantly healthrelated misinformation threatens public compliance with public health safeguards studies have shown that belief in conspiracy theories increases the likelihood that individuals will ignore public health interventions and safeguards from the government or public health agencies 2425 for example less social distancing and hand washing 26 thus monitoring the spread of misinformation on social media is critical to understand the evolution of opinions that may negatively impact public health 27 social bots and humans on social media social bots have made an impact in multiple areas of human concern research has identified interference with social bots in the uks brexit vote 28 and the us 29 french 30 and german elections 9 studies have also reported the impact of social bots on topics such as cryptocurrencies 31 stock markets 32 and climate change 33 and actively engaged in public health discussions about vaccination 34 the covid19 pandemic 1235 and cannabis 36 social bots have also been involved in covid19 vaccinerelated discussions 37 in contrast to bots in antivaccination networks bots in provaccination networks influence the dissemination of provaccination messages 38 social bots also played a role in distorting public opinion and emotional expression they have the potential to actively amplify negative human emotions such as in the us discussion about covid19 where social bots managed to trigger a bottohuman spread of anger 39 previous studies examined the role of social bots in the spread of the covid19 infodemic and the diffusion of noncredible information such as 5g and bill gates conspiracy theories and content related to trump and the who by analyzing retweet networks and retweet items 4041 bots increased the exposure of negative and inflammatory content in online social systems 42 recent research suggests bots are more in tune with political content than healthrelated content while humans focus more on coverup and social distancing utterances bots engage in more political topics 43 social media data and social bots detection social media big data analytics is an effective largescale tool that can identify public health issues and improve national public health policiesfor example covid19 vaccination 44 researchers also used social media data on twitter to assess childrens exposure to violence during the covid19 pandemic 45 however misinformation mixed in with social media data is a serious problem for both ordinary users and researchers misinformation based on the internet and social media remain a common and significant problem during the pandemic the findings suggest unverified accounts contain more erroneous medical information than verified ones 46 therefore it is still necessary for us to consider the influence of unverified bot accounts and proceed through bot detection tools bot detection is crucial in a world where social media is increasingly vital as our communication channel techniques used to develop bot detection models use features such as metadata of tweets or digital fingerprinting of accounts 47 unsupervised methods are more robust than supervised methods because they do not depend on the ground truth quality the research proposed an unsupervised approach that uses features extracted from the retweet patterns of accounts and a clustering algorithm to distinguish bots from humans 48 bot detection is by no means an exact science within the scope of this study we cannot assess which tool is better at making correct predictions about the actual amount of automation 49 the tool employed in this study botometer is an exceptionally welldeveloped bot detection tool used by many influential studies and organizations such as the pew research center due to the uncertainty of the postpandemic era and the possibility of future pandemics it is essential to understand the drivers of misinformation and conspiracy theories and explore strategies to mitigate them especially if there may be technological algorithmic elements such as social bots first while some studies have highlighted the theoretical mechanisms by which social media influences covid19 conspiracy theories 16 the central issue remains empirical research recent empirical study has conducted social network analysis on twitter data for covid19 and 5g conspiracy theories but is limited by not identifying social bot accounts 21 thus ignoring essential drivers of conspiracy theories second in the early stages of the covid19 pandemic researchers topic and sentiment analysis of tweets can help understand the publics sentiments beliefs and thoughts 50 however the potential for future pandemics to continue to pose secondary problems such as the massive spread of rumors conspiracy theories and disinformation on social media forces us to look at the multiple factors that may be driving these problems third existing research lacks the identification of information flow and the identification of network nodes of influential people that stimulate virality finally the visual presentation and social network analysis of humanbot social networks during the covid19 pandemic also need to be strengthened in this article we aim to explore and visualize the communication patterns between social bots and humans on twitter during the prevalence of the wuhan lableak theory more specifically we will answer the following research questions first what are the structural characteristics of social bots and human accounts in social networks second what role do social bots play in the wuhan labrelated topics finally how do tweets spread between humans and social bots a diagram of the analysis process is shown in figure 1 first using the twitter ids gathered in the database we synthesized 120118 tweets second we performed text preprocessing on contents and social bot detection on the accounts we analyzed the content using the lda topic model at the content level at the relational level we use social network analysis to calculate the network structure features of all accounts finally we expect the abovementioned analysis process to help us identify the unique humanmachine themes and interactions in the covid19 pandemic discussions figure 1 steps used in this study materials and methods data in this study twitter was selected as the data source which provides an open application programming interface to provide researchers with a large amount of publicly available information upon specific request as this study deals with historical data during the covid19 pandemic a twitter dataset collected by the information science institute at the university of southern california was used the dataset contains tweet id related to specific keywords and accounts through twitters streaming api and tweepy which has stored covidrelated tweet ids since 28 january 2020 with nearly 2 billion tweets stored so far and continuously updated 51 this study selected the tweet data from 23 may 2021 to 29 may 2021 regarding google trends wuhan lab is more prominent from 23 may 2021 to 29 may 2021 displayed in figure 2 among the issues related to china the word wuhan lab has become the object of stigmatization against china in the international infodemic this study extracted the data of tweet ids in the database from 23 may 2021 to 29 may 2021 and adopted python programming to set random seeds for random sampling of the tweet ids within every hour according to the proportion of 1 and then synthesized the data through twarc twarc is a commandline tool for collecting twitter data in json format from twitter api 5253 after filtering we end up with 120118 tweets social bot detection materials and methods data in this study twitter was selected as the data source which provides an open application programming interface to provide researchers with a large amount of publicly available information upon specific request as this study deals with historical data during the covid19 pandemic a twitter dataset collected by the information science institute at the university of southern california was used the dataset contains tweet id related to specific keywords and accounts through twitters streaming api and tweepy which has stored covidrelated tweet ids since 28 january 2020 with nearly 2 billion tweets stored so far and continuously updated 51 this study selected the tweet data from 23 may 2021 to 29 may 2021 regarding google trends wuhan lab is more prominent from 23 may 2021 to 29 may 2021 displayed in figure 2 among the issues related to china the word wuhan lab has become the object of stigmatization against china in the international infodemic materials and methods data in this study twitter was selected as the data source which provides an open application programming interface to provide researchers with a large amount of publicly available information upon specific request as this study deals with historical data during the covid19 pandemic a twitter dataset collected by the information science institute at the university of southern california was used the dataset contains tweet id related to specific keywords and accounts through twitters streaming api and tweepy which has stored covidrelated tweet ids since 28 january 2020 with nearly 2 billion tweets stored so far and continuously updated 51 this study selected the tweet data from 23 may 2021 to 29 may 2021 regarding google trends wuhan lab is more prominent from 23 may 2021 to 29 may 2021 displayed in figure 2 among the issues related to china the word wuhan lab has become the object of stigmatization against china in the international infodemic this study extracted the data of tweet ids in the database from 23 may 2021 to 29 may 2021 and adopted python programming to set random seeds for random sampling of the tweet ids within every hour according to the proportion of 1 and then synthesized the data through twarc twarc is a commandline tool for collecting twitter data in json format from twitter api 5253 after filtering we end up with 120118 tweets social bot detection the twitter accounts bot score is calculated using the botometer service which assesses the extent to which the account exhibits characteristics similar to social bots 54 botometer examines six main features personal data friends social networks temporal activity patterns language and emotions through machine learning of more than 1000 features of the information communication network such as various descriptors user metadata friend statistics temporal patterns of activities parts of speech and sentiment this study extracted the data of tweet ids in the database from 23 may 2021 to 29 may 2021 and adopted python programming to set random seeds for random sampling of the tweet ids within every hour according to the proportion of 1 and then synthesized the data through twarc twarc is a commandline tool for collecting twitter data in json format from twitter api 5253 after filtering we end up with 120118 tweets social bot detection the twitter accounts bot score is calculated using the botometer service which assesses the extent to which the account exhibits characteristics similar to social bots 54 botometer examines six main features personal data friends social networks temporal activity patterns language and emotions through machine learning of more than 1000 features of the information communication network such as various descriptors user metadata friend statistics temporal patterns of activities parts of speech and sentiment analysis the bot score between 0 and 1 is obtained higher scores indicate a higher likelihood of automation we excluded unauthorized users and undetected users in this study in the experimental environment botometer works really well v4 has an auc of 099 suggesting that the model can distinguish bot and human accounts with very high accuracy 55 bot score dichotomy is adopted in this study and accounts with scores above a threshold are considered social bots in the literature 05 is the most common choice 10 the botometer however is not flawless and may misclassify accounts owing to a variety of factors there is a certain percentage of false negative and false positive accounts 56 depending on the data set on which the training is performed 55 it has been pointed out that botometer scores are imprecise when estimating bots especially in different languages based on this studys considerable data we take 05 as the threshold for determining social bot accounts at the same time due to the instantaneous bot scores we carried out social bot detection as soon as possible after obtaining the tweet data to ensure the accuracy of the data lda topic model firstly the text preprocessing of the data is carried out and the complete text data of each englishlanguage tweet is extracted by python programming the data needed to establish the topic model has been tokenized and removed the stop words the url and the nonalphabetic characters secondly the probability topic modelling is carried out through latent dirichlet allocation 57 finally to ensure the effectiveness of the topic model it is necessary to evaluate the calculation results of the topic model in this study the coherence score was used to calculate the similarity of words in topics we visualized the topic modelling results with pyldavis to determine the appropriate number of topics the lda topic model is used for extended document analysis to extract and summarize topics from documents it contains three layers of structure word topic and document lda has a good effect in analyzing text semantics and can effectively analyze largescale unstructured document sets it is progressively being used for short messages such as tweets 58 the topics implied by the lda topic model are unknown and need to be selfsummarized there has been an explosion of research using lda topic models in social media 5960 lda can identify topics in youtube transcripts 61 or carry out a topicclustering analysis of users online comments 62 social network analysis the theory of social network analysis holds that society is composed of different actors and forms a network through different connections a social network comprises a limited set of groups of actors and their relationships 63 social network analysis is a research method that uses technical means and tools to analyze the network structure and further reveal social relations usually the relationship data needed to construct social communication network mainly includes retweet follow like and comment this study focuses on the retweet relationship on the one hand user behaviors such as following or like are not necessarily closely related to topic diffusion behavior on the other hand the retweet relationship can more clearly reflect the specific communication path of users on social platforms this study uses python client library to clean and process the twitter data which is imported into gephi092 for visualization the specific measurement indicators of the network structure mainly include network scale that is the number of nodes and edges contained in the network structure degree centrality usually nodes with a higher degree centrality are in the core position and have a greater right to speak if the network is directed two distinct metrics of degree centrality indegree and outdegree are specified the degree in these circumstances is equal to the sum of the indegree and outdegree betweenness centrality the node with higher betweenness centrality plays a more vital role as a bridge in this study by extracting the retweet relationship between users the original user is taken as the source node the retweet relationship is taken as the edge and the retweeting user is taken as the target node to form a directed network gephis directed social network analysis graph can obtain the center node size and connection relationship of a social network the humanbot communication network and node connections may then be evaluated results corpus analysis and text preprocessing through a selfwritten python program this study removed meaningless words from the topranked highfrequency words such as corona virus coronavirus covid pandemic still time today and think finally we obtained a set of top 20 highfrequency keywords in tweets according to table 1 people have heightened concerned about vaccines india wuhan first and china text preprocessing is carried out through the powerful natural language processing python library nltk which comes with various corpus processing methods and interfaces in this study the nltk is used to segment the english text of twitter remove special symbols such as emoticons remove stop words remove hyperlinks restore word form and unify the text into lowercase text comparison before and after the text preprocessing is shown in table 2 lda model analysis according to the principle of the lda model the number of topics k of the lda model needs to be specified by the users themselves and there is no optimal solution hence users need to judge based on the effectiveness of the model the coherence score and topic model visualization were used as the criteria to test the models validity a higher coherence score indicates better interpretability and more meaningful topics which are semantically consistent figure 3 shows that the k value should be 8 as shown in table 3 the focus of concern for the outbreakrelated discussion is the prevention and cure of virus source the vaccine social influence family influence virus prevention measures health effects the public interests and other topics of twitter users in previous studies pyldavis was employed to evaluate produced models and visualize the intertopic distance maps 64 65 66 the dynamic interactive lda topic visualization map generated by pyldavis can analyze the correlation between research topics the model is better if the circle in the visualization result is significant and scattered pyldavis can adjust the parameters lambda to control the topic relevanceword correlation according to the test results of previous studies the optimal value of λ is about 06 and its probability of correctly identifying the topics is estimated to be 70 67 therefore in this study the value of λ is set as 06 and the number of topics is eight intertopic distance maps can help us understand the relationships between topics and the distance between circles indicates the distribution similarity between topics each circle represents a different topic and the size of the circle means how many documents contain that topic the number label on the circle represents the order of its size and the as shown in table 3 the focus of concern for the outbreakrelated discussion is the prevention and cure of virus source the vaccine social influence family influence virus prevention measures health effects the public interests and other topics of twitter users in previous studies pyldavis was employed to evaluate produced models and visualize the intertopic distance maps 64 65 66 the dynamic interactive lda topic visualization map generated by pyldavis can analyze the correlation between research topics the model is better if the circle in the visualization result is significant and scattered pyldavis can adjust the parameters lambda to control the topic relevanceword correlation according to the test results of previous studies the optimal value of λ is about 06 and its probability of correctly identifying the topics is estimated to be 70 67 therefore in this study the value of λ is set as 06 and the number of topics is eight intertopic distance maps can help us understand the relationships between topics and the distance between circles indicates the distribution similarity between topics each circle represents a different topic and the size of the circle means how many documents contain that topic the number label on the circle represents the order of its size and the circle with the number 1 is the most critical topic in figure 4 eight topics presented the lda model output distribution of the global view and its most crucial vocabulary associated with the topic themes 3 4 6 7 and 8 are relatively independent while themes 1 2 and 5 have a significant similarity social network analysis of social bots and human accounts social network structure there were 120118 epidemyrelated tweets in this study and 34935 twitter accounts were detected as bot accounts by botometer accounting for 29 in all 82688 twitter accounts were human accounting for 69 2495 accounts had no bot score detected in social network analysis degree centrality is an index to judge the importance of nodes in the network the nodes in the social network graph represent users and the edges between nodes represent the connections between users based on the network structure graph we may determine which members of a group are more influential than others in 1979 american professor linton c freeman published an article titled centrality in social networks conceptual clarification on social networks formally proposing the concept of degree centrality 69 degree centrality denotes the number of times a central node is retweeted by other nodes specifically the higher the degree centrality is the more influence a node has in its network the measure of degree centrality includes indegree and outdegree betweenness centrality is an index that describes the importance of a node by the number of shortest paths through it nodes with high betweenness centrality are in the structural hole position in the network 69 this kind of account connects the group network lacking communication and can expand the dialogue space of different people american sociologist ronald s bert put forward the theory of a structural hole and said that if there social network analysis of social bots and human accounts 431 social network structure there were 120118 epidemyrelated tweets in this study and 34935 twitter accounts were detected as bot accounts by botometer accounting for 29 in all 82688 twitter accounts were human accounting for 69 2495 accounts had no bot score detected in social network analysis degree centrality is an index to judge the importance of nodes in the network the nodes in the social network graph represent users and the edges between nodes represent the connections between users based on the network structure graph we may determine which members of a group are more influential than others in 1979 american professor linton c freeman published an article titled centrality in social networks conceptual clarification on social networks formally proposing the concept of degree centrality 69 degree centrality denotes the number of times a central node is retweeted by other nodes specifically the higher the degree centrality is the more influence a node has in its network the measure of degree centrality includes indegree and outdegree betweenness centrality is an index that describes the importance of a node by the number of shortest paths through it nodes with high betweenness centrality are in the structural hole position in the network 69 this kind of account connects the group network lacking communication and can expand the dialogue space of different people american sociologist ronald s bert put forward the theory of a structural hole and said that if there is no direct connection between the other actors connected by an actor in the network then the actor occupies the structural hole position and can obtain social capital through intermediary opportunities thus having more advantages because gephi is more suitable for processing big dynamic data for observational analysis it has a powerful visualization function and solid dynamic analysis 70 previous studies used gephi for visualization and network analysis 7172 after the processed data is imported into the gephi software the algorithm drawing and visualization operations are carried out for the data sets the information propagation path and law in the twitter social network composed of social bots and human accounts are further analyzed this study with users as node data and retweet relationships as edge data the data is cleaned and processed by python programming imported into gephi for visualization compared with weak connections such as like and follow the number of the specific relationship retweet may be less than the number of user nodes however it has an essential meaning of diffusion and can better reflect the willingness of node users more extensive networks and shorter text tend to increase the number of weak connections and many node users may not have edge connections after processing the data contains 100113 nodes and 86453 edges as is shown in figure 5 the color of nodes is divided into red and blue to distinguish between social bot accounts and human accounts according to the bot detection results accounts with a score over 05 are classified as social bot accounts and marked in red the accounts with a score of less than 05 are classified as human accounts and marked in blue as some public figures and news organizations also have automated manipulation behavior their scores will be higher than 05 after detection it may be that the operation strategy of the team behind them leads to the concentrated sending time of tweets or the application of twitter api for automated operation therefore this study also marks such accounts as bot accounts according to the network of discussions on the twitter platform this study simplified and simulated it as the information dissemination diagram in the humanmachine network as shown in figure 6 in the social network of manmachine symbiosis the social bots and humans are both senders and receivers of information there is a mixing and symbiotic relationship between man and machine in figure 6 the node represented by human a is a highdegree centrality account with poor discrimination ability for disinformation and rumors it is easily affected by misinformation retweeted by social bots at the same time it will also refer to the opinions of other persuasive folk opinion leaders in the retweeting process human b represents the official institutional account which has a high indegree and often pushes the latest news preventive measures and suggestions related to covid19 human c represents a human account with high media literacy which mainly retweets information from information sources with high credibility it has a solid ability to identify information quality and is not susceptible to the proliferation of social bots human d actively creates and spreads rumors and conspiracy theories and only retweets unverified messages that support his views in an attempt to expand the influence social bots k m and n also spread unverified information in the communication network without factchecking social bot l may be a social bot of an official agency indegree centrality analysis degrees are properties of nodes but they are related to edges without edges there is no degree the nodes number of edges is also the nodes degree in a directed graph edges have directions and the degree of a node can be further divided into degree indegree and outdegree the degree is equal to the sum of the outdegree and indegree in this study the degree of a node is directly related to the retweeting relationship the higher the indegree is the more times it is retweeted by other nodes the higher the outdegree is the more it is retweeted the top 30 accounts ranking by indegree are shown in table 4 twitters verified accounts include media organizations politicians industry experts and celebrities according to the top 30 accounts with the highest clickin degree they all have a high number of followers most of them are official verified accounts and their original tweets have been retweeted by other users many times showing the prominent characteristics of opin in figure 6 the node represented by human a is a highdegree centrality account with poor discrimination ability for disinformation and rumors it is easily affected by misinformation retweeted by social bots at the same time it will also refer to the opinions of other persuasive folk opinion leaders in the retweeting process human b represents the official institutional account which has a high indegree and often pushes the latest news preventive measures and suggestions related to covid19 human c represents a human account with high media literacy which mainly retweets information from information sources with high credibility it has a solid ability to identify information quality and is not susceptible to the proliferation of social bots human d actively creates and spreads rumors and conspiracy theories and only retweets unverified messages that support his views in an attempt to expand the influence social bots k m and n also spread unverified information in the communication network without factchecking social bot l may be a social bot of an official agency indegree centrality analysis degrees are properties of nodes but they are related to edges without edges there is no degree the nodes number of edges is also the nodes degree in a directed graph edges have directions and the degree of a node can be further divided into degree indegree and outdegree the degree is equal to the sum of the outdegree and indegree in this study the degree of a node is directly related to the retweeting relationship the higher the indegree is the more times it is retweeted by other nodes the higher the outdegree is the more it is retweeted the top 30 accounts ranking by indegree are shown in table 4 twitters verified accounts include media organizations politicians industry experts and celebrities according to the top 30 accounts with the highest clickin degree they all have a high number of followers most of them are official verified accounts and their original tweets have been retweeted by other users many times showing the prominent characteristics of opinion leaders outdegree centrality analysis in this study the outdegree represents the times of retweeting the higher the outdegree the more the node retweets other nodes according to statistics the top 30 outdegree twitter accounts as shown in table 5 all nodes are unofficial authentication accounts among the most popular accounts many had the word bot in their names indicating that they were social bots whose identities were public according to the previous study social bots can have many good and bad applications like any software they can automate tasks faster than humans such as automatically publishing news or changing templates for all pages in a category on wikipedia 73 social bots that automate tasks on social platforms are mainly used to spread all kinds of news or publish helpful information such as weather updates and sports scores so they must retweet popular tweets frequently betweenness centrality measures the degree to which actors control resources nodes with higher betweenness centrality play the role of bridge between others linton c freeman believes that intermediate members of social networks have a more significant interpersonal influence on members at both ends of the path 74 in other words information communication in the process of public participation in discussion largely relies on accounts with high betweenness centrality through calculation discussion of twitter users betweenness centricity ranking data is shown in table 6 the data in the table indicates that 30 accounts such as nitin043 ansaaral1 yoursurajnaik somenmitra3 and sitansh64621089 had high intermediary centrality it shows that the above users are an essential bridge for spreading epidemyrelated information in the corresponding time and play a more prominent role in the bridging of control ability and information resources of other nodes having a specific right to spread however the average betweenness centrality value of more than 99 of users is 0 their influence is feeble and most users are affected by the top accounts to retweet it indicates that a few node users control the retweeting behavior of many other node users among the accounts that ranked high in betweenness centrality there were few verified twitter accounts but more personal accounts combined with the core topics in twitter discussions it can be speculated that the personalized narratives of ordinary user nodes are more likely to attract other actors to interact in this period that is folk opinion leaders have more communication ability in discussing the lableak theory in addition botometer detected 30 accounts with high betweenness centrality scores and found that except for one account that failed to be detected a total of 19 accounts out of the remaining 29 accounts were suspected to be social bots it can be seen that social bots played a critical role as a bridge in discussions related to covid19 discussion this study analyzed lableak conspiracy theories on twitter in the context of covid19 finding the influence of social bots on social media to manipulate public opinion according to some findings while automated accounts are numerous and actively engaged in discussing controversial issues they generally do not appear to increase human users exposure to negative and inflammatory content 47 however in this study we found that social bots played a bridge role in diffusion in the apparent directional topic like wuhan lab previous research also found that social bots play some intermediary roles between elites and everyday users regarding information flow 43 in addition verified twitter accounts continue to be very influential and receive more retweets whereas social bots retweet more tweets from other users studies have found that verified media accounts remain more central to disseminating information during controversial political events 75 however occasionally even the verified accountsincluding those of wellknown public figures and elected officialssent misleading tweets this inspired us to investigate the validity of tweets from verified accounts in subsequent research it is also essential to rely solely on science and evidencebased conclusions and avoid opinionbased narratives in a time of geopolitical conflict marked by hidden agendas disinformation and manipulation 76 by comparing other studies on conspiracy theories about the origin of covid19 we conclude that controlling social bots is an important way to reduce the spread of conspiracy theories primarily two theories about the origin of covid19 have circulated widely in china and the west one blaming the us and the other on the highestlevel protection laboratory in wuhan the pandemics initial epicenter both theories claim that biological warfare was attempted these claims are unsubstantiated by scientific evidence 77 previous research has shown that conspiracy theories are reinforced in online communities and that social norms change when conspiracy theories are translated into realworld action these actions are posted back to social media where they are reinforced and amplified further and the cycle continues increasing public awareness of conspiracy theories may lead to people viewing them as more popular potentially normalizing them into the mainstream 16 at the same time we should notice the role of social bots in this conspiracy cycle secondarily conspiracy theories can have many negative consequences including harmful effects on healthrelated behaviors 78 as stated in the study the persistence of covid19 conspiracy theories may be one of the reasons for global poor acceptability and ambivalence about covid19 vaccines 79 peoples beliefs about infectious disease conspiracy theories can negatively affect their health behaviors regarding vaccination 80 thirdly selected sources of covid19 information and social media connections predicted the origin of covid19 beliefs 81 therefore the government the medical community social media platforms and media organizations must work together extensively to counteract the spread of conspiracy theories and their detrimental effects to be specific flagging bot accounts and the misinformation they share could be an effective strategy to prevent the spread of false information online 41 platforms can inform users before they encounter false or misleading information or they can correct information to disprove conspiracies 82 to effectively communicate with the public health authorities and the media should adopt a more critical rhetorical strategy 83 at the present time the social bot is embedded in the human communication network which makes the information communication in the social platform show the pattern of humanmachine symbiosis at the same time social bots have become an essential driving force for the diffusion of lowcredibility content affecting the information acquisition and dissemination of regular human accounts through the interconnection and centralized retweeting of many topics social bots can complete the public opinion manipulation process of setting topics strengthening frameworks network cooperation and influencing audiences quickly in the multiple rotations of social bots conspiracy theories and disinformation mixed with other network information are spread more widely causing more ordinary users to retweet thus strengthening the manipulation of public opinion under the joint action of topic manipulation and technology manipulation when ordinary users enter the humanmachine network controlled by hidden forces they must accept the influence and domination of the controlled information therefore although the social bot individual is small it has become a super spreader with strategic significance as an intelligent communication subject in the social platform it conspired with the discourse framework in the mainstream media to form a hybrid strategy of public opinion manipulation conclusions this study visually analyzed the humanmachine interaction misinformation propagation process and revealed the role of social bots providing practical guidance for health authorities on how to combat rumors and conspiracy theories in the context of the pandemic in the future social bots which account for 29 of all accounts were observed to have participated in twitter discussions during the peak of the wuhan lableak theory we discovered that while verified accounts have a greater direct influence on the majority of users in retweet networks social bots have a greater indirect influence than humans they do not set the agenda but they do much to distribute it additionally a small number of nodes or headers control the majority of users retweets unverified accounts played a greater role than any other type of intermediary in the dissemination of conspiracyrelated topics as a result controlling the actions of social bots and spreading misinformation at their source is critical to reducing their impact limitations and future directions twitter data are appropriate for a variety of research issues and have been used in published studies on a number of significant subjects 84 85 86 87 however using twitter as a single data source has advantages and disadvantages on the one hand based on this papers research purpose and tool limitations we chose the twitter platform which is more friendly to researchers and has mature bot detection tools for research on the other hand the social media used by people in daily life are very diverse including some video platforms how information flows and functions among these platforms is a new problem worth studying which is also the limitation of this research moreover little is known about the sampling quality of the twitter api and thirdparty platforms and there is little opportunity to verify how the backend samples so there is some data bias 88 in addition how individual users on social platforms perceive and are affected by the behavior of social bots needs to be further studied whether the influence of social bots is mainly focused on individual users or the overall network structure remains to be explored related to the measurement of social impact and network influence of social bots at the same time this research can further innovate from data methods and case selection and expand the study by combining political theories and information ethics data availability statement not applicable author contributions conceptualization al methodology zw software zw validation zw formal analysis zw data curation zw writingoriginal draft preparation zw writingreview and editing al visualization zw supervision al project administration al funding acquisition al all authors have read and agreed to the published version of the manuscript funding this research was funded by the national social science foundation of china grant number 18zda308 institutional review board statement not applicable informed consent statement not applicable

social media is not only an essential platform for the dissemination of public healthrelated information but also an important channel for people to communicate during the covid19 pandemic however social bots can interfere with the social media topics that humans follow we analyzed and visualized twitter data during the prevalence of the wuhan lab leak theory and discovered that 29 of the accounts participating in the discussion were social bots we found evidence that social bots play an essential mediating role in communication networks although human accounts have a more direct influence on the information diffusion network social bots have a more indirect influence unverified social bot accounts retweet more and through multiple levels of diffusion humans are vulnerable to messages manipulated by bots driving the spread of unverified messages across social media these findings show that limiting the use of social bots might be an effective method to minimize the spread of conspiracy theories and hate speech online

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introduction despite important health development achievements in latin america the region presents one of the most drastic disparities in the world while life expectancy at birth in the region has risen by 6 years over the last 25 years the economic gap between rich and poor has widened in ecuador almost 40 of the population is poor this andean country presents a low development index percapita income at 43 of the regional average and a society that has historically presented profound social key messages inequalities by economic status and ethnicity are strong determinants in the use of health services in ecuador health care reform efforts should address these and other inequalities systematically in order to advance equity in health ethnic and regional inequalities indigenous populations who are mostly concentrated in rural regions experience greater challenges utilization of health care services in ecuador varies greatly by socioeconomic status age gender and urbanrural residency some 2530 of ecuadors population lack regular access to health services while more than twothirds have no health insurance and insufficient resources to pay for the health care services they might require the principal institutions of the sector are the ministry of public health and the ecuadorian social security institute which together have the largest health care infrastructure iess insures approximately 20 of the population while private insurance covers less than 3 of the middleand upperincome population this paper examines the utilization of health services in ecuador focusing on the equitability of service use and the socioeconomic determinants thereof three research questions are proposed 1 to what extend do perceived need and demographic factors influence the utilization of curative and preventive services in ecuador 2 what is the influence of socioeconomic factors on an individuals utilization of curative and preventive services in ecuador 3 based on perceived need predisposing and enabling factors is utilization of health services in ecuador equitable answers to these questions can inform and help policy makers to consider appropriate policy options to improve the equitable use of health services in ecuador further because empirical study such as this is rare in the latin american context findings from this study may also inform researchers and policy makers in other latin american nations to consider future research and policy changes context the ecuadorian health care system the ecuadorian health sector is made up of a combination of public and private institutions both nonprofit and forprofit the financing of each institution is separate adding to the complexity of the system as stated above the main institutions are the mph and the iess the management model of the mph is based on health areas which are small networks of services defined by geographic and population areas and on the technical association of certain administrative programming and budgetary activities the iess has an administrative model operating in nine regions with a network of servicesits own and outsourcedwhose operations follow central planning and financing directives in 2000 the ecuadorian congress passed a major health reform law that incorporated a variety of mechanisms in order to establish a true national health care system however to this day fundamental problems persist in the organization management and financing of the health sector that make it difficult to guarantee equitable access to health services conceptual background in understanding the utilization of health services there are three major concepts described in the literature that require further discussion these are health care inequality health care need and health care utilization many approaches have been applied to assess health care inequality focusing primarily on need and its relationship with utilization of health care services in the context of andersens model of health care utilization behavior equity in health care is achieved particularly when need variables have a strong positive association with health care utilization in other words at the core of this theoretical framework is the value judgment that the health care system would be considered fair or equitable if needbased criteria used in a statistical model would be the major predictors of the amount of health care utilized on the other hand inequity in health care occurs when enabling characteristics and resources such as health insurance or income determine who obtains medical care need in the context of andersens theoretical model refers to illness as a fundamental factor affecting health care utilization hence need could be diagnosed by a health care provider or reported by individualshouseholds as symptoms health problems disability days etc however the perceptions of health care need may be affected by other socioeconomic factors such as income or ethnicity utilization in this paper refers mainly to use of health care services finally aday and awe pointed out the importance of identifying the level of individual discretion when using health services in this context preventive care utilization would be more discretionary while curative care and hospitalization would be less discretionary in latin america there are a number of studies looking specifically at health care use or access for instance glei et al found that in guatemala obstetrical need was a strong predictor of pregnancy care while guarnizo found inequalities in accessing health care services by sex age income and marital status in colombia in mexico paqueo and gonzales found that ethnicity and insurance were significant predictors of use while roserobixby found that a gis platform allowed a better understanding of both population and health care facilities distribution in costa rica in ecuador previous research on social and economic determinants of health care utilization is scarce however two papers are particularly relevant using a national dataset waters measured equity in the distribution of access to health services while his 1999 paper evaluated the impact of publicly financed health insurance on health care utilization methods study design this crosssectional study utilized data from the 2004 demographic and maternal child health survey using a deductive approach the authors applied andersens model of health care utilization behavior as the theoretical foundation to study socioeconomic determinants of health care utilization in ecuador in this context our better understanding of peoples perceived needs and other factors influencing utilization of health care services becomes crucial in assessing socioeconomic inequalities in the utilization of services for such purpose this paper focused on analysing various predisposing enabling and need factors affecting health care utilization in the ecuadorian population ultimately inequalities in the use of health services were examined study population endemain 2004 surveyed households to gather information on utilization of health services and health care and consumption expenditures endemain 2004 used a multistage clustering design to provide a nationally representative sample of 28 908 households in ecuador the health care utilization and expenditures component was completed in 10 985 households nested in 692 census segments which in turn were nested in 17 strata consequently this paper uses the term provinceregion to refer to this level of analysis for use of preventive care curative visits and hospitalization the subsample of participants 12 years and older was used while for use of antiparasitic medicines the subsample of participants under 15 years was used operationalization of key concepts in this section we operationalize two key concepts for this study health care need and health care utilization health care need in this study perceived need was used as a predictor of utilization of health care services endemain 2004 asked individuals if they had had health problems during the previous 30 days and to mention the two most important problems from these questions endemain 2004 created a variable to identify the number of health problems mentioned by the participants in a previous study number of health problems was also used as a need predictor utilization of health care services both preventive and curative measures of realized utilization were employed in this paper endemain 2004 asked participants regarding preventive care if they had visited a physician for a preventive appointment in the last 30 days and regarding curative care if they had visited a physician for a curative appointment in the last 30 days if they had been hospitalized in the last 12 months and if persons under 15 years were taking antiparasitic medicines 1 all these variables were dichotomous except for the curative appointment which was a count other measures besides the key constructs outlined above there are other explanatory variables considered in this study classified following andersens model predisposing factors included age sex ethnicity and marital status for use of antiparasitic medicines household head sex and marital status were included enabling factors were area of residence assets quintile consumption quintile 2 educational level and health insurance affiliation the assets and consumption quintiles were created to rank household economic status from 1 to 5 the assets quintile is based on household characteristics and durable goods availability while the consumption quintile is based on household consumption of goods and services the uninsured category includes people who have neither public nor private health insurance for use of antiparasitic medicines household head educational level was included data analysis the first step of our analysis is to use summary statistics for all discrete and continuous variables table 1 summarizes the variables used in the analysis for use of preventive care number of curative visits and hospitalization table 2 summarizes the variables used in the analysis for use of antiparasitic medicines given that the endemain 2004 sampling frame had four levels individual household census segment and provinceregion multilevel models were used to examine the influence of predisposing enabling and need factors on utilization of health care this study recognized the need to account for clustering in such a complex sample design the multilevel structure allowed for the simultaneous analysis of data at the various levels of hierarchy in endemain 2004 hence there was no need to identify a single appropriate level of analysis furthermore multilevel modelling offers the possibility of adding contextual richness and complexity to the analysis various recent studies have used multilevel modelling to assess health care utilization preliminary analysis to assess the relevance of a fourlevel model was conducted moreover significant variance was a requirement for adding higher level predictors into the conditional models for each model variables were assigned to each significant level to build three conditional models in a sequential order spss 115 and stata mp v92 were used for data preparation and mlwin 202 was used to fit all multilevel models results the results for use of preventive care services curative visits and hospitalization are presented in table 3 due to space considerations only the final conditional models are presented except for age all predictors were entered in the models as indicator dummy variables following andersens health care utilization behavior model for preventive care need as expected was not a significant predictor of use the constant in model 4 represents a mestizo man aged 35 who is married and lives in an urban area belongs to the highest assets and consumption quintile categories with college education and health insurance and reports no health problems during the previous 30 days at the time of the survey in other words this best group had a 96 probability of using preventive services within 30 days adjusting for predisposing factors at the individual and household levels and enabling factors a statistically significant positive relationship between household economic status and use of preventive services was observed more importantly there was a strong gradient in assets and consumption quintiles in the use of preventive services compared with the wealthiest group had a statistically significant negative association with number of visits similar to use of preventive services there was a gradient in the relationship between household economic status and number of curative care visits however none of the assets quintile levels were strongly related to number of curative care visits for hospitalization the nonconditional model showed that there was no significant variation at the household and census segment levels hence no householdlevel predictors were included in all conditional models after adjusting for predisposing factors variation at the census segment level was statistically significant consequently the censuslevel predictor was added to the final conditional model similar to number of curative visits need predictors had a strong positive association with use of hospital services the group of older single or widowed individuals with one or two health problems was more likely to have used hospital services during the last 12 months after adjusting for need and predisposing factors living in a rural area and being uninsured significantly decreased the odds of using hospital services the constant in model 4 represents a man aged 27 who is married and lives in an urban area with high school education and health insurance and reports no health problems this best group had a 26 probability of hospitalization within the past 12 months the results for use of antiparasitic medicines are presented in table 4 model 1 shows significant variation at the household census segment and provinceregion levels model 2 reveals that only having a second health problem is slightly significantly related to use of antiparasitic medicines however when adjusting for predisposing and enabling factors need becomes a strongly significant predictor of use model 3 shows that being of indigenous descent statistically significantly decreased the odds of a child using antiparasitic medicines and the magnitude of decrease was substantial the constant in model 4 represents a mestizo boy age 7 who lives in an urban area belongs to the highest assets and consumption quintile categories has health insurance reports no health problems and whose household head is male married and with college education in other words this best group had a 643 probability of using antiparasitic medicines within 30 days when adjusting for predisposing and enabling factors and need there was a significant positive relationship between household economic status and use of antiparasitic medicines there was a similar gradient to that observed in the use of preventive services the very poor households were least likely to use antiparasitic medicines while the betteroff households were closer to the ideal use of antiparasitic medicines rural residence had a strong positive association with use of antiparasitic medicines on the contrary compared with households where the household head had college education childrens odds of using antiparasitic medicines decreased significantly when the household head had no formal education discussion based on a nationally representative crosssectional sample of ecuador this study found evidence of inequalities in the utilization of health care services these results can provide policy makers with clear evidence of vulnerable segments of the population that require differential treatment following andersens theoretical assumptions perceived need was found to be a statistically significant predictor of use of antiparasitic medicines curative care visits and hospitalization and played a nonstatistically significant role in the use of preventive services however major differences in health services utilization by economic status and ethnicity were found first for all utilization outcomes where economic measures were considered families in the lowest 20 consumption quintile were least likely to utilize health care services even after adjusting for other factors similarly to the relationship between income and selfrated health as described by subramanian et al for the case of chile this paper found that there was a gradient in the relationship between economic status and utilization of health care services in ecuador for instance when comparing with households in consumption quintile 5 the odds of using preventive services decreased 63 for households in consumption quintile 1 in contrast the odds of using preventive services decreased 19 for households in consumption quintile 4 although this paper did not attempt to evaluate health insurance programmes health insurance status was consistently found to be a significant predictor of health care use 3 undoubtedly insurance coverage is one of the key elements for reform in ecuador considering the high levels of poverty low percentage of population with some form of health insurance the regressive distribution of government expenditures on health and the heavy dependence on outofpocket expenses which accounts for almost 65 of the health financing mix second indigenous ethnicity was a strong predictor for less frequent use of preventive care antiparasitic medicines and curative care visits for the last two outcomes the same held true even after controlling for enabling factors for example the odds of using antiparasitic medicines decreased 25 for children of indigenous households in mexico previous research found a negative association between ethnicity and utilization of medical consultations and dental services paqueo and gonzalez also found that indigenous people were more likely to use preventive services in turn this paper found initial evidence that indigenous ethnicity was negatively associated with use of preventive services however this relationship was not statistically significant when adjusting for enabling factors which in turn may reiterate the importance of socioeconomic status regardless of ethnicity nevertheless it is relevant to keep in mind that more than 75 of indigenous ecuadorians are poor their life expectancy at birth is 1020 years below the general population and infant mortality is 15 to 3 times higher than the national rates the situation is similar throughout latin america despite their increased political power and representation the significance of indigenous ethnicity being negatively associated with utilization of health care therefore calls for policy makers attention although the rise and increasing political power of the ecuadorian indigenous movement since the early 1990s has advanced the dialogue the differences and exclusion conditions experienced by the indigenous populations remain almost intact consequently the coverage and quality of social programmes including health care nutrition and education needs to be expanded however expansion needs to go hand in hand with a culturally appropriate approach in other words it is necessary to analyse debate and incorporate traditional healing practices in the public provision of services the cotacachi otavalo and riobamba experiences of more holistic alternative models of health care provision are key milestones in advancing the concept of an intercultural health care system which could be systematized and considered for adoption by regional and national authorities here the political and financial support of the direccion nacional de salud de los pueblos indigenas is crucial in advancing such an agenda if successful it could become an intercultural health care model for other latin american countries gender equality in health care utilization is another issue we explored in this study in latin america there are serious gaps in policies affecting the health of women particularly poor indigenous and lesseducated women this study found a positive relationship between being female and use of preventive care curative care and antiparasitic medicines and nonstatistically significant relationship for hospitalization levine et al pointed out that women and men had similar resources for use of health services and health insurance coverage but mostly concentrated in highincome households this assertion is supported by the present study since households in the lower assets and consumption quintiles were significantly less likely to use preventive or curative care nevertheless the particular health care needs of women need to be taken into account a recent study found that ecuadors law for the provision of free maternity and child care has significantly improved primary health care utilization future research should look more specifically at the use of health care services among women and its differences by ethnicity socioeconomic status and regular source of care similarly use of antiparasitic medicines requires more attention to the authors knowledge this is the first time a study has analysed the reported use of antiparasitic medicines nationally further it controlled for the influence of household heads sex marital status and educational level the results of this study indicate that the probability of poor indigenous children having access to these medicines is low future research should specifically contrast prevalence by ethnicity income and other socioeconomic factors such as parental education level the case of antiparasitic medicines relates to the previous discussion on indigenous health poor indigenous childrens access to these medicines was low consequently it is necessary to determine systemlevel mechanisms of appropriate treatment distribution more importantly a political decision is needed to incorporate conventional and traditional treatment options this study has a number of limitations first by using secondary data there was a risk of inheriting problems that could alter the analysis and its interpretation for instance no providerlevel factors were included in this analysis by design generalizability is limited to the following levels national provinceregion and urbanrural residence second since variables were measured at a single point in time the possibility of inferring causeeffect relationships was limited third endemain 2004 relied heavily on participants report of behaviour rather than observation therefore measurement error could have been introduced by respondents recall errors instability of their opinions misunderstanding of questions and lack of honesty in their answers ie respondents might have tended to give socially desirable answers fourth multilevel analyses only considered main effects in other words this study did not consider specific interactions or look at subsample effects conclusions contributing to the growing empirical research on health inequalities in latin america this study found strong evidence of various inequalities present in the ecuadorian health care system from a policy perspective this study highlights the need for health care reform in ecuador to address these inequalities systematically our interest in equity in utilization of health care is guided by our concern for equity in health assuming that better health care is an important contributor to better health further given the existing inequalities in socioeconomic status in ecuador improving equity in health care services may serve as an equalizer to reduce the overall inequality this is especially important when other social determinants of health are either harder or take longer to change the relationship between utilization of health care and health outcomes therefore also calls for further attention endnotes 1 the use of antiparasitic medicine is significant in the ecuadorian context because there is a relatively high prevalence of parasitic diseases various local studies on lowincome schoolaged children in ecuador found prevalence of parasitic infections ranging between 48 and 84 2 although there is a relatively high correlation between these two measures of economic status we included assets and consumption quintiles because they are measuring economic status from different perspectives in lowincome settings more traditional measures such as income or consumption become problematic due to limitations of collecting accurate information therefore assets owned in a household can be a better reflection of economic status 3 since evaluating the impact of health insurance was not the purpose of this paper no correction for selection bias was attempted however it is important to recognize that the effect of insurance on the use of health services may be endogenous to the use of health care leading to selection bias therefore ignoring the endogeneity of insurance could possibly exaggerate the effects of insurance on demand for services

this article examines socioeconomic determinants and inequality of health care utilization in ecuador despite health reform efforts in latin america drastic socioeconomic inequalities persist across the region including ecuador almost a third of ecuadors population lack regular access to health services while more than twothirds have no health insurance and insufficient resources to pay for health care services using andersens model of health care utilization behaviour relevant variables were selected from the 2004 national demographic and maternal child health survey endemain household survey four outcomes were assessed use of preventive services number of curative visits hospitalization and use of antiparasitic medicines adjusting for various predisposing enabling and need factors a significant negative relationship was found between household economic status as measured by assets and consumption quintiles and utilization of preventive and curative services the same was true for use of antiparasitic medicines further indigenous ethnicity was found to be a significant negative predictor of health care utilization regardless of economic status these socioeconomic inequalities in the use of health care services suggest the need for health care reform in ecuador to address these issues more systematically it is necessary for public health authorities to move forward on a reform that will expand coverage particularly to indigenous and lowand middleincome households

19877_0

i t is with regret that we report the death of dr j p cassidy of 2112 yonge st toronto on december 12th 1938 dr cassidy was the victim of two automobile accidents occurring within a few seconds of each other he was thrown from his own car when it skiddecl on an iceglazed pavement and was injured further when a second auto struck him as he was lying in the ditch dr cassidy was a native of tweed ontario and graduated from the ontario veterinary college in 1935 following his graduation he located on north yonge street in toronto where he es tablished a lucrative smallanimal prac tice while of a somewhat retiring nature he was well liked and highly regarded by neighbouring practitioners the sympathy of the profession is extended to the bereaved relatives r n walsh d v s d r r n walsh huntingdon died on december 31 1938 in the mont real general hospital where he had been confined for six weeks dr walsh was born in huntingdon on october 1 1863 he attended the public schools and later graduated from the huntingdon academy entering mcgill university he graduated from the fa culty of comparative medicine and ve terinary science with the degree of dvs in 1890 returning to his home he set up practise and almost immediate ly enjoyed a large clientele the re spect in which he was held was evidenced by the many municipal offices to which he was elected and later by the highest honour which the constituency could bestowelection to the house of com mons in this body he sat for several years being finally defeated by the hon ourable james robb dr walsh was in religion a life long presbyterian and in politics a conser vative not only has dr thompson served the profession well in so far as his personal activities are concerned but also for the future since two of his sons dr k h thompson and dr s n thompson who have recently graduated are now as sociated with the health of animals branch on field work in the province of manitoba a third son d thompson en tered the freshman class of the school this year family of veterinarians dr thompson is taking a wellearned holiday and on his trip has visited the ontario veterinary college at guelph the new york state veterinary college at ithaca and has also been to new york toronto chicago and minneapolis 29 o canadian journal of l30 comparative medicine twentyfifth annual meeting wnestern new york veterinary medical association by a visiting veterinarian t his association with headquarters in buffalo ny is a local organiza tion designed to serve the interests of the profession in the western extremity of new york state summer meetings are held at various centres in the area but the annual meeting is always in buffalo the date of the meeting this year was december 15th 1938 and it was held in the spca building the afternoon from 1 pm to 430 pm was devoted to the examination diagnosis and operative procedure of a number of clinical cases submitted for the occasion one case of considerable interest had been diagnosed as intestinal obstruction by a foreign body a laparatomy was performed with the intention of removing the obstruc tion when the abdominal viscera was exposed a diffuse peritonitis and enteri tis were evident in a portion of the in testine an obstructing mass of foreign material mixed with feces was found in corporated in the mass was a thread which extended forward in the gut and could not be removed by traction it was then decided to destroy the animal and after searching the viscera a needle was found which had passed completely through the wall of the intestine and to which the thread was attached following the clinic a business meet ing was held in which the president dr j v hills of gowanda ny gave a re port of his tenure of office the secretary then submitted a financial report for the year and other items connected with the business of the organization the meeting then adjourned to the hotel touraine where a dinner was served and which was graced by the presence of the wives of many of the veterinarians fol lowing the dinner dr w a dennis of case reports january 1939 vol iiino i jamestown ny entertained the assem bly by putting on several reels of motion pictures which he obtained on his eu ropean trip to the international veteri nary congress held in switzerland this last summer the pictures were in color and proved to be highly instructive as well as entertaining for they depicted scenes and places of note in the british isles holland belgium germany aus tria italy and back through the alp mountains to switzerland owing to the press of time all of his reels could not be viewed which was to be regretted the remainder of the programme con sisted of the presentation and discussion of the following itemsa paper on diseases of small animals by dr l j desson of rochester ny the pre vention and treatment of encephalomyelitis in horses by dr e b igmand of the field research department of the pitmanmoore co of zionsville ind this address was illustrated by the use of two motion picture reels of the clinical aspects of the disease and discussed by dr h r potter of niagara falls canada the latter gentleman having had considerable experience with an outbreak of the disease in the niagara peninsula during the summer other members anid visitors present also took part in the discussion of these topics canadian visitors at the meeting were dr f j cote of guelph president of the ontario veterinary association dr w j rumney of hamilton secretary of the ontario veterinary association dr rice of london ontario and dr r a mcintosh of the ontario veterinary college guelph wanted a position as assistant either mixed or small animal practice graduate ovc 1914 avail able at once r l dove vs dunville ont

we regret to announce the death of major daniel lemay vs montreal d v s mcgill on the 28th de cember 1938 at the age of 80 born at st martin p que on june 19 1858 major lemay was educated lo cally and in montreal he graduated in 1879 from the montreal veterinary col lege and in the same year entered practice in baltimore maryland where in 1880 he became state veterinarian in 1886 he was appointed veterinarian to the 1st united states cavalry and he served with various cavalry and artillery regiments in the united states and cuba until 1916 during this period he took part in such historic events as the march from fort douglas utah to fort ethan allen vermont 600 miles in 20 days and pershings punitive expedition into mexico in 1916 he intermitted his army work in 1886 to obtain the degree of d v s from mcgill in 1916 he retired owing to ill health but rejoined the colours the following year in 1919 he retired to civil life major lemay is sur vived by his sister mrs james cochrane king and by his soin vincent le may both of montreal the major was highly respected both at home and in the united states and his colleagues in canada mourn the loss of a fine person ality

19878_0

introduction early childhood development is the foundation for later development and is associated with later academic achievement and labor market returns despite early childhood being the foundation for later outcomes there is limited evidence of gender differences in early childhood development or its causes gender differences in academic achievement and labor market participation limit economic development and wellbeing this work documents gender differences in early childhood development and the role of family characteristics health investments and parentchild interactions in nine countries understanding gaps early in life may allow for a better understanding of how children develop and possible sources of gender gaps later in life this understanding may inform the design of policy to promote gender equality small sample studies have found that at early ages girls have an advantage in several developmental realms including language social and motor a largescale study documents gender gaps using a sample of 7582 children ages 3 to 5 in the east asiapacific region consistent with small sample studies the authors found girls outperformed boys in a composite development score in four of the six countries in the study however boys did not outperform girls in any the authors concluded that child education health and nutrition influenced gender gaps the sources of gender gaps continue to be debated while their understanding is critical to inform policy 1 existing hypotheses about reasons for the gender gap include biological and social explanations biologically sex differences start with chromosome determination at conception followed by inutero exposure to androgens which lead to structural and functional differences in the brain asymmetries in brain morphology appear as early as 2 to 5 weeks after birth and differences continue through childhood and into adulthood 2 however evidence on the impact of anatomical or physiological sex differences on cognitive performance is weak 3 another possibility is that pervasive social norms about how to treat a child according to their sex could give rise to differential unobserved parental attitudes or interactions leading to gaps parents in lowincome countries are relatively more likely to take their child outside name count draw read and apply harsher disciplinary treatment with boys than with girls when compared to higherincome countries 4 the plasticity of the brain and modulating response to external stimuli make development pathways sensitive to family and environmental inputs however the documented differences in treatment across children of different genders tend to be small and inconsistent across countries methods study participants we used all data available with child development assessments for children ages 48 months or younger in 2008 or later the water and sanitation trials by the world bank produced data for india indonesia peru and senegal social programs supported by the interamerican development bank produced data for brazil chile colombia nicaragua and peru the brazil colombia and nicaragua data are representative of children living in disadvantaged households the india indonesia peru and senegal data are representative of children living in rural areas the chile data is nationally representative the uruguay data is representative of localities with more than 5000 inhabitants sample selection we defined our sample as children less than or equal to 48 months with data on both language and socioemotional development we excluded children younger than 48 months with insufficient withincountry observations around their age to allow for convincing age standardization of the outcome measures the final sample is 26055 children we 2 brain structures in males have features associated with the functioning of connectivity between perception and coordinated action relative to females whereas brain structures in females are associated with more communication between analytical and intuitive processing modes relative to males 3 the complexity of establishing the causality between anatomical or physical characteristics and cognitive output derives from the fact that there is a significant overlap in anatomical characteristics there are multiple behaviors regulated at a given anatomical hub the two sexes may involve different anatomical substrates to regulate a given task and brain functioning and output is heavily regulated by exogenous influences such as stress testing conditions or prior experience 4 for example in india mothers are more likely to breastfeed boys by age 32 months girls hear twice as many diminutives as boys and hear warmer phrases more specifically boys and girls experienced similar levels of physical punishment in the lac region for instance in chile the exposure to harsh parenting is higher for boys but the difference is insignificant using selfreport measures 44 of girls versus 45 of boys receive some harsh parenting and using observational measures this is 21 for girls and 24 for boys in uruguay this difference is higher whereas 34 of boys experienced some form of physical punishment 183 of girls did it moreover notwithstanding income level maternal education level or type of area households with girls show better home environments 1 most gender equality policies focus on addressing human capital and economic opportunity gaps across males and females by removing constraints deriving from social norms however it is not clear what the role of other nonobserved factors or innate differences play in gender inequality for example social norms and equality of educational or economic opportunities do not explain why women tend to concentrate in lowproductivity sectors across developed and developing countries in contrast the recent progress in closing gender gaps demonstrates that gender disparities are sensitive to policy when sources are well understood for example investments in higher education have resulted in a reversal of the gender gap there were 12 men for every woman in higher education in 1985 in oecd countries but 12 women for every man by 2005 also used smaller samples when adding the control variables supplementary table s2 reports the portion of the sample in each country missing these variables by gender variables all countries have language development and personalsocial assessments and most countries have a motor assessment either fine or gross the data did not include any measurement of cognitive ability we chose to separate the fine and gross motor skills because previous research indicates these are not highly correlated and gender differences have been found in opposite directions although a few tests separated language skills into receptive and expressive subcategories we combined these scores because they are different expressions of the same construct with variations in how the child can express them due to age not underlying ability trained surveyors collected data using the following instruments denver ii for nicaragua and brazil asqiii for peru india indonesia senegal and uruguay bayleyiii for colombia and tadi for chile trained surveyors made the assessments through direct observation for nicaragua brazil uruguay colombia and chile but caregiver reporting for peru india indonesia and senegal supplementary table s3 lists the assessments age ranges subscales measured number of items and the scoring method we use the following sets of variables in our regressions family characteristics are the mothers age an indicator variable for the mother having finished secondary school household size an indicator variable for the father living in the household and an asset index we constructed an asset index from the different assets reported on each survey with factor analysis we omitted specific assets for which over 90 of respondents did not report health investment variables are indicator variables for the child breastfed during the first six months an indicator for appropriate vaccination completion for age and heightforage zscore a cumulative measure of nutrition in childhood reported parentchild interactions are available for all countries except indonesia we created three indicator variables for caregiver reports of parents reading to the child parents telling stories and parents using physical punishment physical punishment information is not available for india peru or senegal observed parentchild interactions are available for brazil chile nicaragua and uruguay we created two indices from behavior indicators reported by the interviewer built upon the home observation for measurement of the environment scale the home affirmation index includes whether the caregiver expresses affection to the child responds verbally to the child shows or explains something spontaneously talks to the child conveys positive sounds and hugs or kisses the child the home harshness index includes whether the caregiver shouts at the child expresses hostility toward the child beats the child scolds the child and prohibits the child from having something the home harshness index is not available for chile procedures within each country the assessment scores were standardized by age using females as the reference group we grouped girls in twomonth age windows and calculated the windowspecific mean and standard deviation each age window had at least 30 observations we began grouping at the lowest age if the lowest and second lowest age did not have 30 observations we grouped the second and third lowest ages omitting observations from the first lowest age out of our analysis likewise if this second group did not have 30 observations we continued to the third and fourth oldest ages once we found the youngest twomonth age group with 30 observations we continued with the subsequent twomonth age groupings throughout the rest of the sample we excluded age groups with less than 30 observations for indonesia and senegal we broadened the age windows to threemonth age windows because there were many gaps due to insufficient observations in addition to using the agewindow groupings for the asq test we also forced the agewindow grouping cutoffs to be at the testing age cutoffs we calculated the female agegroupspecific means and standard deviations using a tobit model to consider ceiling and floor effects when no observations were at the ceiling or floor the tobit defaults to the classical calculation of mean and standard deviations each males score was transformed into a standardized score using the corresponding female standards for that age in each country statistical analysis we estimated gender gaps by comparing the average agestandardized development score of males to that of females 5we used survey weights when available and cluster errors as advised by the survey methodology or at the smallest geographical level available the null hypothesis is for no gender differences we also examined whether parental investments that could vary based on child gender explained the gaps we tested if family characteristics health investment and parentchild interaction could explain the gaps in the development of children by comparing averages of males to that of females while controlling for these characteristics 6we estimated gender gaps four times one time including each set of variables separately and then including all control variables together we checked that sexselective abortion or early mortality did not bias the sampling we tested if the availability of information on the children may differ by child gender thus biasing our results for each type of control variable we calculated the portion of children by gender in each country missing data we then used a ttest to check that the likelihood of missing any control variable within each variable set is equal across genders within each country we also tested if errors in age reporting could bias our estimates we tested that the probability of appearing in the data set did not differ by child gender within each country within each country we explored the differences across population groups and applied an ftest to examine if the gender gap is statistically distinct across groups we examined gender differences of children in different years of age and used each countrys wealth index to divide the population into quintiles finally we tested for crossstudy heterogeneity using an isquared statistic which measures the percentage of variation attributable to heterogeneity across studies the isquared takes values between 0 and 100 with 100 indicating high heterogeneity across studies results main results girls performed better than boys on all language and socioemotional tests in all countries the size of the performance gaps is 014 on average ranging from 006 to 022 standard deviations in language and 017 on average ranging from 006 to 038 standard deviations in socioemotional development differences are statistically significant at p 010 for all countries except for senegal in language and india and senegal in socioemotional tests gender gaps in gross motor skills for the seven countries with data on gross motor are mixed with some countries indicating statistically significant gaps favoring girls and others favoring boys in all three countries where we have data on fine motor skills all gaps favor girls however the gap of 022 standard deviations is only statistically significant for uruguay using a metaanalysis approach we found that gender gaps vary in size across countries the isquared statistics indicate a large percentage of variation attributable to heterogeneity across countries behavioral explanations when controlling for family characteristics health investments reported parentchild interactions and observed parentchild interactions both separately and together we found a minimal reduction in the differences by gender with a few minor exceptions to check for evidence of sexselective abortion or early mortality we tested that the mothers age the mothers education the fathers presence in the household household size and a wealth index did not predict child gender we found no evidence of selective abortion or early mortality in all countries except india which suggests that most of our sample is unbiased additional births can also be contingent on the gender of the previously born children we also confirmed that results are similar for children living in households with only one child we find some errors in age reporting with bunching at multiples of 12 months and to a lesser degree at the halfyear points error rates do not differ by gender in our sample thus it will not impact relative findings between genders which is our focus though it may influence absolute findings the pvalue of the twosample kolmogorovsmirnov test for equality of distribution between genders is greater than 040 in all countries with the values for 7 out of 9 countries above 0807 finally a focus on early childhood allows observing differences less prone to measurement biases due to identity effects identity effects are changes in behavior to comply with the norms of the group with which an individual identifies this behavior heterogeneities gaps open early in life and peak around age two when children socialize with other children and people beyond immediate caregivers however this pattern is different across countries we found variation in the magnitude of gender gaps among age groups and child development domains where children younger than one year old tend to show smaller gaps gaps among children younger than oneyearold are smaller in magnitude compared to the average of all age groups in senegal for language senegal nicaragua and brazil for socioemotional and peru for gross development we found no other patterns for children younger than one in the other countries gaps among oneyearold children are larger in magnitude than at other ages in nicaragua for gross and fine motor gaps among twoyearold children are larger than the average in india for language chile and india for socioemotional development and nicaragua for gross motor gaps among fouryearold children are lower than the average in chile for socioemotional we found no differences among age groups in any development domain in indonesia colombia or uruguay gaps are not associated with wealth we found no differences among quintile groups in any development domain in chile india indonesia peru or colombia we found some variation in the magnitude of gaps among wealth quintile groups and child development domains but did not identify a consistent pattern some countries have the highest gap among the poorest quintiles the gap is highest for the second quintile in brazil for gross motor and lowest in the fifth quintile in uruguay for gross motor other findings show the highest gap among the wealthiest quintiles the gap is highest in the fourth quintile in brazil for language and in senegal for socioemotional the gap is smallest in the first quantile in nicaragua for language and socioemotional and in senegal for socioemotional finally there is an example of a ushape the gap is lowest in the third quintile in brazil for language and gross motor these disparate findingswhere they existsuggest wealth does not play a key role in differentiating boys and girls early life abilities discussion our key findings are that young girls 7 to 48 months consistently outperform boys on language and socioemotional development tests across nine countries on three continents the language and socioemotional gaps are around 015 standard deviations even when adjusted for parental inputs our findings are similar to those documented among children ages 3 to 5 and represent a reasonable effect size for preschool programs we also found that girls outperform boys in fine motor skills and boys outperform girls in gross motor skills in a subset of countries however these gaps are generally smaller in magnitude than those found for language and socioemotional skills this evidence is consistent with the role of various contextual factors in development we fail to fully explain the sources through which gender gaps arise despite a wide range of data on socioeconomic status family characteristics parenting practices and health inputs we find parentchild interactions do not explain gaps even in brazil chile nicaragua and uruguay where a third party assessed them our study has several limitations the age distributions of the children are not the same for each country though surveys covered twoyearold children in eight of the nine countries the child development tests in our sample are not the same for each country in four of the nine countries parents answered questions about child interactions rather than children being observed and assessed by trained interviewers our data for household resources health investment and development stimulation are not comprehensive of the many environmental and social factors influencing development except for chile our samples are not nationally representative the samples in our analysis include lowincome households in brazil colombia nicaragua and rural households in india indonesia peru and senegal we only have data for urban households in uruguay despite these limitations our study has a variety of strengths the data allows testing the effect of a broad set of context variables on the gap for four countries we have observed measures of parentchild interactions in addition the data come from several regions and many different cultural contexts which allows for ruling out unobserved environmental differences not observed in the conclusions this study aims to estimate gender gaps in agestandardized language socioemotional and motor skills scores we hypothesized that gaps are present at very early ages we also hypothesized that the magnitude of gaps is elastic to the socioeconomic and environmental conditions the data shows girls consistently outperformed boys on language tests and socioemotional development and no systematic differences for motor development we found that family characteristics health investments or parentchild interactions did not explain the observed gaps the observed gender gap across diverse socioeconomic and environmental conditions is counterintuitive because child development depends on the familys socioeconomic status and the environment we cannot rule out biological or nonobserved environmental inputs present in all nine countries explaining the gaps however more individual data on biological or nonobserved contextual inputs is necessary to explore the role of additional mechanisms the mechanisms that could contribute to the observed gaps are multiple one crucial factor is societal discrimination against young children based on sex we do not find empirical evidence of a systematic attitude toward young children that could explain the observed differences as measured by family characteristics health investment and homereported and homeobserved parentchild interactions however the dimensions we explore are not exhaustive unobserved societal discrimination which does not vary across the nine countries in our sample may explain part of the gaps we observe a second important factor is that girls and boys have different biological dispositions for development despite the data limitations to pinpoint the exact mechanism our findings contribute to the literature on early child development for three reasons first this study documents gender gaps at ages younger than other systematic studies on children representative of whole populations this data covers a comprehensive range of countries and contexts thus allowing us to document the pervasiveness of gaps across children in different societal and cultural contexts second this study provides evidence of gaps considering rich data on inputs that could explain such gaps data for very young children is rich relative to older age groups because individuals have a relatively short history it covers household characteristics parenting behaviors and health investment data as a result the data allows us to test a subset of social discrimination theories to explain the gap not available for many other systematic studies without detailed data or focusing on older individuals third focusing on early childhood allows observing differences less prone to measurement biases due to identity effects identity effects are changes in behavior to comply with the norms of the group with which an individual identifies thus focusing on the first years of life provides a measurement with fewer biases relative to a focus later in life our findings provide insights into the ubiquity of gender gaps in development in early childhood and the possible causes behind them we conclude that the factors that promote gender gaps in favor of females in language and socioemotional development are present in the wide range of contexts we analyze we find no evidence for systematic gender gaps in motor development since family characteristics or health investment did not explain the gaps such contextual characteristics may be limited to inform gender policy early in life with this information future research may further investigate gaps in other contexts and consider other mechanisms to better understand early child development data availability data for uruguay chile colombia peru senegal india and indonesia are available online links are listed in table s1 of supplementary materials data for brazil and nicaragua will be made available upon request and if the paper is accepted for publication the data will be published in the interamerican development bank data repository funding the authors thank the interamerican development bank for funding the research

some evidence suggests that there are significant gender gaps in early child development in lowand middleincome countries with girls generally outperforming boys however few studies have tested for the existence of such gaps at a large scale our objective is to examine gender disparities in early child development in brazil chile colombia india indonesia nicaragua peru senegal and uruguay with 26055 children aged 7 to 48 months we estimate gaps using crosssectional studies with language socioemotional and motor skills development assessments consistent with smallsample findings the data shows girls consistently outperformed boys on language tests 014 standard deviations and socioemotional development 017 standard deviations with differences consistent across all nine countries there were no systematic differences by gender for motor development we explored how family characteristics health investments or parentchild interactions influenced the gap we did not find evidence that variation on these characteristics across children explained the gap our findings suggest that gender gaps in language and socioemotional development emerge very early in life

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introduction in early 2020 there was a crisis in canadian agriculture the covid19 pandemic forced a temporary suspension of the seasonal agricultural worker program as a result canadian farmers announced catastrophic scenarios for the agricultural supply chain and raised concerns regarding the nations food security 1 preventing workers from reaching canadian fields would mean a severe labor shortage during the harvest and planting season since its creation in 1964 and the gradual incorporation of the caribbean and mexican workforce the sawp has functioned uninterruptedly making it the international model of regulated migration programs after attempts to use available national labor canada imposed new guidelines for employers and workers and the program resumed in april 2020 2 the caribbean and mexican workers were admitted to the country if they complied with several international health protocols 14day isolation upon arrival early detection of possible outbreaks social distancing at the workplace and remaining in provided housing however workers documented negligence on the part of employers poorly suited housing for isolation and generalized mistreatment that made national and international news 3 these situations reinvigorated the debate between the need for a profound program restructuring and its elimination under the campaign status for all4 civil society organizations working groups from canadian universities and outside north america called for labor and human rights recognition for workers in the program demanding open work permits and improved housing and workplace conditions while these petitions have been raised for several years by organizations such as the united food and commercial workers union migrant worker alliance and justicia for migrant workers international coverage of covid19 outbreaks and the deaths of three5 mexican farmworkers on canadian farms brought renewed and increased attention to the sawp and how similar programs had shaped decades of international migrant management schemes in addition this situation led to some reports that addressed the conditions under which migrant workers entered canada during the pandemics early stages one example is the report published by the ufcw and the agriculture workers alliance in august 2020 which highlights the complicated situation experienced by mexican and caribbean farmworkers at the canadian borders and in workplaces 6 the report delves into the need for immigration status changes and more straightforward pathways to canadian citizenship as one way to address the deplorable working and housing conditions of those who enter the program canadian government labeled foreign farmworkers as essential meaning that their labors were essential to the survival of the canadian system during contingent times like the pandemic this labeling allowed workers to move internationally despite health restrictions and enter canada and continue working in agricultural fields this represented how canadian consumers perceive this work and worker in somewhat symbolic terms nevertheless naming temporary workers essential to canadas agricultural business emphasized their generalized disposability and precarity in this article we argue that the seasonal agricultural worker program has exacerbated the precarity and disposability of mexican workers by restructuring family dynamics and care chains the sawp has increased the dependency of families upon migrant wages while also deepening the historic proletarianization of mexican peasants the importance of the sawp to the mexican peasantry and their involvement in global migratory routes is analyzed from a historical perspective contrasting it with the experiences of mexican workers who participate in the program and from family members who stay in mexico we describe the origin of this form of regulated migration to explain how these programs although not new have been part of the recruitment of migrant workers throughout welldefined cycles and periods in the development of global capitalism also we delve into the debate between abolition and reform of the sawp by presenting the diverse labor experiences of mexican migrant peasants in canada and their families who stay in mexico finally we argue that the difference between the two proposals represents an unfinished solution to the labor problem of the disposable workforce in the context of regulated migration this article presents the disposability precarity and proletarianization of mexican workers employed in the program and their families in mexico from a theoretical and ethnographic standpoint conceptually we use precarity not as a synonym for vulnerability7 but as millar explains as a condition necessary in creating capital for millar precarity is the norm of capitalism not its exception and all workers share it whether employed or unemployed this reasoning allows us to understand a myriad of labor experiences within state management migration and opens the possibility of analyzing particular household conditions under programs like the sawp furthermore we analyze labor under the sawp from the perspective of carbonella and kashmirs concept of disposability which expressly refers to the varied acts of disorganization defeat and enclosure that are at once economic martial social and cultural and that create the conditions for a new set of social relations this particular use of disposability resonates with siders understanding of the historical production of difference and inequality depending on intertwined continuous social processes in this article mexican sawp workers and their families find themselves in continuous migrantwage dependency cycles of debt and various inequalities due to disposability as sider notes being disposable is being put in a situation where what you can earn or produce through your labors combined with what you are given by the state community your kin and others is less than what you need to make it to tomorrow in addition we understand the proletarianization of the mexican peasantry as a historical process of land dispossession and unequal development that intersects with a gradual introduction of peasants to a reduced local labor market in their places of origin in this sense international migration has become one of the most used strategies by mexican workers to alleviate their generalized poverty however migration entails an exacerbated exploitation that tends to separate the costs of production and reproduction making a cycle of dependency on migrant wages this article draws on semistructured interviews conducted between august and september 2019 with mexican workers employed in the swap and their families in tlaxcala méxico interviews were conducted once the agricultural season in canada was over and they were already in their hometown8 by reflecting on the experiences of workers in canada and their spouses and children who remain in mexico we explain how the sawp has used the exacerbated conditions of disposability precariousness and the historical exploitation of the mexican proletariat to consolidate canadian agribusiness capitalism we use pseudonyms to protect the identities of the workers and families who shared their labor experiences under the program with us in the pages below we first identify three waves of temporary programs in modern global history that allowed the sawp to operate in current conditions and model the present scenarios of workers the forms of employer management and state responsibilities secondly we frame the sawp in a conceptual discussion regarding the proletarianization of the mexican peasantry and its use of a disposable migrant workforce considering the work experiences of mexicans in canada then we focus on the current critiques of the sawp to delve into how disposability dependency and exploitation of mexican workers are functional for canadian agribusiness finally we argue that within the reform versus abolition debate more attention should be paid to the historical origin of the program and the broad structural consequences it has had in countries like mexico our ethnographic data shows how workers in the program are immersed in cycles of debt and unemployment periods that affect their families in mexico in diverse ways temporary foreign worker programs in the history of disposable labor as hahamovitch argues guest worker programs and temporary foreign worker programs have existed throughout history as a legal alternative to unauthorized migration this type of program represents a form of work explicitly designed to alleviate production problems in host countries while also serving as a proven antiimmigration strategy whose objective is to dissuade certain foreigners from establishing in those countries although these strategies are typical in the current highly globalized world the reality is that these programs have existed for over a century and a half to manage surplus populations for the ends of potential exploitation as griffith explains the history of temporary worker programs parallels modern capitalist development in this sense hahamovitch describes three waves that have together comprised the contemporary characteristics of highly regulated temporary worker programs the first one represents a continuity of slavery indentured servitude and colonialism through the mechanism of racialized labor within host countries european colonial extraction of natural resources labor through slave institutions and land exploitation were elemental examples of this process consequently once sovereign nations were born intricate systems of exploitation emerged from colonialism catalyzing workers to work outside their home countries as a flexible workforce in this period countries such as the usa france and england restricted the immigration of chinese citizens and poor white europeans similarly during the 1880s and early 1900s australia the usa the netherlands sweden argentina and chile prohibited hiring chinese workers while exploiting irish and scottish laborers through indentured servitude this racial bias in selecting workers worldwide prompted the first guest worker programs in prussia australia and south africa while offering a clear distinction between citizens and noncitizens internal and external individuals thus essentializing labor skills in terms of racial and ethnic characteristics these patterns remain in todays regulated migration the second wave of the guest worker programs began during and after world war ii at that time national labor shortages due to war mobilization accelerated the hiring of foreign workers especially in the agricultural sector building on previous experiences with established programs germany bulgaria the netherlands japan and the usa used a diverse workforce from eastern europe korea mexico and jamaica respectively notably the south african gold mine programs that had used a temporary migrant workforce since the nineteenth century set the basis for those european and north american countries in regulating migrant labor similarly in the usa the bracero program 9 that employed thousands of mexican seasonal farmworkers from 1942 to 1964 and the h2a visa for jamaican sugarcane laborers in the early 1950s became key models for subsequent programs that employed special restrictions and limited labor rights other examples include the programs bringing 9 the bracero program is commonly referred to as the first massive regulated labor program in mexico thousands of mexican workers were directed to us agricultural fields in early 1943 to help fill the job positions of native workers leaving for world war ii although the program ended in 1964 its consequences have been widely studied our primary interest is the opening to regulated labor migration in the form of visas and temporary worker programs stemming from the bracero bureaucratic structure for a history detailed analysis and the various consequences of the bracero program see durand haitian braceros to the dominican republic to cut sugarcane at the beginning of the twentieth century and the import of haitians and jamaicans to cuba in these two programs and as in the south african mines the production of the other as racially distinct was used to reduce production costs and at the same time increase workers dependence on the temporary labor structure the canadian sawp was also born in this second wave in 1966 although canada had already received a significant number of immigrants before and after the second world war mainly polish danish and irish citizens it was the sawp that allowed the bureaucratization of the labor immigration system in canada expanding and formalizing diverse forms of temporary work programs with noneuropean citizens in the third wave the consolidation of cycles of dependence on remittances from sending countries was accompanied by several other changes in contrast to the primarily male force of the previous waves in countries such as the usa canada and france the workforce expanded to include of women through other regulated programs workers who entered these countries required specific skills in specialized industries such as oil or technology in addition during this time the countries mentioned above and others such as germany and portugal created bilateral agreements with other states to allow noncitizens to enter as contract workers for example from the mid1970s and well into the 1990s the philippine state concentrated its efforts on organizing an army of workers recruited mainly for their export to countries that required cheap and agile labor for care or domestic labor similarly during this period mexico secured the binational agreement for seasonal agricultural workers with the usa and a new one with canada which led to the gradual replacement of caribbean workers by mexicans in north american agribusiness this wave is characterized by a high degree of bureaucratic administration whereby states manage and send their surplus populations this characteristic dynamic is combined with the symbolic and political discourse of globalization in statestate agreements for the hiring of migrants an example of this is the financial and labor policies and the differentiated consequences of the north american free trade agreement between mexico the usa and canada as mize et al 2010 xxvii explained nafta has increasingly bound each nations production and consumption practices to one another in all three nafta nations it is the most marginalized of mexican laborers who do the hard work of production for the consumerdriven economy in the three waves described by hahamovitch each period contains a history of racialized work tensions between the differentiation between free and unfree work and migratory movements managed by the state or private companies as in the case of the canadian farms in addition it is evident how the limitation of citizenship became the best way to administer surplus populations moving through various industries and demanding better labor conditions for example the current canadian sawp and the us h2a visa program remain the two most extensive programs for caribbean and mexican temporary migrants and the most stable binational agreements for both receiving and sending states although the number of mexican and caribbean workers employed in the us h2a is more significant than in canadas sawp the latter has become the model program for other similar programs worldwide that manage labor migrations shaping their internal regulations agreements between nations and most importantly the treatment of workers the canadian case seasonal agricultural worker program the sawp is a temporary foreign worker program designed to alleviate shortages in the canadian agricultural sector by hiring cheap temporary foreign labor while increasing production intensity born in 1966 as a bilateral agreement between jamaica and canada the sawp was implemented to prevent the vices of illegal migration while ensuring a stable workforce for the canadian agribusiness in times of crisis in 1967 other caribbean islands became interested in the program and sought to sign labor migration agreements with canada andre argues that the sawp began as a regulatory scheme legitimizing the exploitative nature of the program utilizing the caribbeans colonial history and its ties to the commonwealth to direct a needed workforce in canada the transition from the family farm to a new form of intensive agriculture required a new labor force to allow production to keep pace with the rapid growth in demand historically this transition is a narrative of land dispossession by agribusiness and other industries that brought several changes in canadian agricultural laws and protection to agricultural production in the country ie agricultural exceptionalism migrants from the netherlands and poland for whom no special immigration status was required and whose transition to citizenship was expected and desired initially entered the workforce on family farms however as these migrants abandoned farm labor the sawp channeled precarious and racialized populations outside canada to alleviate the resulting labor shortages and ensure fast and profitable food production without clear paths to citizenship or permanent resident status as with the migrants of the turn of the century with this background in 1966 jamaica sent its first 264 workers to the tobacco farming industry in southern ontario then in 1967 the first workers from trinidad and tobago and barbados were admitted to the program under conditions like the jamaican workers finally dominica st keith andnevis joined in 1971 by 1973 the canadian agricultural sector began to rely heavily on foreign labor and more and more producers began applying for the program and hiring noncanadian workers thus in 1974 the sawp was expanded to include mexican citizens taking advantage of the infrastructure left behind by the bracero program currently the sawp operates in almost the entire canadian territory in 10 of its 12 provinces with more than 40000 agricultural workers primarily mexican men married and with children from rural areas of mexico who spend between 4 and 8 months in canadian fields and greenhouses the nature of the employment contract under the program is straightforward the workers are temporary not eligible to apply for permanent residence or citizenship and thus not subject to the rights and obligations of those statuses in addition the sawp establishes a fragmentation of legal responsibilities and labor rights applied differently across canadian provincial governments labor laws wage rates and employer responsibilities differ depending on the province where migrant workers are employed in addition the combination of federal laws provincial labor laws and regulations of the workers countries of origin make it challenging to homogenize work experiences situations of exploitation and demands on labor rights the programs general agreement establishes closed employment contracts restricting labor mobility by linking the worker with a single employer throughout the entire season worker transfers to other farms are highly complicated even in cases where the worker has reported inconsistencies in their contract or mistreatment when a worker decides to report labor exploitation harassment or abuse there is always the constant threat of immediate deportation the employers obligations require them to provide adequate housing near the farm or within the premises with appropriate accommodations for workers to work a minimum of 240 h within the contract period in recent years the sawp has also made use of a gradual process of ethnic replacement and labor surfing an example of this is the creation of different branches of agricultural work parallel to the sawp that have included guatemalan and salvadoran temporary workers and industries such as domestic work and care that have benefited from cheap filipino labor in this regard roberto a 43yearold mexican worker with 15 years of experience in the sawp explains where i was the farm stopped asking for mexicans before there were like a thousand or maybe eight hundred what happened is that guatemalan labor is cheaper because they guatemalans have to pay for everything they have to pay for their transportation paperwork and everything and we dont the boss pays the transportation for us mexicans and when we arrive at the farm the employer takes it from our paychecks they also pay rent but the wage is the same as ours so the boss is happy because they are cheaper and everything is done with less money he even built a house for them and now he has about sixty guatemalas at forty dollars a week each and they also pay him to rent migrant advocacy groups and workers have also documented the poor housing conditions for example in our interviews with mexican workers we found overcrowded houses resulting in conflicts due to not having the time and space for bathing changing cooking properly and eating before leaving for the workplace for example roberto says so there are fiftytwo of us in the house the kitchens are separate there are eight workers in each kitchen we share the bathrooms upstairs on the third floor there are two bathrooms there are three toilets and many urinals but just about twelve showers for fiftytwo people employers prefer male workers who are married with children and wives who reside in their country of origin the employers hope that family separation will minimize the chances for the worker to change their immigration status however as binford explains the sawp uses those desired characteristics to tighten exploitation and racially segment farm labor usually contrasting caribbean cultural values with the moral values of mexicans additionally in contrast to their caribbean counterparts mexican laborers lack of english language skills often keeps them from reporting abuse as a result participating in this program also involves a complicated international family dynamic involving an increasing dependence on remittances and canadian wages in the countries of origin a related tendency for wives of mexican sawp workers to take on more unpaid domestic labor and consequently a complexification of the chains of care that support the raising of children and grandchildren the experience of margarita her husband and their daughter antonia show these contradictions margarita is 43 years old and the wife of a sawp worker who has been on the sawp for eleven seasons her eldest daughter antonia 26 has recently joined the program and has done half a season in canada antonia is a single mother and her mother margarita takes care of her daughter while she is not in the country margarita speaks about family life under this type of work it was harder when the kids were growing up then when they turned into teenagers that was the hardest part you know all the shitty stuff was for me working here the little kids and he wasnt here it is hard when your family is used to being together the bad thing is that you get used to this new life you always get used to new stuff to see your people going back and forth back and forth you know its annoying changing every time they come and go for me its the same the only difference is that i take care of my granddaughter she is the sole responsibility i have when my daughter is gone thats why i keep going with my stuff and i try to keep everything to myself because she leaves us and i stay here all by myself and with the kid i knew it would be hard and the money wont be enough in contrast to margaritas comments about the difficulty of staying at home antonia talks about her sawp experience as a kind of vacation from housework and childcare in mexico the women working with me said were here on vacation i had to work the night shift i started at 6 pm and finished at 5 am because we lived one hour away from the farm we would get home at 6 am and we sometimes slept all day sometimes you get something to eat at work you have a break and you adapt to the overnight work when you get home the only thing you want is to sleep we used to get up at 1 pm or 2 pm we would get something to eat cook shower and then after that we would leave at 4 pm so its like you only get home eat sleep get up shower and get to work again its like i get it ive told my dad you men get here and dont worry about anything not like what happens to us women you go to bed eat work and repeat although employers favor men for farm labor positions the hiring of mexican and caribbean women has increased preibisch and hermoso santamaría and barndt have documented these changes and cases like antonias reflect employers changing hiring practices the desired profile is a single mother with children under ten or childless women who have a partner in mexico the canadian migration system interprets such a profile as limiting the likelihood of permanent residence family migration or applying for citizenship among our interviews we find womens experiences that coincide with the hiring of single mothers and couples who have stayed in mexico for example antonia says when i tried to enter the program the first time they told us that no single mother would be accepted so we attended a meeting in a room and then a man told us ill say it only once if you are a single mother forget it…you will not be accepted in this program leave the program now he just told us that married women would be the only ones hired the second experience corresponds to hernán 42 years old the husband of a female worker employed in the sawp he tells us she told me that most female workers were single mothers when she got to that place the application call said that no married woman would be accepted but that year she tried anyway even though her profile didnt fit but they accepted her just like that she says it was a little weird since most women were single mothers divorced or widowed they discriminated against those who had a partner they were told they didnt have the right to be there mexican women are told you have a husband you shouldnt be here just imagine being at home in a safe place protected with people you love and then going to this other place where everyone is aggressive she was fingerpointed a lot and they made her feel terrible as we see care chains have become more complex under the program also the share of unpaid domestic labor for womenand to a lesser extent for men who assume this role in contingency situations like hernánwho stay in mexico increases with these changing family dynamics hernán for example discussed the implications his wifes labor migration had on his gender role his family and the couples dynamics taking all the responsibilities was really hard honestly i told my wife that we werent closedminded i wanted to be responsible and to be able to take the role now i know what women do the way it is laughs it isnt very easy it would be like some sort of single mother job i understood it that way and i felt it and i was able to do it and i think life with another person is complicated i dont think we even pictured it all these years that we have lived together wed never been far away from each other suddenly we were separated we hadnt even discussed it we didnt picture ourselves like that when we faced reality about being away from each other we didnt imagine what it would be like none of us did it we were very close to each other and having this in our lives affected our relationship i didnt see it coming we didnt see how complicated this situation was when you look at the problem from the outside its easy its like oh shes gone but those people have never been in something like this to say you know my wife or my husband is gone thats when you realize there are six or seven months in between us yeah whatsapp and facebook exist and we video call all the time but this is not the same there are many complications you have to be honest and many personal issues its not the same knowing that life fills those spaces and it is tricky the adaptation of returning workers to mexico complicates the already complex family dynamics established in their absence the following interview excerpts show some problems concerning family adaptation in and outside of mexico margarita emphasizes how the sets of labor conditions and migration within the sawp changed her husband it changes them a lot that country canada changes them too much they the male workers get used to be just by themselves so it is more difficult when they come back and we the families also change because there are too many conflicts i tell my husband that most people the couples are only together because its a habit after all you stop loving people many things are lost when you are far away when they come back the only thing they do is get angry and anything could be an excuse for that they say tell the children to shut up kids go to bed turn off the light when i was in canada by this time i was already sleeping there are many problems now each one has a room and does their stuff alone her husband and her this way we dont fight he had a schedule over there at the canadian farm he has to get along with us every hour and every second he wanted to have breakfast on one occasion but we were sleepy too much trouble unfortunately the remittances and savings of the sawp farmworkers are not enough for families to make ends meet throughout the year in interviews the workers we spoke with were immersed in a neverending cycle of debt that depended on income diversification and migrant wages families diversify income with alternatives that vary between small businesses such as handicrafts sold in tourist places or traditional weaving garments for tourists margarita for example says they go away and leave their job here when they come back they cannot find another job if they had some savings but couldnt find a job they go again to canadas sawp i tell him her husband why cant you just tell the farm that youll be gone eight months and will work four many people here cannot get out of that vicious circle theyre here but cannot work so they go and come back without a job you cannot even save a cent the money he saves disappears in four months why because they dont work we started a small business but we wont have anything again because when he has to leave again ill be by myself again the complex international family dynamics that we showed above are evidence that the conditions mexican laborers faced on the sawp affected the workers and their families the hiring process the dependency upon migrant wages the increasingly complex care chains that rearrange every year and the adaptation process after the season ends impact in a multifactorial way every member of the workers family this situation forces us to focus on the programs consequences on workers and their families in mexico and question its origins proletarianization of the mexican countryside creating disposable labor in addition to these complex family conditions employers favor hiring mexicans and caribbeans with experience in agricultural work which often results in a simplistic reduction of the workers status as a peasant in his country of origin furthermore employers favor hiring male workers men who own small family plots with a low level of productivity or who have been employed in previous seasons on the same farm and can now show that they want to do peasant work we analyze the process of peasant proletarianization in mexico from a historical point of view to argue that the selection of peasants for agricultural work in canada is directly related to this process to understand mexican peasantry proletarianization and its inclusion in programs like the sawp we delve into peasantry as a historically grounded concept that shows broader global processes within the history of social formations peasants have played a role as direct producers within various modes of production embedded in the social world in diverse ways to understand the historical formation of the mexican peasantry we examine its characteristics through a historical and relational approach that reconstructs a structural totality we argue that observing the peasantry from an ahistorical linear progression leaves no room to construct broader analytical relationships firstly we frame our argument with the analysis of stavenhagen paré and warman stavenhagen and paré analyze the mexican peasantry as a sector gradually marginalized since the 1940s this marginalization is due to public policies that have increased peasant material crises through their growing reliance on state subsidies thus exacerbating the inequality of agricultural production and land ownership warman analyzes the political and material connections of the mexican peasantry in the midtwentieth century with the state via unions peasant organizations credits and support programs and the structural consequences of this relationship we found both historical characteristics in the sawp workers and their families interviewed agricultural activity in mexico has been significantly impacted by several factors shaping its current forms such as land ownership and peasant struggles of the midtwentieth century and the institutionalization of the welfare social system and internal colonialism dynamics from the 1940s to the 1980s mexico saw major rural dispossession and a low familial agricultural production that directed the agricultural semiproletariat towards wage labor this proletarianization marked by inequality and poverty had formed rural regions that were engulfed in ecological and economic crises peasants were thus led to diversify income both in urban centers and in waged activities in their places of origin migration in this sense responded to several situations ranging from dispossession to low agricultural productivity and pushed day laborers to seek employment requiring skills like their agrarian work the intensification of this migration is a direct consequence of decades of postrevolutionary social recomposition and labor leveling where industrial jobs proliferated during the 1970s and until the 1990s indigenous groups in mexico supplied temporary labor reserves for the national labor market while also turning to the usa in large numbers as part of a needed but unwanted illegal migration furthermore as macip explains current mexican migrations fetishize workers ethnic identification and utilize it for production this process describes how an international migrant proletariat sustained by networks of production and based on previous systems of exploitation becomes part of agribusiness in the usa and canada in the case of the sawp uneven capitalist development produces a disposable and interchangeable labor force both with new generations of workers and with other types of precarious populations in organized projects to capture surplus populations with the state as the regulatory entity this selectivity generates specific differentiation criteria according to the need for capital in this case temporary mexican agricultural workers are proletarianized and precarious in their places of origin this process of proletarianization and increased precarity has impacted many of the regions that the sawp targets to extract a flexible workforce such as morelos puebla tlaxcala zacatecas and the state of mexico in those places various local crises in rural areas point to diverse factors such as the land and water dispossession connected with macrostructural processes such as the implementation of nafta in addition the demand for the labor associated with the development of horticultural agroindustrial zones a system of widespread sharecropping dispossession and chiefdom has led to planned forced indefinite temporary internal and international family migrations that often become generational in summary a variety of different structural factors and historical processes of the proletarianization of the mexican countryside explain why mexican peasants travel to canada year after year to join the sawp the precarity of this peasantry and its disposability are the product of incorporating mexican rurality into internal and international migration as an option for survival miriams experience 50 years old with her husband as a sawp worker for more than 18 years condenses the historical characteristics of the mexican proletariat and its incorporation into global labor markets my husband tells me that if it were not like that that he migrated they would never have given education to their daughters before my husband went away he spent time in the fields growing corn and beans on our land he also worked as a day laborer for people with more land than us he wanted to go to canada before but he wasnt accepted because he studied in high school they said no those studying cannot be accepted what they wanted was campesinos plain and simple and i guess campesinos dont go to school so it has been 18 years going back and forth every year right now hell be coming in november and leaves in april id like to go over there but my husband doesnt like the idea he tells me no you wont youll suffer a lot here its also hard to be without him my daughters feel better when hes around and they say that i shouldnt let him go they say dont let him go just imagine what will happen if he continues like this one of my daughters has just been accepted into university and its four years and we need money for that every time he leaves he says now that i think about it its too far away i wish i didnt have to go the money he sends is money i spend i save some for the food for other things like school our animals food or any other bills to pay right now im using some of that savings ive just bought this she points out a bag with coats inside to sell so we get enough money because sometimes its not enough with what he sends by introducing the concept of proletarianization into the discussions on the sawp we recognize the structural origins of the labor force incorporated into the north american agricultural sector we approach the workers and their families as a proletariat with a history of dispossession and precariousness to open the analysis of hegemonic processes of labor selection under capitalism moreover paying attention to the consequences of the sawp in the workers family life enables a complex understanding of the freedom of workers to sell their labor power and the obligation to depend on wages extracted in deplorable conditions finally this line of analysis also helps explain how historical stereotypes of different national and ethnic groups shape workforce selection which has led to a division of workers on canadian farms a vision of good workers or ideal migrants is predominant when training the workforce in specific sectors abolition and reform many scholars have explored the historical conditions of the sawp such as the use of the exploitable caribbean and mexican populations as a platform for discussing the impacts of temporary immigration status better labor rights and whether the continuity of the sawp and other temporary worker programs is still desirable in economic or ethical terms however as binford points out most sawp literature focuses on specific situations instead of analyzing the economic and historical structure on which the program relies missing the opportunity to delve into the conditions that organized these programs for example most temporary worker programs such as the sawp find temporary migration attractive because it allows greater flexibility in the labor market and reduces immigrants apparent threat to native workers similarly temporary and regulated migration enables the intense production of commodities without bearing the social consequences of labor exploitation by externalizing maintenance costs while ruhs and martin examine whether placing the responsibility on the host countries in regulating low and high skilled immigration will improve their working conditions silverman and hari weiler et al andbridi argue that granting labor rights to foreign workers once they are on canadian land prevents abuses and reduces exploitation and protects workers once they leave agricultural work one of the most critical points of potential reform is the formation of unions to allow for collective bargaining on labor rights beyond the programs provincial restrictions however as vosko has described union organization within the sawp is hugely complicated and is permanently under attack through different strategies ranging from workers blacklisting deportation threats and constant attrition also canceling closed contracts can increase labor mobility within the program forcing employers to restrict control over workers by allowing workers the right to cancel contracts workers would attain more mobility thus loosening employers power over them however without resolving the most difficult situations of the program the workers will face the same problems that constrain them to farm work exploitation although these are essential goals it is essential to emphasize that states and agribusiness companies have explicitly designed the sawp to eradicate workers negotiation power as a result states and private agencies have monopolized agreements to achieve a kind of labor force extraction without the workers voice present in other words the worker exists insofar as his workforce is present reducing the worker to its expected labor power at the same time the programs long history in places like mexico has resulted in a deep dependency on migrant wages as the workers interviewed have shown in this regard binford vogel bacon and vonk and holmes emphasize that the problem to understand is not the dependency on remittances but the long history of rural disarticulation and internal migration that pushed peasants to choose being part of programs like the sawp the bracero or the h2a we approach this debate by drawing on rosa luxemburgs social reform or revolution to frame the contradictions between these positions in this essay luxemburg constructs a critical question that can be used to examine the sawp does gradually reducing the exploitation inherent in capitalism lead to a workers conquest of political and legal power or does it lead to tacit acceptance of the impossibility of obtaining it in other words attenuating the internal contradictions of capital in this case expressed by the defective functioning of the program appeases crises benefits the middle class by soothing the most utterly exploitative elements of the labor structure and expands capitalists profits by diverting attention from the total elimination of surplus value extraction from workers we share luxemburgs 145 disenchantment regarding palliatives in the form of reforms as the only method to resolve conflicts in capitalism by regulating the economic system and controlling the labor market hence by emphasizing that those palliatives stem from an idealistic and utopic desire to mend the systems wounds seeking immediate results to historical structural problems and waiting for the necessary conditions to subvert them luxemburg points towards its contradictions reformism aims to construct an objectively harmonious and universal narrative binding together capitalist development and the modern model of democracy to enhance a variety of rights while leaving the programs guiding principle intact simultaneously it seeks the attenuation of class antagonisms as slow historical progress involving a diminution of different kinds of abuse sawps abolition on the contrary compels us to see exploitation as inherent and fundamental to the program and the only escape is to eliminate any form of exploitation in this sense the debate falls between two divergent positions the conciliatory reform position recognizes what can be modified within the program to maintain the program while creating the friendliest possible terms for both the worker and the employer in contrast those in favor of abolition call for the programs total elimination seeing that as the only possible solution for ending all exploitation of migrant labor in programs such as the sawp we argue that both positions will benefit from a historical analysis of the formation of a highly exploitable proletarian class and the regional dependency of mexico on the usa and canada conclusion as of april 2021 canada has officially recorded the deaths related to covid19 complications of three mexican sawp workers10 additionally more than 2800 temporary workers in ontario another 2000 more in quebec and more than 1000 in british columbia have contracted the virus while working complying with mandatory isolation or traveling to the farms 11 between june and july 2020 the canadian and international media reported how the pandemic exposed the poor treatment that temporary workers received in canada workers denied care after contracting covid19 restrictions on their health insurance coverage deportations unjustified dismissals 12 in early june 2020 mexican media reported that agricultural worker travel to canada was suspended due to the rise in covid infections 13 this suspension represented a temporary production diminution on canadian farms and a profound destabilization of the income of mexicans who depend on the sawp given the health emergency the canadian and mexican governments reformulated the sanitary measures to reactivate the regular migration of farm laborers by the end of june migration was reactivated and new health measures were implemented 14 while the contagion numbers increased there were no more official records of deceased workers in canada or mexico in conclusion we want to highlight the conceptual intersection between disposability precarity and proletarianization shown in this article through the historical and ethnographic exploration of the mexican countryside and the mexican peasantry as we ethnographically described sawp migrant workers are directed and contractually pressured to tolerate their role in the program at the same time those conditions are extended as permanent scenarios that influence their family lives even when not working on the sawp consequently working on the program translates as a complex situation that frequently undermines every aspect of life in canada or their home countries moreover as we showed the program has done little to alleviate the structural poverty of mexican workers and their families who often remain jobless in mexico while remaining utterly dependent on their essential role in the canadian food system most workers regularly hired on the sawp have cut ties with the labor market of their home country making them depend solely on the program furthermore the generational replacement aimed to attract a much healthier workforce has left workers with years of experience in the program unprotected perpetuating the idea of an unfree worker vulnerable and highly precarious unable to circulate in the labor market inside and outside canada this limitation of labor mobility emerges as constrained freedom obtained through stateregulated exploitation that directs its productive population to profitable labor markets the practical struggle for reforms for improving the conditions of the workers within the framework of the existing social order thus may appear to be a reasonable means to overcome the most visible horrors of the program in the case of the sawp the requests for an open work permit that mexicans and caribbeans can use to circulate in the canadian agribusiness labor market for permanent residence upon arrival in the country and less bureaucratized ways to obtain citizenship seem to be palliative in a structure that needs these 13 mexico temporarily suspends sending agricultural workers to canada after deaths from covid19 eleco nomis ta com mx inter nacio nales mexicosuspe ndetempo ralme nteenviodetraba jador esagric olasacanadatrasmuert espor covid1920200 6160036 html retrieved march 2 2021 14 the deaths of mexican farmworkers juan lópez chaparro bonifacio eugenio romero and rogelio muñoz santos during the 2020 season prompted the publication of a report by the deputy chief coroner of ontario outlining 35 recommendations to make conditions safer for farmworkers and temporary laborers mcscs jus gov on ca sites defau lt files conte nt mcscs docs report 20 20dcc 27s 20rev iew 20of 20cov id19 20rel ated 20dea ths 20of 20tfa ws 20in 202020 pdf retrieved june 20 2021 this report was due to pressure from advocacy groups in ontario and academic groups such as the migrant worker health expert working group exploitable workers for its correct continuity although it immediately alleviates the most abusive conditions the deep wounds that the program has left in the workers and their families in their places of origin persist focusing on functional failures and the possibility that they can be solved assumes the continuity of the program under its same structural statutes the program has adapted throughout more than 50 years of operation no matter what type of crisis it faces the most extensive model program of temporary and regulated migration in history only seems contradictory when its most entrenched working conditions exceed the tolerable levels of common sense the visible horrors of the program stand out in a multiplicity of daily and persistent intransigence to which workers are subjected on canadian soil and in their countries of origin the economic dependence of the workers and their families on the program has limited livelihood strategies in their countries of origin creating circles of debt that widen with the inclusion of new generations of workers much more attention has to be directed to how caribbean mexican and canadian states regulate the hiring and mobilization of workers year after year in the same way it is necessary to dismantle the master narrative of canada as a benevolent tolerant and altruistic country where migrants can stake their hopes on the search for a better future the sawp demonstrates that canada has succeeded in securing a regular nonfree and easily superexploitable source of labor based on the unequal sociohistorical development of the caribbean and mexico under a scheme that adapts and functions through colonial ties dispossession the systematic precariousness of the global peasantry and the recruitment and redirection of surplus populations such as temporary agricultural workers precariousness is the norm within this type of program sustaining extensive disposability processes with various consequences in the countries where it is applied at the same time it is important to hold both migrantsending countries and host countries politically legally and economically responsible worker demand from mexico and the caribbean responds to unequal state and bureaucratic functioning situations in canada likewise the sawp tripartite systemstates employer and workerhas placed most of the bargaining power with the employer and has lowered the level of worker political participation to almost eliminate any possibility of improving the system itself under these conditions the decision between reform and elimination does not seem complicated funding social sciences and humanities research council of canada4352090661 publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

this article addresses the seasonal agricultural worker program sawp between mexico and canada by examining the forms of disposability and job insecurity of mexicans employed in canadian agribusiness we argue that the seasonal agricultural worker program has exacerbated the precarity and disposability of mexican workers by restructuring family dynamics and care chains this article represents a critique of the sawp as a model of regulated labor migration serving as a basis for analyzing the consequences of the proletarianization of the mexican peasantry and its use as disposable labor for export

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introduction since the human society is aging agerelated problems are becoming more and more prevalent in the general population frailty is one such problem associated with the ongoing demographic changes and it constitutes a significant burden for both health and social systems as well as national economies frailty is usually considered as a set of physical deficits causing a decrease in overall reserve capacity however it can also concern psychological and social domains of human functioning deficits in any of these domains may result in deficits in another and their interactions accelerate functional decline of the elderly people therefore an approach to frailty should be multidimensional because such a concept more adequately reflects a complexity of the decrease in physiological reserves associated with aging moreover the elderly people may present different types of functional deterioration and hence require an individualized approach to ensure their independence and good functioning communitybased senior organizations are considered to be a platform which may increase physical activities among elderly people their social connections and their mental functions such organizations gather people in a social atmosphere in their communitybased meeting points and may help in promotion and realization of various healthy projects however despite all these potentials little is known about how the participation in these organizations influences the prevalence of frailty and particularly its impact on different frailty dimensions this study explores how the involvement in communitybased senior organizations affects the frailty prevalence as well as physical psychological and social domains of human functioning among community dwelling elderly people materials and methods communitybased senior organizations in poland senior organizations are financed either by local government or by nonprofit organizations and they are run by seniors themselves in addition they may be supported by workers of local social centers these organizations integrate elderly people from different societies and generations and their goal is to motivate seniors to take active part in the local social life establish new connections and spend time together such organizations promote healthy lifestyle particularly encourage seniors to increase their physical and mental activities propagate culture and art and provide courses concerning computer technologies and diverse domains of knowledge as well as language courses they organize trips social meetings theater and movie shows as well as meetings with various experts and personalities the organizations cooperate with each other and they also establish international cooperation activities are scheduled monthly and they are announced on websites and local meeting points memberships in these organizations is voluntary and usually free of charge statistical analysis descriptive data are presented as mean ± standard deviation or frequency and percentage as appropriate the normality of the variables was tested using the kolmogorovsmirnov test and visual inspection of histograms although most variables did not reveal a normal distribution they were presented as mean ± sd to enable numerical comparisons differences between variables were compared using the mannwhitneyutest or the fishers exact test independent determinants of participation in communitybased senior organizations were identified with logistic regression through multiple testing variables with p 01 in adjusted analyses were not retained in the final model determination coefficient and area under curve were calculated for the regression model the threshold probability of p 005 was taken as the level of statistical significance all analyses were performed using ncss 12 statistical software ncss llc kaysville utah usa ncsscomsoftwarencss results participants characteristics the study group comprised 1024 participants over the age of 65 years and 270 were males most of the subjects presented a high school education level and a moderate economic status they usually followed a partially healthy or healthy lifestyle and 449 of them participated in senior organizations a majority of them lived in a city and previously had intellectual occupations half of them lived in relationships some of them experienced various events and diseases however 882 declared satisfaction with living conditions the detailed characteristics including frailty components are given in table 1 the prevalence of multidimensional frailty was 546 the prevalence of physical frailty was 63 and a nonrobust status was diagnosed in 529 among all frailty components those with the highest prevalence were missing other people feeling nervous or anxious and feeling down participation in communitybased senior organizations table 2 presents differences between members and nonmembers of senior organizations subjects participating in senior groups were slightly younger and presented a higher education level and economic status a majority of them lived in a city and had a former intellectual occupation they less commonly experienced the death of a loved person serious illness or a traffic accident and they also declared higher satisfaction with living conditions in terms of tfi the individuals from senior groups revealed a lower prevalence of all physical components and problems with memory however they more often lived alone consequently they presented a lower rate of multidimensional frailty comparing with nonmembers of senior groups ie 441 vs 631 p 00001 respectively this was mainly caused by a lower number of physical deficits and memory problems however the sum of social deficits and the prevalence of the most common frailty components were not different in both groups according to the frail scale members of senior groups presented lower levels of physical tiredness and a smaller number of chronic diseases in addition they less frequently reported an inability to walk up one flight of stairs or 200 m and an unexplained body mass loss consequently physical frailty was significantly less frequent in members than in nonmembers of senior organizations while a nonrobust status accounted for 393 vs 64 p 00001 respectively logistic regression analysis revealed several independent determinants for participation in the organized senior groups a high school and university education level as well as living in a city positively determined membership in the senior groups subjects were also more likely to belong to these groups if they experienced a criminal event in recent time or missed other people on the other hand a healthy lifestyle living in a relationship death of a loved person serious illness difficulty in maintaining balance poor hearing physical tiredness and a lack of support from other people decreased the likelihood of being involved in senior organizations discussion in this study multidimensional frailty was present in 546 of 1024 subjects over the age of 65 years and 63 revealed physical frailty whereas 529 were nonrobust a concept which is intended to solve some of the deficits associated with aging and consequently decrease the prevalence of frailty is a communitybased senior organization a wide range of initiatives of such organizations may potentially cover various types of seniors needs however little is known about their impact on different frailty dimensions and which factors encourage people to participate in such initiatives in this study subjects who took part in senior organizations presented lower prevalence of all physical frailty deficits in both tfi and the frail scale as well as had fewer memory problems yet they more frequently lived alone as a result elderly people associated with senior organizations presented significantly lower prevalence of multidimensional frailty physical frailty and nonrobust status several independent determinants for the participation in senior organizations have been identified but it is not clear which of these variables are causes and which are effects of the involvement in senior groups indeed numerous physical deficits may preclude elderly people from active participation in the organized senior life eg poor hearing may prohibit them from establishing social connections on the other hand it is possible that the involvement in senior communities may motivate elderly people to a higher physical activity and consequently such a cohort presents lower physical frailty however despite these favorable effects in the physical domain no such positive outcomes were observed in terms of social domain in other words social deficits were not less prevalent and the sum of these deficits was not smaller in organized senior groups poor social relationships are some of the main reasons for low quality of life among elderly people moreover for frail older individuals social contact is the most important factor for their life while nonfrail subjects consider health as the most critical one it has been shown that loneliness is an independent determinant for functional decline and mortality in old age thus social factors are paramount in elderly populations however the present form of senior organizations seems to be ineffective in improving social life in addition senior organizations also had no influence on the most prevalent psychological deficits ie feeling down and feeling nervous or anxious in the report by gobbens and van assen feeling down was the only frailty component that had an effect on all aspects of quality of life therefore psychological problems seem to constitute the biggest challenge in dealing with the elderly people indeed aging is associated with an unavoidable awareness of elapsing time which reminds elderly people of the approaching end of life and significantly affects their psychological condition depression appears to be an ingredient of the aging process and hence it should be early recognized and appropriately treated giving a chance to improve peoples mood and motivation for their active life loneliness and a lack of occupation may lead to the loss of the life purpose which is a key element to activate elderly individuals it has been shown that a stronger purpose in life among subjects over 50 years is associated with a decreased allcause and some causespecific mortality purposeful living may potentially improve both social and psychological domains of individuals functioning and thus this should be a task for communitybased senior organizations moreover a life purpose is a correctable risk factor and as such may be subjected to interventions there are some data indicating that the prevention of physical frailty may defer psychological frailty and this aspect should also be considered by senior organizations in planning an appropriate management circumstances and external stimuluses may involve some activities in the elderly people provided that the intensity of these factors does not cross the limits of their capabilities the necessity to deal with daily needs and various kinds of problems may extract some layers of energy in the elderly people and it is connected to the aforementioned purposeful life and having a task in life this is directly related to the idea of aginginplace the ideology promoted worldwide by the world health organization senior organizations may constitute a critical ingredient for this ideology however the present study shows that social and psychological aspects are not sufficiently covered by the current form of these organizations since societies are aging problems of social frailty along with psychological frailty will be growing hence public awareness of these problems and an adequate adjustment of the activities of senior organizations are essential to abort or defer the functional elderly degradation in fact the approach to seniors should be individualized to their needs recently it has been shown that simultaneous employment of tfi and the frail scale may identify elderly people who require different managements ie subgroups presenting predominantly social and psychological frailty and those with mainly physical deficits these simple tools can be used by both seniors themselves or professionals in senior organizations to detect particular needs and plan an individualized management strategy moreover these instruments may be utilized for monitoring the effects of senior organization activities indeed such quality measures of social psychological and physical effects in subjects participating in the senior organizations may reflect their real value and help to improve their effectiveness study limitations the present study has however some limitations which should be acknowledged first we used selfreported questionnaires which were distributed among elderly people attending meetings dedicated for healthy lifestyle promotion and therefore some selection bias cannot be ruled out particularly the participants were predominantly females which is presumably due to the fact that the meetings probably attracted more females than males second the crosssectional nature of this study does not permit adequate causeeffect interpretations of the associations between various variables third although the frail scale has been validated as a tool for quick diagnosis of physical frailty whereas tfi for diagnosis of multidimensional frailty they do not provide data coming from direct measurements of physical performance conclusions in the community dwelling elderly people over the age of 65 years more than one half present multidimensional frailty which corresponds to a similar percentage of nonrobust subjects participation in communitybased senior organizations is associated with lower risk of physical frailty yet it has no effect on social frailty and the most common psychological problems social and psychological deficits are common among elderly people however since the present concept of senior organizations seems to be ineffective in solving these problems some measures should be undertaken in order to adjust the activities of such organizations for the needs of elderly people these observations have important implications for practical management with senior problems and may influence community strategies concerning elderly people data availability statement the datasets generated for this study are available on request to the corresponding author ethics statement the studies involving human participants were reviewed and approved by komisja bioetyczna przy uniwersytecie medycznym w poznaniu ul bukowska 70 60812 poznan 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

the study explores how the involvement in communitybased senior organizations affects the prevalence of multidimensional and physical frailty among community dwelling elderly peoplethe group of 1024 elderly people 270 males over the age of 65 years mean age 726 ± 63 years range 6593 years took part in this study the subjects completed a questionnaire regarding multidimensional ie the tilburg frailty indicator tfi and physical frailty ie the frail scale as well as factors associated with frailty and participation in senior organizationsthe prevalence of multidimensional frailty if at least 5 points in the tfi was 546 and the prevalence of physical frailty if at least 3 points in the frail scale and a nonrobust status if any point in the frail scale was positive was 63 and 529 respectively the most prevalent frailty deficits were missing other people 666 feeling nervous or anxious 659 and feeling down 655 members of senior organizations presented a lower prevalence of multidimensional and physical frailty comparing with nonmembers this was mainly caused by a lower prevalence of physical deficits and problems with memory however the prevalence of social deficits was similar in both groups senior organizations had no influence on the most widespread frailty deficits ie missing other people feeling nervous or anxious and feeling down conclusions multidimensional frailty and physical nonrobust status are common among people over the age of 65 years participation in senior organizations is associated with lower risk of physical frailty however it has no effect on social frailty and the most prevalent psychological deficits this information has important implications for practical management with senior problems and may influence community strategies concerning elderly people

19881_0

where midwifery services are wellintegrated into the health system model of care 9 10 11 12 here women are supported to make informed choices about their maternity care including where to give birth 45101314 for women at low risk of complications this integration of health system support for home birth in highresource countries has been associated with maternal and newborn outcomes similar to those of women experiencing hospital delivery 1516 however in lowand middleresource countries birth at home occurs much more frequently and may be associated with high mortality although the number of facilitybased births is increasing 1718 up until 2016 an estimated 03 to 906 of all births take place outside of healthcare institutions in lowand middleresource countries worldwide 19 in 2017 an estimated 810 women worldwide died daily from preventable complications of pregnancy and childbirth with 94 of these occurring in lowresource settings 20 in lowresource settings the provision of safe home birth is complicated by multiple factors these include a lack of skilled birth attendants 2122 access to and quality of care in obstetric facilities in the event of complications 67 pregnant womens knowledge of complications 2324 their cultural beliefs 2526 and societal norms related to womens autonomy 27 within this myriad of personal societal and health system influences women decide whether to birth at home their partners decide whether and how to support them and practitioners and policy makers plan deliver and evaluate home birth services evidence from research examining the experiences of key stakeholders including women partners family members health care practitioners policy and decisionmakers could usefully inform personal and policy decisions regarding home birth different stakeholders perspectives can provide an important source of evidence underpinning quality of care in both hospital facilities and planned home births 28 listening to diverse womens experiences of birth across different countries and under varied circumstances can also address gender equity issues in health 29 a large amount of qualitative research on womens experiences of home birth exists and may be useful however this evidence comes from diverse populations several previous systematic reviews have examined the perspectives of women midwives and nurses the majority of these focus on womens views in highresource countries 30 31 32 33 34 35 36 37 38 39 of these six are now outdated and the remaining current reviews focus on perspectives in the united kingdom only 3139 or are systematic review protocols 3435 fewer systematic reviews focus on practitioners perspectives of home birth three systematic reviews examined the perspectives of midwives and nurses and of these two conducted with stakeholders in hrcs are no longer current 4041 the third examines midwives perspectives of home birth in lmrcs 42 no systematic reviews were located that sought the perspectives of other key stakeholders in highor lowresource settings including those of fathers other health care providers or policy decisionmakers the primary research exploring perspectives other than women or practitioners is disparate and may provide conflicting findings in countries where home birth is and is not well integrated 43 44 45 46 47 48 49 these primary studies have also highlighted a range of topic areas including decisionmaking and satisfaction the characteristics and risk status of those who choose home birth and the influence of geographic location on birthplace 50 51 52 53 54 55 56 57 58 59 to facilitate evidenceinformed decisionmaking among women their support persons health care professionals and those setting clinical and policy standards there is a need to understand the body of research examining the experiences and perspectives of home birth as voiced by those who are involved in home birth decisions this involves first understanding the breadth of evidence that has been conducted and the types of participants settings and contexts in which home birth research has been conducted by mapping or scoping the breadth of research on peoples perspectives of home birth our aim is to understand the range of debates on the value and place of home birth in different communities and among different populations by mapping or scoping the breadth of research on peoples perspectives of home birth our aim is to understand the range of debates on the value and place of home birth in different communities and among different populations collating this research literature will identify the breadth of research on this topic examining determinants such as ethnicity socioeconomic status disability sexualgender orientation migration status age geography and with health system factors which interact with issues of sex or gender and influence birth processes and outcomes 6061 such understanding could help women decide where to give birth allow clinicians to provide individualized evidenceinformed care that enlightens and supports choice and help policy decisionmakers assess the fit between the research evidence service user needs and values and the availability of birth place options 62 to foster these decisions we conducted a scoping review to identify the breadth and nature of the evidence worldwide objectives in order to prioritize the populations and topics where home birth research exists and could be synthesized usefully for evidenceinformed policy practice and personal decisions the research landscape must be understood 63 a scoping review is best suited to this purpose scoping reviews utilize systematic review methods and map the breadth of research undertaken on home birth its key characteristics and any evidence gaps where future primary research is needed 6364 two research questions were addressed how is the research literature on stakeholder perspectives opinions and views of planned home birth characterized in terms of populations settings and identified issues where are there gaps in the research evidence on stakeholder perspectives of planned home birth a review protocol was published on the mcmaster midwifery research centres website in march 2020 65 methods stakeholder engagement as part of a larger cihrfunded knowledge planning and dissemination grant we consulted an advisory group comprised of midwifery researchers obstetric family practice and midwifery practitioners and a member of the public with maternity policy expertise advisory group members were consulted twice first to advise on review methods and identify potentially relevant key research and second to consider and interpret emerging findings search strategy searches were updated from our previous systematic review of home birth 1516 and supplemented using a range of medical and social databases including embase medline cinahl amed assia proquest thesis dissertations and cochrane library in addition key websites and journal hand searching were conducted searches were conducted from january 2010 to april 2021 search terms incorporated subject headings and freetext terms for home birth or home delivery translated from medline out to other databases a search strategy and resultant outputs for all databases is provided in appendix eligibility criteria all identified references were screened hierarchically and included in the review if they • were an empirical study • concerned womenclients who planned to or did give birth at home • aimed to elicit views perspectives opinions or experiences of any stakeholders • were published in english or are translatable and • were published from 2010 onward we excluded narrative descriptive birth stories that described events or outcomes but any research including rationales reasons motivation values perspectives and decisionmaking as part of the descriptive were included as english language is the research teams primary language this was the minimum required for adequate eligibility screening however studies in other languages were marked for possible future research to ensure that the included research reflected current professional guidance and stakeholder perspectives on home birth a date limit of 2010 was used this reflected either the date since data were collected or when the reference was published studies were also excluded that focused solely on hospital birth or alternative birth center settings data extraction data from included studies were extracted using previously developed modified coding frameworks that were informed by the advisory group 3165 extracted data included study aims geographic location type of participant or parity highand lowand middleresource countries were defined as per current world bank definitions 8 emerging findings were shared during consultations with advisory group members this helped the research team to interpret the findings evaluate our methods and determine future research and dissemination collaborations to support evidenceinformed decisionmaking data analysis to establish the breadth of research conducted on home birth extracted study characteristics were descriptively analyzed and summarized in tabular format descriptive frequencies of all study characteristics were calculated using excel assessing risk of bias or critical appraisal of studies was not undertaken as this stage is not appropriate for a scoping review where the aims are to understand the nature and breadth of research in an area of inquiry 6667 similarly assessment of both metabiases and confidence in cumulative evidence are not appropriate for a scoping review 6668 findings from the scoping review are reported separately for highresource countries and lowand middleresource countries this is due to differences in health systems provision of integrated home birth services which may influence both stakeholders perspectives as well as the nature of the research conducted 969 quality assurance eppireviewer software was utilized for review processes the protocol and final report were developed as per prisma reporting guidelines 7071 for screening and data extraction two researchers worked independently establishing agreement on a common subset of studies with disagreements resolved by a third researcher results protocol alterations as a scoping review registration was not possible in prosperos systematic review register instead the protocol was made publicly available on mcmaster universitys midwifery research centre website 67 two alterations in the protocol were made at the request of and confirmation by our advisory group first very few studies reported whether the women planning or experiencing home birth were considered to be of low risk therefore all studies of women who planned or gave birth at home regardless of risk status were included in the scoping review second a high number of studies conducted in lmrcs focused on reasons for home birth despite access to health facilities this was considered by the advisory group to be an important need to understand thus these studies were also included for analysis overall findings searching identified 10196 references after duplicate removal and screening on title and abstract a total of 720 references were retrieved for assessment based on the full report of these 460 met the eligibility criteria and were included in the scoping review analysis most studies were excluded at titleabstract or full text screening stages because they were not empirical research were not focused on home birth or were not research on peoples perspectives the flow of studies through the review is provided in fig 1 stakeholder perspectives of home birth have been studied globally across 73 different countries a range of focus group interviews and qualitative survey designs were employed studies were distributed fairly equally between hrcs and lmrcs 8 with 54 conducted in lmrcs compared to 46 in hrcs home birth in highresource countries a total of 210 studies examining stakeholder research on home birth were located within 25 hrcs as illustrated in fig 2 research examining stakeholders views of home birth was conducted most often in the uk followed by australia the usa the netherlands and canada it should be noted that some studies sampled from more than one country hence numbers add up to the overall totals for hrcs reported above several hrcs were not represented including chile and colombia south korea and several countries within europe populations studied in highresource countries the experiences of a wide range of clients support persons and health care practitioners were sought across highresource countries as illustrated in fig 3 womens experiences were most often reported although the perspectives of fathers and family members were also included in some studies midwives were the most frequently researched healthcare providers followed by obstetricians nurses and family practitioners pediatricians and other health care providers were studied less often the views of service managers and staff members were studied infrequently the perspectives of community leaders and policy makers regarding home birth were rarely studied home birth issues studied in highresource countries a range of issues related to home birth were studied within highresource countries as shown in fig 4 within hrcs home birth studies focused most often on the perspectives of those who were planning or had experienced home birth another 67 studies focused on understanding home birth from the perspectives of those providing home birth services the perspectives of different types of clients were also the main focus of a group of studies perspectives of home birth among women experiencing their first pregnancy were reported in 23 studies within hrcs with only 5 asking multiparous women the experiences of rural and remote participants indigenous groups and immigrants were less often reported some studies also explored purposely the views of partners and family members the perspectives of fathers or partners were the specific focus in nine studies only one study sought the experiences of childrensiblings who were present during home births perspectives on risk in home birth were also a focus a total of 11 studies considered the experiences of those who chose to freebirth the experiences of home birth for those with highrisk pregnancy were reported in eleven studies and of women who had a previous hospital delivery in eight studies the perspectives of those who experienced transfer from home to hospital during birth were reported in 15 of the included hrc studies home birth in lowand middleresource countries a slightly higher proportion of the included studies took place in lowand middleresource countries a total of 250 studies eliciting the views of stakeholders about home birth across 48 countries this is shown in fig 5 studies of stakeholder perspectives of home birth were conducted in multiple lmrcs as illustrated in fig 6 the largest body of research in this group has been conducted in ethiopia a modest number of studies have been conducted in other countries with high rates of maternal mortality including brazil nigeria india tanzania and kenya and zambia nepal ghana and bangladesh countries with the highest maternal mortality rates as defined by the who unicef the un population fund and the world bank 72 were partially represented three studies were located in sierra leone and four studies in sudan however no research on stakeholder perspectives of home birth could be located originating from chad the distribution of included studies across countries with high very high and extremely high maternal mortality is further illustrated in table 1 populations studied in lowand middleresource countries as in studies conducted in hrcs the perspectives of women experiencing home birth in lmrcs were most often sought this is shown in fig 6 many other types of stakeholders participated in home birth research studies across lmrcs fathers perspectives were explored in 45 studies as were family members a diversity of healthcare providers perspectives were also studied including outreach workers health extension workers and unspecified health workers the experiences of traditional birth attendants were reported in similar proportions followed by midwives nurses and skilled birth attendants the experiences of service managers and staff members and obstetricians family practitioners and pediatricians were less often reported a modest number of studies within lmrcs included the perspectives or community leaders followed by community members and policy makers perspectives of academics or social service personnel and religious leaders were less often stated home birth issues studied in lowand middleresource countries a wide range of topics were studied across lmrcs as shown in fig 7 within lmrcs participants perspectives shaped by geographic and economic determinants were evidenced with studies of those experiencing rural or remote home birth in poorly resourced areas nomadic or pastoralist communities studied almost one third of the studies in lmrcs sought to understand home birth from the perspective of those people experiencing home birth the focus of those providing home birth services was examined in 32 studies many of the studies conducted in lmrcs sought to understand why home birth took place despite an emphasis on promoting health facility delivery other related studies examined perspectives of women who experienced home birth despite receiving antenatal care or not utilizing antenatal care the views of those women experiencing previous hospital delivery were reported in four studies another six studies specific populations at risk of poor outcomes were less often studied including first time mothers multiparas and indigenous groups refugees and migrants and those with highrisk pregnancies studies originating in lmrcs with a specific focus on the perspectives of fathers only were rarely reported discussion stakeholderfocused research it has long been considered important that health policy and practice decisions should be informed by the perspectives of those who plan provide and are affected by them 73 the research literature on womens perspectives of home birth in highresource countries including the uk and brazil have been systematically reviewed 313941 however these syntheses are in need of updating the large number of recent research from hrcs on womens perspectives of home birth could address this need while current efforts are underway to review the research on womens perspectives of home birth across all highresource countries 3435 consideration should be given to the differences between countries in terms of the nature and quality of health care provision including the integration of home birth services 9 there is also a need to understand womens experiences of home birth in lmrcs research with women in lmrcs comprised the largest body of evidence located in our scoping review this evidence has been systematically reviewed and synthesized for home birth in ethiopia 74 ghana 75 and brazil 76 studies examining factors influencing and perspectives of home birth in ethiopia and ghana note similar barriers to hospital delivery due to access 7475 others note that planned home birth in brazil is most often utilized by women of higher socioeconomic status 77 but there is scarce and poor quality research regarding midwives role in brazilian home birth 76 examination of these perspectives of women and birth attendants both within and across countries with the highest maternal mortality could highlight areas where fig 6 lowand middleresource countries type of participant health systems could be strengthened while a large body of research was located examining nulliparous womens views of home birth in highincome countries this has yet to be integrated into a qualitative evidence synthesis similarly the primary evidence on multiparous womens experiences of home birth in hrcs has accumulated and could usefully update and inform previous research syntheses of this population 30 in hrcs a body of research was located on fathers and samesex partners experiences of home birth a synthesis of the existing literature on these partners perspectives of home birth in high resource countries is an important area of need as this appears to be a new area of birth research in lmrcs it has been suggested that fathers and other family members influence womens health care decisions including place of birth 78 79 80 81 82 our scoping review identified several studies eliciting the views of fathers and other family members in lmrcs about home birth which could be synthesized usefully integration of this evidence could further identify the ways in which family members influence the decision on womens place of birth in lmrcs 8384 a substantial number of studies examining lmrc community members views of home birth were also located this could further supplement existing evidence syntheses of community interventions to prevent maternal and newborn mortality 8586 in addition a small body of literature was located examining the perspectives of community leaders and policy makers in lmrcs regarding home birth synthesizing this literature would provide an understanding of the health system factors that must be leveraged in order to integrate midwifery and skilled birth attendant home birth services into lmrc health system infrastructure table 1 number of studies conducted in countries of high very high or extremely high maternal mortality health professionals perspectives of home birth also hold the potential to inform maternity policy and practice however only one previous systematic review was located which examined midwives discussions of place of birth options with women in hrcs 40 this scoping review located multiple primary studies that assessed the views of midwives medical staff and other health care providers in highresource countries further synthesis of this literature would add to the existing evidence and could expand our understanding of the views of other health care providers in highresource settings in lmrcs one recent systematic review examined the perspectives of midwives and skilled birth attendants concerning home birth 42 this evidence could be enhanced and updated by synthesizing the evidence located in our scoping review which identified research with community health workers health extension workers lady health workers and service managers and staff members by understanding these perspectives birth services may be configured to address key stakeholders concerns issuefocused research several topics or issues of interest also emerged from the analysis of hrc research on stakeholder views of home birth this included new primary research on peoples perspectives of freebirth or unassisted birth where women choose to birth without a trained professional present even where there is access to medical facilities previous syntheses of this research suggest that women make this choice for reasons of autonomy choice and control over their own bodies due to midwives and current maternity services 3287 this body of literature is currently being further synthesized in order to supplement previous research in this area 8889 similarly our scoping review identified multiple research studies of stakeholder perspectives on home birth in highrisk pregnancy in those who had a previous hospital delivery and among women experiencing transfer from home to hospital integration of this body of research conducted in highresource settings could broaden our understanding of home birth with reference fig 7 topic focus of included studies lowand middleresource countries to safety and risk for example this could update an existing evidence synthesis examining perspectives of transfer from home to hospital 33 this focus was also seen in lmrcbased studies several studies focused on stakeholder perspectives of transfer from home to hospital their experiences of home birth in highrisk pregnancy and the experiences of those who give birth at home despite access to antenatal care andor hospital facilities a synthesis of these topics would update and extend prior outdated work in this area 90 several studies originating in lmrcs also examined stakeholder perspectives of home birth where the population is rural remote or has poor access to health services it has been noted that poor geographic access to hospital facilities in lmrcs impedes health care utilization 91 stakeholder research of rural and remote access and home birth in hrc populations has been previously examined 3637 but has yet to be synthesized for populations living in lmrcs a synthesis of this literature could further inform understanding of the factors influencing where women give birth and how health systems infrastructure could better support childbearing women in rural and remote locations gaps in primary stakeholder research on home birth this scoping review of stakeholder research about home birth also identified several gaps in primary research for example in highresource countries very little research was identified which sought the views of samesex childbearing partners or other family members such as grandparents given the influence of family members on womens birth decisions 788182 this constitutes an important gap in the evidence perspectives of those experiencing home birth in highresource rural and remote locations is also lacking this evidence could help to inform maternity service provision and personal decisions while several studies of indigenous perspectives of home birth exist in both highand lowand middleresource countries 9293 more recent research in this area could reflect recent changes to service provision in some highresource countries 5494 the views of specific populations concerning home birth also bear further examination these include the perspectives of stakeholders in countries of higher maternal mortality including countries in subsaharan africa and southeast asia 20 research on the perspectives of firsttime mothers and multiparas whose experiences may differ from one another could also suggest different avenues of health system support in addition primary research seeking young mothers perspectives of home birth was rarely located given that the highest rate of maternal mortality in lmrcs occurs in women aged 10 to 14 years this is an important area of future research 20 finally primary stakeholder research on home birth among specific and potentially more vulnerable populations is also lacking in both hrcs and lmrcs including indigenous populations immigrants refugees and migrants displaced populations are at higher risk of maternal mortality due to the associated conflict and humanitarian crises 72 this suggests that this may also be a very useful area of future primary research inquiry to influence maternal service provision in these fragile states 72 strengths and limitations of the review the main strength of this systematic scoping review lies in its broad search for relevant literature and consistent methods of screening coding and analysis to our knowledge this is the first representation of the landscape of qualitative literature worldwide focused specifically on stakeholders experience and perspectives of home birth as such it provides a valuable resource for researchers members of the public and decisionmakers for informing personal and policy decisions related to home birth and identifies areas for future research the results of this review are limited by the depth of analysis possible using scoping review methods a challenge noted by others 9596 the breadth of research and resources available limit the amount of data extraction and analysis possible 63 however the intent of this scoping review was to inform subsequent qualitative evidence syntheses to mitigate this data extraction was designed in consultation with an advisory group of stakeholders to capture key characteristics of the studies which will inform future collaborative research decisions conclusions our systematic scoping review identified a large body of research literature that privileged the experiences and perspectives of a wide range of key stakeholders about home birth in both high and low and middle income countries groups of primary research focused on different topics and populations within hrcs and lmrcs could be usefully synthesized to inform personal practice and policy decisions however these research syntheses would be best informed by collaboration between researchers and childbearing women and their support people clinicians professional organizations research funders and clinical and policy decisionmakers these stakeholders can better inform personal and policy decisions by working together to collectively identify emerging issues priorities and the associated research questions 739798 important gaps in primary research should also be addressed with respect to perspectives of family members in hrcs stakeholders in countries with high maternal mortality young mothers and indigenous populations immigrants migrants and refugees appendix search strategies and outputs competing interests the authors declare they have no competing interests

home birth is experienced by people very differently worldwide these experiences likely differ by the type of stakeholder involved women their support persons birth attendants policymakers the experience itself lowrisk birth transfer to hospital previous deliveries and by the health system within which home birth occurs eg highresource versus lowand middleresource countries research evidence of stakeholders perspectives of home birth could usefully inform personal and policy decisions about choosing and providing home birth but the current literature is fragmented and its breadth is not fully understood we conducted a systematic scoping review to understand how the research literature on stakeholders perspectives of home birth is characterized in terms of populations settings and identified issues and what potential gaps exist in the research evidence a range of electronic webbased and key informant sources of evidence were searched located references were assessed data extracted and descriptively analyzed using robust methods our analysis included 460 full reports findings from 210 reports of studies in highresource countries suggested that research with fathers and samesex partners midwives and vulnerable populations and perspectives of freebirth and transfer to hospital could be synthesized gaps in primary research exist with respect to family members policy makers and those living in rural and remote locations a further 250 reports of studies in lowand middleresource countries suggested evidence for syntheses related to fathers and other family members policy makers and other health care providers and examination of issues related to emergency transfer to hospital rural and remote home birth and those who birth out of hospital often at home despite receiving antenatal care intended to increase healthcareseeking behavior gaps in primary research suggest an examination is needed of perspectives in countries with higher maternal mortality and among firsttime mothers and young mothers our scoping review identified a considerable body of research evidence on stakeholder perspectives of home birth these could inform the complex factors influencing personal decisions and health system planning around home birth in both highand lowand middleresource countries future primary research is warranted on specific stakeholders worldwide and with vulnerable populations in areas of high maternal mortality

19882_0

background so far there has been extensive research revealing socioeconomic health inequalities across different societies 1 2 3 explanatory approaches of why such health inequalities do persist have amongst others focussed on social relations two reasons have been put forward to underline the argument firstly social relations have been associated with socioeconomic status 4 5 6 and secondly social relations have generally been recognised as an important social determinant of health 7 8 9 10 social relationships can affect health in different ways social ties might influence healthrelated behaviours while social support might be valuable to cope with stressors 11 therefore research on social relationships generally distinguishes between quantitative and qualitative aspects 91213 quantitative characteristics of social relationships are for instance the frequency intensity or permanence of social contacts measures of quantity are widely used in socialepidemiologic research and they usually form an index which provides information on the extent of social integration 14 moreover concepts were developed and further promoted for assessing qualitative characteristics of social relationships social support is typically divided into subtypes which include emotional and instrumental support 12 emotional support is related to understanding esteem and help in decisionmaking while instrumental support can be manifested in many forms including practical help and financial support numerous studies have shown an association of social relationships with morbidity as well as with selfrated health 912 15 16 17 18 a recent metaanalytic review across 148 studies concludes that the influence of social relationships on mortality risks is comparable with wellestablished biomedical and behavioural risk factors 10 despite some inconsistencies it can be summarised that the effect of social relations on health can be found for the quantitative as well as the qualitative dimension of social relationships most of the studies analysing health effects of social relationships do not or only insufficiently consider socioeconomic factors according to krause 19 there are at least two ways in which socioeconomic variations in social relationships may be manifested on the one hand it is possible that differences occur between socioeconomic status groups regarding the extent of social relations on the other hand it is likely that healthrelevant effects of social relationships differ between status groups in general in the first mentioned case it is presumed that lower status groups have lesser or poorer social relationships for example less social contacts or less emotional support than higher ses groups the latter case assumes higher vulnerability regarding adverse health effects of insufficient quantity and quality of social relationships in lower status groups ie social relations and health show stronger correlations in lower ses groups results are inconsistent in terms of the differential vulnerability hypothesis 1520 with our analysis we try to shed light on the following research question does ses affect the association between social relationships and health we assume that the link between social relations and health is affected by ses ie that ses moderates the association of social relations and health functional as well as structural aspects of social relations are considered for the analysis as it was proposed for research in this area 13 as there is evidence for gender differences in health inequalities as well as in health effects of social relations 16 20 21 22 23 24 25 it is likely that potential moderator effects differ between men and women methods sample data stem from the baseline examination of the heinz nixdorf recall study which is an ongoing prospective populationbased cohort study in an industrialised urban region in western germany rationale design and methods in this study have been described in detail elsewhere 2627 respondents were recruited from the german population aged 4575 years living in three adjacent cities recruitment was based on a random sample from mandatory citizen registries overall 4814 men and women participated in the study with a response rate of 56 27 extensive baseline examinations were conducted from december 2000 to august 2003 and a five year followup has recently been completed the main objective of the hnr study is to improve prediction of coronary heart disease by combining already established with new cardiovascular risk factors ses social relationships and health were assessed figure 1 the moderating effect of socioeconomic status on the association of social relations and health in the baseline screening as part of a social risk factor assessment by facetoface interviews and paperandpencil questionnaires socioeconomic status income and education were used as ses measures education was classified according to the international standard classification of education as total years of formal education combining school and vocational training this variable was then grouped into four categories with 18 and more years of formal education as the highest category and 10 or less years as the lowest category 28 income was measured by equivalent household income including information on disposable income and size of household with number of adults and children according to oecd criteria the so called oecdmodified scale 29 the respondent was attributed with a weight of 1 while every other member of the household was given a weight of 05 for the analyses both ses indicators were dichotomised social integration index the social integration index which was originally constructed by lisa f berkman 30 captures quantitative aspects of social relations it includes the marital status respectively living with a partner the number of contacts with close ties as well as the affiliation with voluntary associations each of these three domains score from 0 to 2 depending on the grade of integration marital status or cohabitation was scored 2 all else 0 number of close ties was scored 0 for 02 contacts 1 for 311 contacts and 2 for 12 or more contacts participation in voluntary associations was scored 0 for no participation 1 for participation in one association and 2 for participation in more than one voluntary association the total score ranging from 0 to 6 was categorised into four levels of integration level i ii iii and iv these four levels of social integration were recoded into a dichotomised exposure variable with the levels i and ii indicating low social integration versus high social integration social support measures of support include instrumental and emotional support both were assessed by a german adaptation of the new haven epese questionnaire 31 instrumental support refers to help available in daily tasks for example shopping cooking washing or others emotional support means having someone to talk to someone to discuss problems with or someone who helps making difficult decisions first questions of both support measures assessed the perceived availability of someone to help and the presence of one or more persons to approach when problems were experienced in a second step respondents were asked who actually provided support and whether that support was appropriate based on the combination of information four categories were built support not needed support appropriate support inappropriate and support needed but not available cutpoints for the two measures of social support were chosen when either the support was inappropriate or when support was needed but not available with all else representing appropriate social support health measures subjective health status and depressive symptoms were used as health indicators subjective health is a widely accepted measure for health which has been linked to mortality and morbidity in a wide range of studies 32 in the hnr study it was assessed by one question on a 5point likertscale persons reporting moderate subjective health or worse were opposed to those with good subjective health or better depressive symptoms were classified according to a short version of the centre for epidemiological study depression scale 3334 this frequently applied screening instrument contains questions about the 7day prevalence of different types of depressive symptoms answers are given on a 4point likertscale ranging from less than one day to 57 days a total score of all items ranging from 0 to 45 was calculated with higher values indicating a higher symptom load depressive symptoms were dichotomised with gender specific and distributionbased cutpoints with a score in the upperquartile representing a comparatively high frequency of depressive symptoms cutpoints were 9 for men and 12 for women respectively 34 statistical analysis logistic regression models were calculated with the dichotomised health measures subjective health and depressive symptoms as dependent variables the two health measures were regressed on composite variables of the two dichotomised exposures of low social relations and low ses in order to detect a potential moderator effect of ses on the association between social relations and health the relative excess risk due to interaction score was calculated and is presented in the tables methodology and calculation of reri is explained by rothman and greenland who propose reri as an approach for measuring interaction and therefore detect possible moderating effects in epidemiologic studies 3637 interaction can be referred to as departure from additivity of effects on the chosen outcome scale meaning the existence of superor subadditivity of two different measures on a specific outcome if there is no interaction reri equals 0 if there is superadditivity reri is 0 and subadditivity will yield a reri 0 reri is calculated using the following equation reri or or or 1 in the equation ab represents the negative health effect when both exposures low ses and low social relations persist while ab stands for the effect associated with low social relations only and ab for the negative health effect of low ses the reri score is used here as it is a clear and comprehensive measure of interaction effects moreover the score facilitates the understanding of the direction of the interaction effect a positive reri score representing superadditivity and a negative score indicating subadditivity hosmer and lemeshow explained how to calculate confidence intervals in interaction analysis 37 analyses were conducted for the whole sample as well as for men and women separately all statistical analyses were carried out using the pasw statistics 18 program 38 results a description of the variables used is presented in table 1 results reveal that about a quarter of the population under study have a household equivalent income of less than 1000€ per month and 11 report 10 years or less of formal education regarding the indicators of social relationships women report being less socially integrated women also significantly more often lack appropriate instrumental support compared to men general subjective health is distributed as follows altogether 47 rate their subjective health as good or better while 53 find it moderate or worse men significantly more often report very good subjective health whilst women significantly more often show depressive symptoms table 2 presents the multivariate adjusted odds ratios for the overall sample the three categories inappropriate social relations but high ses appropriate social relations but low ses and inappropriate social relations and low ses are compared to the reference group appropriate social relations and high ses highest odds ratios for reporting less than good subjective health and depressive symptoms can be found in nearly all cases for the inappropriate social relations and low sesgroup most reri scores are positive underlining the hypothesised superadditive interaction of the two exposures yet only one score reaches statistical significance a significant positive reri score can be found for depressive symptoms in the group with low income and a low level of social integration the results regarding the two different indicators for ses show hardly any differences ors are very similar between income and education qualitative aspects of social relations ie support measures show strongest associations with the health measures used while social integration being a measure of quantitative aspects of social relationships shows modest associations with both subjective health and depressive symptoms associations between the measures of support and health indicators are rather strong results in women are more consistent than they are in men ors for ill health are higher in women than in men when either social relationships are inappropriate or when both exposures inappropriate social relations and low ses persist this pattern of stronger associations in women is emphasised by four significant and positive reri scores they indicate that the interaction of low income and inappropriate social relations is stronger than the addition of the two exposures discussion this is one of the first studies to analyse the effect of ses on the association of social relations and health our results indicate that accumulation of the two exposures low ses and inappropriate social relationships lead to highest health risks measured by subjective health and depressive symptoms the combination of low ses and inappropriate social relationships is related to a 225 to 575fold increased odds ratio for ill health compared to persons reporting high ses and appropriate social relationships in most cases the two exposures interact and their combined negative effect on health exceeds the addition of each exposure alone positive reri scores point towards such moderating effects even though most of the reri scores remain insignificant this ambiguity makes interpretation of results difficult on the one hand a majority of the presented reri scores are positive and highest odds ratios are found in the group with double exposure of inappropriate social relations and low ses on the other hand most reri scores remain insignificant therefore the hypothesis of differential vulnerability can only partially be supported similarly ambiguous results have also been found in an earlier study with the same study population regarding the effects of social status on the association of social relations with health behaviour 41 only few studies have examined how socioeconomic factors might influence the association between social relations and health in terms of potential moderating effects of ses on the association of social relations and health a study by knesebeck did not support the hypothesis of differential vulnerability 15 while huure and colleagues found partial evidence 39 stronger evidence was found by heritage and colleagues in a french study 40 concerning gender differences evidence for a moderating effect of ses on social relations and health is particularly strong in women especially when ses is measured by income significant moderating effects of income on the association between social relations and health are identified a majority of the reri scores are clearly positive and four reri scores reach a significant level thus low ses and inappropriate social relationships interact and their ors for ill health potentiate rather than add up these gender differences suggest that future studies on health inequalities and social relations should use genderspecific analyses results vary depending on the indicators used qualitative aspects of social relations ie emotional and instrumental support show strongest associations especially with depressive symptoms mental health has been linked to social relationships before social isolation and loss of social ties have been found to be most potent predictors of depressive symptoms among the elderly 42 moreover a similarity in measurement of depressive symptoms and social support might partly account for this association if one feels rather depressed or alone a tendency to deny availability of support is likely therefore our results suggest that indicators of social relations and health should be chosen carefully as results differ depending on the indicators selected overall our results indicate that research on social relations and health and research on health inequalities should be brought together as socioeconomic factors influence the association of social relations and health until now most studies have either focused on the association of social relations and health or on socioeconomic inequalities in health but these two strands have rarely been put together translating our results into interventional practice this would mean that interventions aiming at the reduction of health inequalities should also focus on social relations health benefits of interventions targeting on social relations would be more pronounced in low ses groups improving social relations in low ses groups could be one measure to reduce inequalities in health such improvements can be achieved on a structural as well as on an individual level structural aspects such as the data used for our analyses has many merits it is based on a large and unselected urban population of middleand olderaged men and women in the hnr study special emphasis was put on quality control of data collection and data handling as evidenced by external certification 26 also complex measures of social support indicators were used when constructing the items for measuring support both availability as well as adequacy of support were considered as proposed in earlier research 43 as the hnr study specifically focused on the detection of arteriosclerosis as a risk factor of coronary heart disease we additionally stratified our analyses for known chd results indicate that the exclusion of persons with known chd did not alter the results in terms of methodological limitations potential graded effects between different status groups can not be displayed as independent as well as moderator variable were dichotomised mainly for clarity of results also the crosssectional design does not allow conclusions concerning the temporal sequence of events from a theoretical point of view it is considered that social relations affect health though this causal direction can only be proven on the basis of a prospective study design compared to the population of the study area there is a tendency towards an underrepresentation of lower status groups and a slightly higher proportion of persons with good health status 27 which in turn might lead to an underestimation of the associations of social relations and health the nonsignificance of reriterms can partly be attributed to statistical limitations reri as a method of detecting interaction effects is robust ie needs large differences in ors and depends on large sample sizes tests for nonadditivity as well as tests for other statistical interaction have very little power at typical sample sizes and their estimates lack precision 36 conclusions the results of the analysis presented show that research on the associations of social relations and health should consider socioeconomic factors as these are likely to have impact on this association the negative health effect of inappropriate social relationships is stronger among lower status groups compared to the effect in higher socioeconomic groups therefore psychosocial and health interventions aiming towards the enhancement of social relations should consider the situation of the socially deprived author details 1 department of medical sociology and health economics university medical center hamburgeppendorf hamburg germany 2 institute of medical informatics biometry and epidemiology university duisburgessen essen germany 3 clinic for cardiology university clinic essen essen germany authors contributions khj re js are principal investigators of the hnr study ok is the principal investigator of the dfgfunded project health inequalities and social relationships nd sm and sw participated in conducting the hnr study nv conducted the statistical analyses nv jk and ok were responsible for interpreting the data and writing the manuscript all authors contributed to drafting the manuscript and approved the final version competing interests the authors declare that they have no competing interests

background social relations have repeatedly been found to be an important determinant of health however it is unclear whether the association between social relations and health is consistent throughout different status groups it is likely that health effects of social relations vary in different status groups as stated in the hypothesis of differential vulnerability in this analysis we explore whether socioeconomic status ses moderates the association between social relations and health methods in the baseline examination of the heinz nixdorf recall study conducted in a dense populated western german region n 4814 response rate 56 ses was measured by income and education social relations were classified by using both structural as well as functional measures the social integration index was used as a structural measure whilst functional aspects were assessed by emotional and instrumental support health was indicated by selfrated health 1 item and a short version of the cesd scale measuring the frequency of depressive symptoms based on logistic regression models we calculated the relative excess risk due to interaction reri which indicates existing moderator effects results our findings show highest odds ratios ors for both poor selfrated health and more frequent depressive symptoms when respondents have a low ses as well as inappropriate social relations for example respondents with low income and a low level of social integration have an or for a high depression score of 285 95 ci 232449 compared to an or of 144 95 ci 112186 amongst those with a low income but a high level of social integration and an or of 172 95 ci 145203 amongst respondents with high income but a low level of social integration as reference group those reporting high income and a high level of social integration were usedthe analyses indicate that the association of social relations and subjective health differs across ses groups as we find moderating effects of ses however results are inconsistent as nearly all reri scores are positive but do not reach a significant level also moderating effects vary between women and men and depending on the indicators of ses and social relations used thus the hypothesis of differential vulnerability can only partially be supported in terms of practical implications psychosocial and health interventions aiming towards the enhancement of social relations should especially consider the situation of the socially deprived

19883_0

internal passport or registry document when they wished to go to schools that had controls based on soslovie when they were in need of aid from community resources most of the files begin at the moment an individual or a family registered in a new status and then expand to include these various life events for family members over potentially several generations they can therefore serve as an incomplete but tantalizing outline of the lives of imperial subjects beyond the nobility and intelligentsia peasants merchants traders industrialists clerks teachers and many others the tsarskoe selo ratusha handled cases from the town of tsarskoe selo and also from several nearby smaller towns the four family stories recreated here all had ties to one of them gatchina originally a small village gatchina was transformed legally into a town at the start of the reign of emperor paul it was a bustling place in the last years of the eighteenth century given that the new emperors favourite palace was there and so the court often visited after pauls assassination in 1801 however the court left and gatchina seemed to fit the stereotype of the faraway provinces dusty and empty and not very interesting 3 a v evald who grew up there in the 1840s later described it as something in the way of that town in which our friend ivan aleksandrovich khlestakov so successfully played the role of the inspector general a reference to gogols play that came to represent this stereotype 4 in the middle of the century the railway arrived and then emperor alexander iii moved his family to the palace after his fathers assassination and his accession to the throne by the start of the twentieth century gatchina was a busy place again with a growing population and links to st petersburg and to the surrounding area it was not precisely typicalit could not be with an imperial palace on its edgebut its atypicality probably meant above all that it was better documented than other provincial towns of similar size lives lived in gatchina were with some particular exceptions tied to the palace not that different from lives lived in other small towns around the empire the archival files of the ratusha only give glimpses of a few moments in individual lives and often quite mundane ones at that other sources including archival files from other town institutions city directories which included regional town addresses for much of its run newspapers and memoirs all enhanced by the ability to do fulltext searches make it possible to flesh out the larger histories of at least some of the families whose papers covering several generations lie in the ratusha archives these family stories can still be frustratingly incomplete with disappearances and gaps that may hold meaning or may simply reflect poor recordkeeping working to piece together the family histories from these scattered documents requires time and imagination and a willingness to be guided by the sources rather than impose a narrative on themone reason these archival files have rarely been used by scholars looking at these four family histories together in all their variety illuminates a particularly contested part of our understanding of tsarist russia the families here are all part of imperial russias elusive middle class or middling sorts worry over russias missing middle class dates back to the nineteenth century itself and historians since then have sought to find it in specific social or economic groups or as a political factor or as a cultural milieu 5 these family histories not only display the many variations on middling existence but also emphasize two particular elements of that existence first they show clearly the significant role that women played in middling families women held economic power women submitted petitions women changed their status through both marriage and education their efforts were part of the way that these families maintained themselves within the middle classes second these family histories in particular show the role that social mobility played in the construction of the tsarist middle classes in keeping with several recent efforts to reconstruct family histories that emphasize social andor geographic mobility 6 the four families all involve movement between legal statusesfrom serf to townsperson or merchant between town statuses or from economically based status to professional statusemphasizing the ways in which studying the middle classes requires attention to the fluidity of tsarist russias social structure at the same time however the archival information demonstrates the limits of that mobility particularly when it comes to economic definitions of the middle class the only people who ended the tsarist era as wealthy merchants show up in these histories that way too everyone else either lived lives that flirted with economic precarity or gained prosperity and stability through other means i in march 1829 the brothers ivan and fedor dorofeev lifantev petitioned for a change in their legal status they were they reported currently gatchina townsmen and they wished to be given the status of merchants that change would free them from paying the soul tax levied on every male soul below a certain social status although it would also require them to keep up their 5 alison k smith honored citizens and the creation of a middle class in imperial russia slavic review 76 pp 32749 alison k smith the missing or forgotten middle of tsarist russia in christof dejung david motadel and jürgen osterhammel eds the global bourgeoisie the rise of the middle class in the age of empire pp 295312 6 anna joukovskaia and evgenii akelev iz kazakov vo dvoriane shagarovy mikroistoriia sotsialnoi mobilnosti v rossii xviixviii v cahiers du monde russe 57 pp 457504 alexander m martin from the holy roman empire to the land of the tsars one familys odyssey 17681870 and alexa von winning intimate empire the mansurov family in russia and the orthodox east 18551936 merchant guild fees and prove their economic standing every year because there were no complicating factors like outstanding military duties that might make the commune loath to let them shift their status the gatchina town commune agreed to the change and provided them with a document signed quite neatly by the communes members as a result they were elevated into the status of merchants with what seems from the documents to have been very little fuss 7 even just the names reported by the two brothers shows something about how they fitted into tsarist society although the standard patronymic ending for men is now ovichevich and for women ovnaevna before the beginning of the twentieth century only nobles and some merchants used it instead most people like these two brothers used a simpler ending with the same meaning ovev or ovaeva as an earlier traveller to russia explained the termination of witz in proper names is a mark of nobility for instance one alexander a man of common extraction whose fathers name was john calls himself alexander ivanow but if he is of noble birth or ennobled he will style himself alexander ivanowitz 8 families like the lifantevs who largely maintained the simpler patronymic ending were marking themselves as commoners even if upwardly mobile ones others like members of the kosichkin family below moved to using the more elevated form even retroactively implying a long family history of prosperity the two brothers had roots in the area that reached back to gatchinas first years as a town their father dorofei lifantev had been living in the gatchina region as early as 1794 in that year he presented a petition to baron von bork the overseer of the gatchina estate lifantev described himself as a merchant from the nearby town of sofiia who was trading on the estate and wanted permission to open a drinking house and to build a stable with a blacksmiths outfit to serve passing carriages 9 it is unclear from this document whether he was given permission but later files suggest he was the journals of the gatchina town administration mention a merchant named lifantev twice in connection first with a shop in 1798 and then with a tavern in 1799 10 in that second case he was fined 50 roubles for observed indecency in his tavern for not having clean rooms and food for travellers and for allowing peasants into the tavern 11 this was a lot of money more than the yearly salary of some of those who worked at the palace but earlier in the year such a sum might have been well within his reachat least someone with the family name lifantev purchased five silver table spoons and five silver table forks from an estate sale in 1799 paying a total of 82 roubles 12 soon dorofei lifantev sought to establish himself more firmly in gatchina completing his registry as a gatchina merchant in 1799 despite the fact that he was perhaps not the most lawabiding of tavern proprietors two sons were registered then too although their names were not listed in the report of registry filed in the gatchina town administrations papers they may have been ivan and fedor a later document suggests that ivan at least was born around 1794 13 there may have been another brother named vasilii in the familyin a later petition ivan mentions that my brothers all are dead implying that there had been more than one and petitions from a woman named maria vasileva lifanteva who gave birth to a child out of wedlock in 1862 are interleaved with other papers in the file about the family 14 he may have already died by the time ivan and fedor asked to restore their merchant status or perhaps there had been a falling out that led him to separate from his brothers in any event the brothers spent the early years of the nineteenth century as the sons of a prosperous merchant that prosperity did not last however as at some point before 1829 and perhaps much earlier than that they had fallen into the ranks of the lowerranking townspeople that was not an unusual path for if someone failed to keep up their guild dues they automatically lost their merchant status it might have happened to their father after a business failure being a tavern keeper in a town where the tsarevich and later emperor regularly brought his court was clearly profitable after emperor paul was assassinated in 1801 and his son stayed away from the palace however business may well have dried up or perhaps dorofeis death in 1820 had caused problems with the business leading the two brothers to fail to keep up their merchant dues 15 they were still young men then perhaps not as savvy as their father or perhaps simply dealing with the practicalities of taking over a business and there is the mysterious vasilii his death or departure could easily have led to not only a familial but an economic disruption whatever reason had caused their fall by the end of the 1820s the brothers had become more prosperous and were now in a position to return to their higher merchant status after the two brothers returned to merchant status fedor almost immediately asked to be released from town status to join a monastery and thereafter disappears from the longer archival record the results of the request are unclear because the page has been cut off but the fact that there are no more records about him in the ratusha file suggests he was allowed to leave this was an unusual path for a young man a bit earlier than the monastic revival of the nineteenth century 16 to push for that kind of change fedor must have had a strong urge to the religious lifeperhaps he had never felt at home engaging in trade and perhaps that had something to do with their earlier business problems in contrast ivan settled down into family life he was already married to a woman named fekla martinova almost ten years younger than himself they eventually had three daughters anna tatiana and avdotia 17 in march 1862 ivan who was by this time back at meshchanin rank petitioned the ratusha to allow anna and avdotia to transfer their registry to st petersburg because they lived and worked in the capital his petition was refused however almost certainly because the gatchina commune did not want to give up its connection to the women although no official reason was given for the refusal the commune likely wanted to make sure that ivan and fekla were supported in their old age by their daughters as long as their registration remained in gatchina the two women would have to appeal to the commune regularly for permits to live elsewhere that gave the commune some disciplining authority over their actions toward their parents as it turned out however if the commune had hoped that anna and avdotia would support their parents it was disappointed in february 1868 ivan lifantev petitioned the town ratusha for aid because of the agedness of my years and my deafness he asked place me in the poorhouse or give me monetary aid for sustenance from communal funds he went on to say that neither he nor his wife was able to work and asked for the return of his yearly tax payments on the grounds that other town communes freed everyone over the age of sixty from paying them at the end he gave a brief precis of his family helpers of the male sex i do not have only two daughters unmarried who exhaust themselves with work but barely are able to support themselves and furthermore he noted all the above years i spent in one commune he had been a gatchinite all his life had paid his dues or taxes responsibly and now in his declining years requested the towns aid 18 the gatchina commune responded to the request by making an inquiry into whether ivan deserved aid first it confirmed the ages of all family members based on records from the last tax census revision according to those records ivan lifantev was at the time of his request seventyfour years old and his wife sixtyfive their daughters were fortytwo and thirty next it investigated the familys economic situation and found that ivan has no property and is in a poor condition given these factors the commune agreed that the family was worthy of aid it decided to give him a grant of 3 silver roubles every month payable on the first of each month starting immediately 19 two years later ivan petitioned yet again this time thanking the commune for its monetary aid but asking that he instead be given a place in the poorhouse for life on his own was becoming increasingly hard the commune refused giving no reason 20 perhaps they felt that if he lived on his own it must have been his fault for he had a wife and daughters he did live alone for fekla martinova clearly lived separately from her husband in october 1871 she sent a petition on her own behalf in which she described herself as a gatchina meshchanka living in st petersburg in kolomna district probably because one or both of her daughters lived there i lifanteva am aged and sick i am seventyone years old i cannot do any kind of work until this time my two unmarried daughters have supported me from their labour but now work is very scarce because of the large number of worker women and sometimes there is no work at all now it is hard for them even to support themselves and they suffer from great want and they have no means other than labour as a result she was asking for monetary aid again the commune conducted an inquiry and although they reported her age as different they agreed to give her too a sum of 3 roubles a month in aid 21 that she had success in requesting aid but ivan did not suggests that blame for their marital separation lay at ivans feet there was no divorce in tsarist russia but living separately was one way that women got out of bad marriages 22 ivan eventually died on 19 september 1878 and was buried in the gatchina new graveyard on 23 september fekla followed a few years later dying on 26 january 1881 buried on 29 january 23 the same priest signed both of their death notices which were placed on the back of their last residence tickets their daughters must have submitted their papers back to the ratusha but beyond that they leave no trace their mothers petition noted that they had once supported themselves easily but by the early 1870s their lives had been disrupted by an influx of women workers to the city although she does not explain why the problem was almost certainly the end of serfdom in 1861 which marked the start of more significant movement of former 19 ibid l 15 20 ibid ll 1616ob 17 21 ibid ll 19 19ob 22 barbara alpern engel breaking the ties that bound the politics of marital strife in late imperial russia 23 o zapiske lifantevykh ll 21 22 novoe kladbishche spisok zakhoronenii peasantsincluding large numbers of womento towns in search of work 24 whatever the daughters lives in st petersburg they were modest ones for they never appear in the citys address books 25 however they never requested aid from the gatchina commune so perhaps despite their mothers worry they managed to support themselves or perhaps they managed to find aid in the capital where they had spent their working lives separate from the place where they had been born almost certainly however they were coming to the end of the nineteenth century in a much less prosperous place than their grandfather had entered it ii while the lifantevs came to gatchina already as merchants the kosichkin family story began in serfdom in may 1864 a temporarily obligated peasant from iaroslavl province named anisim efimov kosichkin petitioned to register as a gatchina second guild merchant along with his large family they already lived in gatchina in a building in ingenburgskii district owned by a man named varygin where several families rented apartments the petition was accepted and the family was formally registered by the end of the year anisim his wife ekaterina semënova three sons konstantin vasilii and pavel and a daughter aleksandra 26 there were possibly errors in this initial documentation in 1868 anisim requested documents that would allow aleksandra to marry a st petersburg merchant named sergei mikhailovich ushin in his request he stated that aleksandra was eighteen which would have meant she was only fourteen at the time of her registry not nineteen the town authorities were confused by this and the request has a note on the back that stated that their information suggested that she was twentythree not nineteen 27 in addition the family had had another son aleksandr born in 1857 who died as an infant 28 the kosichkins had been established in gatchina for several decades by this time but presumably had not been able to formalize their residency there because they like many other serfs were unable to persuade their owner to free them 29 according to konstantins birth certificate he was born in gatchina in 1842 and had a gatchina merchant wife as a godmother at that point anisim was described as a peasant belonging to count sheremetev which meant that he was owned by the wealthiest serf owner in all the empire 30 many sheremetev serfs some quite wealthy lived away from their villages engaging in trade and sending back rents and taxes by the 1840s sheremetev was willing to hear requests for manumission but expected payouts in return amounting to hundreds if not thousands of roubles so relatively few were able to gain their freedom 31 that did not stop serfs like the kosichkins from settling firmly in their new homes by the time the two younger sons were born the family had ties that reached back to their place of origin and to new relationships vasilii and pavel shared a godfather the greek subject vasilii emmanuilov karatsel vasiliis godmother was apparently another sister who had either died or married out of the family by the time they entered the merchant commune from iaroslavl province uglich district pogoreloka village the peasant of count sheremetev onisim efimov kosichkins daughter olga kosichkina pavels godmother was a peasants wife from the krasnoe selo estate near gatchina named aleksandra petrova 32 godparenthood also tied anisim to the town in other ways in 1866 he was named as godfather to ilia bogdanov the newborn son of nikolai bogdanov who also lived in varygins apartment house and transferred his registry to gatchina that same year 33 anisim kosichkin seems to have been fairly prosperous in the years around his formal registry in 1854 he donated 3 roubles to a fund to support soldiers families during the crimean war 34 this was nowhere near the largest donations of hundreds of roubles by some of the richest serf owners in russia but it was significantly more than the 10 or 25 kopeks that many donors contributed 35 a decade later at the time he formally registered in gatchina anisim was still doing well even before formally registering he held temporary trading rights as a second guild merchant and paid 20 roubles for the right to sell snacks in varygins house 36 of years later he took part in the efforts to found a philanthropic society in gatchina serving as one of the initial members of its council 37 he also purchased a house on baggovutovskaia street and became a landlord himself 38 the fact that aleksandra anisimova married a st petersburg merchant again suggests that the family was prospering sergei mikhailovich gained merchant status on his own account the same year they married although his family had been merchants in the capital since 1847 39 he came to run a cloth store in the great central merchant arcadeif it had been his fathers perhaps aleksandra came to the capital to shop and they met in the store sergei mikhailovich was by later evidence a prosperous presumably wellrespected figure by the end of the century he maintained his merchant status without apparent trouble and gained hereditary honoured citizen status before 1895 he was named a church elder at the church of st nikolai the miracleworker on gorokhovaia street as of 1887 and was elected as a delegate to the st petersburg duma in 1877 holding the position into the 1890s 40 aleksandra however only saw some of this success she and sergei had at least three children daughters mariia and olga and a son sergei 41 she would therefore have spent her twenties in a prosperous merchant household raising children seeing her husband find success in business and in local politics sergei was eventually awarded a gold medal for his service on a committee to help the poor of st petersburg so perhaps she took part in charitable activities alongside him 42 their life had tragedies too olga died in childhood probably in 1877 43 aleksandra herself died in the very early 1880s 44 sergei eventually remarried and then took sergei sergeevich into his business the two of them were still running it in 1917 and sergei sergeevich at least survived the revolution into 37 kratkii istoricheskii obzor sushchestvovaniia i deiatelnosti gatchinskogo blagotvoritelnogo obshchestva 18671893 g p 9 38 s perepiskoi po raznym voprosam i o raznykh rasporiazheniiakh rgia f 491 op the early 1920s 45 that meant that he the son of a woman born into serfdom was a prosperous merchant at the time the empire endedand then faced an uncertain world aleksandras brothers also lived in st petersburg for part of their lives in april 1871 konstantin transferred his registry to the st petersburg merchant commune a definite step up that suggests he had ambitions to become something more than a provincial merchant he lived on borovaia street not far from the moscow train station and traded in cosmetics on nevsky prospekt itself the main street of the capital 46 but he apparently suffered a setback shortly thereafter and was reduced to a meshchanin along with his wife maria ivanova by 1873 three years after that anisim asked that konstantin be returned to the gatchina commune as part of his household 47 after anisim died in 1880 his widow ekaterina and her two younger sons submitted a petition that suggests a reason for konstantins business problems they requested that the younger son vasilii take control of the family property on the grounds that pavel was ill and konstantin together with his wife are constantly in an inebriate state and therefore not capable of handling business affairs 48 in reality although the petition asked that vasilii take control ekaterina seems to have been the actual person in charge when konstantin began to rack up medical bills ekaterina was the one who turned to the commune for money to help pay them 49 she was listed as the resident owner of the house in gatchina in 1897 50 ekaterina probably took charge because by the 1890s vasilii too was living and working in st petersburg though not as a merchant instead he held the rank of candidate of commerce which meant that he had graduated from the st petersburg commercial school and worked for the st petersburg town council in the accounting department as an assistant to the comptroller 51 in the 1890s he lived at 32 basseinaia street only a block off nevsky prospekt he married there too the ratusha records list his wife as a prussian woman named emma emilia prints as of 1898 an emma gustavovna kosichkina is listed as living at the same address as vasilii 52 it seems likely that she was the daughter of gustav gustavovich printts who was an attorney at the st petersburg commercial court holding the rank of actual state councillor and who lived at 34 basseinaia street vasilii seems to have married the girl next door 53 it also means that vasilii born into serfdom ended the century the husband of someone with noble rank through her fathers service vasilii and emma stayed on basseinaia until 1903 when they moved to the northern fringes of st petersburg to the chernaia rechka embankment living in two different apartments in the area 54 vasilii continued to work in the same job at the st petersburg town council but the early years of the twentieth century brought challenges first emma died in 1910 55 then around 1912 vasilii seems to have lost his job when the council underwent an internal administrative reorganization 56 over the next several years he remained in st petersburg but never listed another place of employment or professionsurely finding a new job was particularly challenging during the years of the first world war when refugees crowded the city he moved several times too perhaps finding more and more modest lodgings he was still listed in the st petersburg city directory in 1917 living on nevsky prospekt near the nikolaevskii now moscow train station 57 vasilii might have known about his last recorded residence because his niece had lived there a decade before when konstantin died in 1886 at only fortyfour years old he left behind two children 58 one a son named vasilii was born in 1872 during konstantins time as a st petersburg merchant his grandmother requested information that would allow him to study at the st petersburg military medical school but there is not much more information about him 59 konstantins daughter aleksandra born around 1868 also studied and earned the profession of governess 60 that does not seem to be what she did for a living however instead in the 1890s she lived in st petersburg in several different apartments around the nikolaevskii station 61 according to the city directory over much of this time she worked for the st petersburg town council like her uncle although she is not listed among the employees at the council office so precisely what she did is unclear whatever her employment up to that point in july 1907 she petitioned the gatchina town authorities for aid writing out a petition in her own neat beautiful hand as of february of this year i find myself without an income and not having means to support myself i suffer from most extreme need which is why i have been forced earnestly and respectfully to request you grant me either a onetime allowance or monthly allowances until i find work my grandfather anisim efimovich kosichkin and my father konstantin anisimovich kosichkin were merchants for more than forty years and paid their guild duties to the ratusha i have been promised a place at one of the petersburg chancelleries this winter but at the given time i do not even have the ability to pay for my room because everything that i have earned by my labours has already been spent and i am threatened by death from starvation when i had an income of course it never even came into my head to ask the ratusha for a pension even though i had a right to it in light of the many years that my grandfather and father paid guild duties 62 aleksandras petition workedto a point the ratusha awarded her an allowance of 5 roubles but at the same time looking into her case showed that she was living in st petersburg on a permanent residency permit due to her status as a teacher as a result the ratusha decided to exclude her from the official ranks of the gatchina commune this might seem to have been the end of her relationship with the commune but it was not instead she petitioned again in the summer of 1908 noting that she was ill and that her doctor suggested she go to the south of russia to take kumysfermented mares milk a fashionable cure at the time 63 the gatchina authorities were sympathetic and granted her a monthly allowance of 3 roubles a month 64 she last appears in the st petersburg city directory in 1911 suggesting that she either moved elsewhere permanently or perhaps given her health problems diedif so she would have died young at around fortyfour just like her father while her cousin sergei ushin prospered and her uncle vasilii found at least a modest life in the capital aleksandras life was more economically precarious nevertheless she ended the era as an educated professional woman capable of seeking a fashionable cure making her story one of a contested modernity too iii there is almost no precarity in the story of the chikin family in the tsarist erait is at first glance the most straightforwardly successful of all the family stories here as it begins and ends with prosperous merchant industrialistsbut it swerves in surprising ways involving family law and archaic estate 62 o zapiske kosichkina ll 5656ob 63 maya peterson steppes to health how the climatekumys cure shaped a new steppe imaginary slavic review 81 pp 831 64 o zapiske kosichkina ll 5661ob structures in fact it is only due to those archaic estate structures that this is a story of gatchina at all for there is no evidence that any of the chikins ever lived in gatchina itself ivan filippovich chikin was already a merchant registered in vilmanstrand when he transferred his registry to gatchina in february 1868 in a second petition later that year he asked that his wife nastasia ivanova and daughter elizaveta age nine be added to his household 65 for chikin this registry was almost certainly a matter of convenience rather than of close ties to gatchina itself instead he was linked to two different places st petersburg where he at one point held temporary merchant status and the village of daimishche about thirty kilometres south of gatchina 66 in the early nineteenth century daimishche was part of the estate of the noblewoman mariia fedotovna donaurova who purchased it along with several other villages in the area in 1835 she established several new commercial enterprises on her lands including a flour mill a sawmill and a metalworks located on the oredezh river upstream from daimishche itself 67 the metalworks dated to 1842 and chikin may have been the first person to run it although it belonged to donaurova he was known as its proprietor by 1847 68 her son peter mikhailovich inherited the estate in 1852 and sold the metalworks to chikin in 1859 69 or rather he may have sold it to anastasiia ivanova in may 1859 anastasiia ivanova chikina wife of a vilmanstrand and st petersburg temporary merchant was listed as the new owner of a metalworks the land under it to the amount of 170 acres with all of the machines in the factory and all the living residential and nonresidential properties and the dam on the river oredezh purchased with a 16000rouble mortgage to be paid back in six years 70 because tsarist russia had a regime of separate marital property husbands and wives could choose who would be a legal property owner or who would take on a debt considerations of debt may well have been behind the decision for anastasiia to be the legal owner of the factory at this point 71 the chikins seem to have been doing very well at the time they entered the gatchina merchant society their daughter elizaveta was born around the time they became legal owners of the factory at some point they built a manor house chikinonear the factory as well in february 1860 an imperial hunting party stopped at the factory for breakfast 72 in 1866 the factory employed thirtyeight masters and workers and produced 75731 roubles worth of goods 73 at the 1870 allrussian manufacturing exhibition in st petersburg ivan chikin received a silver medal for the quality of his metal wares 74 in 1876 however ivan petitioned the ratusha to bring a significant change to his family over the course of more than thirty years i have had in my possession a copper smelting factory near the village of daimishche in tsarskoe selo district rozhdestvenskii township considering by right this factory to be my own creation the result of many years of my hard work and attention i would like to keep it in my family due to not having sons i have had to find and take in another child to educate my choice has stopped on ivan the young son of anna vasileva a peasant woman from the village of daimishche who i propose to give an education and upbringing appropriate to him taking on the factory business in the future 75 the ratusha investigated the case and met to decide whether to allow the adoption anna vasileva had agreed in the presence of a police officer that she was willing to give chikin all parental rights and duties regarding her twoyearold son so at first they agreed to the plan soon though complications arose in february 1877 chikin was asked to provide a statement that ivan was not his own illegitimate child and then in july of the same year another wrinkle appeared in the case because chikin had a daughter he was not allowed to adopttsarist law stated that only childless couples might adopt children 76 by february 1878 a very different story had emerged ivan filippovich submitted another petition this time asking not to adopt but instead to legitimize his own sons born to anna vasileva ivan and aleksandr aleksandr had presumably been born out of chikins continued relationship with anna in other 72 nikolai kutepov imperatorskaia okhota na rusi konets xviii i xix vek vol 4 p 135nn sergei glezerov predmestia sanktpeterburga byt i nravy nachala xx veka p 498 73 fabriki i zavody v speterburge i spetersburgskoi gubernii v 1866 godu p 40 74 otchet o vserossiiskoi manufakturnoi vystavke 1870 goda v sanktpeterburge prilozhenie p 54 75 o zapisi chikina l 10 76 ibid ll 99ob 1415 16 k shmatkov uzakonenie i usynovlenie detei p 68 words ivan filippovich admitted that he was the father of the two boys and asked that their birth be legitimized even though he was not married to their mother ivans birth certificate showed a yet more complicated set of relationships he had been baptized on 4 february 1874 in st petersburg at the nikolobogoiavlenskii naval cathedral near the mariinskii theatre his godparents were a st petersburg second guild merchants son named dimitrii prokopiev zmeev and an artist of the imperial st petersburg theatres named khristina ivanova rozenshtren 77 perhaps anna and ivan met not in the countryside but in st petersburg around the theatres ivan filippovich also fell from the merchantry to common town status that same year implying either an economic setback or distraction given that he had had two children with a woman other than his wife and that his wife may have been the legal owner of the factory he ran one can only imagine the possible complications that faced the business and his personal life that year after the legitimization was finalized chikin returned to the first merchant guild within the next couple of years though he did go back and forth between the first and second guilds several times before his death in 1892 78 these events may also have caused a permanent rift between ivan and anastasiia in the 1890s she was living in volkovyshki now vilkaviškis lithuania though she still needed to receive documents from the ratusha as the widow of a merchant registered there 79 perhaps her daughter had moved there for work or for a husbands work and anastasiia followed or perhaps anastasiia had taken her daughter away with her after falling out with ivan in any event the boys were formally added to the family on 31 march 1878 their fathers temporary fall into the meshchanstvo caused later problems for ivan ivanovich however because of the persistence of legal estate status in 1881 ivan ivanovich began to study at the gymnasium in tsarskoe selo but when his father looked in to sending him to the commercial school in 1885 they ran into a problem according to the st petersburg provincial administration the school refused to accept him because he as one adopted by chikin when he was in the meshchanstvo does not have the rights of adoption during chikins time in the merchant guild there was a protest and soon thereafter the provincial administration agreed that the two boys should have received the rights of merchants sons when their father regained his merchant status 80 still it was a stark reminder of the role that official legal status still held in individual lives even for the privileged and even in modernizing late nineteenthcentury russia despite that temporary setback ivan and aleksandr fulfilled their fathers wishes and continued to operate the factory after his death in 1892 although ivan failed to send in his guild dues and was demoted to townsman in 1902 it seems to have been a momentary lapse rather than a significant 77 o zapisi chikina ll 20 27 78 ibid ll 20 27 43 79 ibid ll 545 80 ibid ll 3941 downturn in their economic status 81 the factory was listed in guides to russian industry in 1899 and 1912 according to the later guide they had branched out to producing aluminium goods as well the factory employed 217 workers and produced 963000 roubles worth of goods a year 82 the following year the company went public and the new jointstock company was renamed the siverskii metal factories formerly i f chikin 83 the issue may have been that aleksandr left the business in 1914 a manufacturing directory did not list him as among the board of directors ivan was still there and with the move to a different financial footing the company had grown even larger employing 350400 workers and with yearly production of 1500000 roubles worth of goods 84 all this growth did not come without a cost however in 1888 the factory overseer a meshchanin named nikolai iurevskii was found guilty of violating child labour laws in many ways he hired local peasant boys younger than age twelve he kept them at work from six in the morning until eight at night and he put them at work for which they were not properly trained the case came to greater attention when a child labourer lost several fingers in an industrial accident although the court was initially unsure whether to blame chikin or iurevskii in the end iurevskii was sentenced to a fine and a month and a half in jail 85 there is no evidence of further wrongdoing on the part of the factory and the case was unusual enough to get picked up by a st petersburg paper but clearly the companys success was not a storybook one the lack of oversight may have come about because ivan filippovich was distracted around this time at least several later sources mention a woman named ekaterina ivanovna chikina born in 1886 and linked to the factory 86 given the ages of the two ivans in this family story she must have been the child of the elder and the sister of the younger who her mother was is unclear anastasiia had given birth around 1859 which means it would have been technically possible for her to have had another child in 1886 she was living elsewhere by the 1890s however so it seems unlikely it is more likely that ivan filippovich had another child with anna vasileva or another woman in any event the arrival of a new child in his waning years could easily have pulled his mind away from business 81 ibid l 65 82 vsia rossiia russkaia kniga promyshlennosti torgovli selskogo khoziaistva i administratsii vol i ivan ivanovich eventually moved to st petersburg around 1907 first to a building on the fontanka and then around the corner to 6 nikolskii square a handsome area near the mariinskii theatre and the griboedov embankment and the church in which he had been baptized 87 chikino the family estate near the factory was still part of the brothers lives however and attracted visitors including reportedly the great operatic bass fedor chaliapin fishing was a great lure for the estate had a special fish hatchery where they cultivated trout the writer aleksandr kuprin apparently used a holiday trip to chikino as the setting for one of his short stories in it he describes being invited to see a christmas tree and no ordinary one instead it was to be a living tree in the forest decorated with electric illumination as modern as modern could be 88 vladimir nabokovs family had several estates along the oredezh too and the woods of the area gave him some of his earliest memories including his first forays into lepidoptery perhaps the two families interacted 89 the end of the tsarist era first brought even more success to the chikin family because their business profited from the first world war even before it began they were doing well both the company board and ivan chikin separately donated funds to the war effort in 1914 90 but then the war brought even more business and even greater economic success the companys archives include correspondence with military authorities and armaments factories and references to producing grenades 91 as a result the chikin brothers probably ended the tsarist era in as prosperous position as they could be the revolution though must have shattered their lives what happened to ivan and aleksandr is unclear scattered poorly referenced internet sources claim that aleksandr at least died in 1917 but there are few other traces of either man neither was still listed in the new leningrad city directory in 1926 though one or both may have retreated to chikino or emigrated or been killed what happened to their sister ekaterina ivanovna may however give a different vision of a possible fate for such a family in 1909 she married a man named aleksandr anatolevich pushkin the greatnephew of the famous russian poet and soon had two daughters and a son aleksandr died fighting against the bolsheviks during the civil war and in 1919 ekaterina left chikino and went to narvaabout to be in newly independent estonia after the second world war ekaterina and one daughter ended up first in a displaced persons camp in germany before emigrating to picton ontario ekaterina lived there with her daughter until the age of 104 reading russian novels and watching soap 87 vp 1907 vol iii p 724 vp 1911 vol iii p 975 vp 1912 vol iii p 984 88 glezerov predmestia sanktpeterburga p 498 89 brian boyd vladimir nabokov the russian years pp 447 6885 90 russkii invalid 2 apr 1915 supplement 91 tsgiaspb f 1224 operas most of which must have paled in comparison to the upheavals of her own life 92 iv if the chikin family story was one of more or less continuous success in trade and then a sudden diversion the shubin story involved peasant origins and a life changed through education in 1851 a woman named fekla egorova shubina registered in gatchina as a meshchanka along with her four children gavrila egor pavel and ekaterina 93 all but pavel had been enserfed peasants from the village of rozh d estveno thirty kilometres to the south owned by a nobleman named efremov and very close to daimishche and the chikin factory already this is a story with less prosperity at the start than even that of the kosichkins also originally serfs for entry into the meshchanstvo simply required freedom not any financial status that would suit a family for the merchantry unlike the kosichkins somehow the shubin family got itself freed a decade or so before emancipation possibly upon their owners deathin 1853 his heirs put the entire estate up for sale 94 their manumission document showed that they had been freed in a family group along with feklas husband petr and motherinlaw avdotia but those two had either died or chosen to register elsewhere after manumission pavel was born after the family received their freedom 95 there is scant information about most of the family but their place of origin suggests some possibilities rozhdestveno as it is now known had a long history with gatchina it had been a town in the eighteenth century but shortly after paul elevated his own village of gatchina to town status he turned rozhdestveno into a village as a result the merchants and townspeople of rozhdestveno found themselves legally registered in gatchina 96 in 1838 there were 194 gatchinaregistered merchants and townspeople living in rozhdestveno alongside 592 peasants 97 the family may well have remained in rozhdestveno after registering in gatchina fekla at least lived another quarter of a century as a townswoman dying only in 1878 at the age of seventytwo at least some of her children had long been married by that point given the proximity of rozhdestveno and daimishche perhaps some of the children or their descendants even ended up among those hired to work in the chikin factory gavrila the oldest of the four children included in the initial registration had at least one daughter born in 1862 and two sons fedor and nikolai the two sons in particular had distinctly different fates the younger nikolai appears to have been in trouble with the gatchina police in 1891 when they are recorded as looking for him but apparently that trouble passed the archival file includes his passport from 1898 he was at that point thirtythree worked in trade and had a daughter varvara then aged five the passport also represents a family tragedy its original form notes that nikolai was married to a woman named mariia illarionova but pencilled marks have her name crossed out and widower added above his marital state the back of the passport includes her death notice signed by a priest she died only weeks after nikolai received the passport 98 his seems to have been a story of trouble in his early twenties then settling into a modest married life altered by a family tragedy fedor on the other hand led a life transformed by education in 1881 he began to study at the imperial st petersburg historicalphilological institute a postsecondary institution founded to train teachers 99 he would have been one of the very first to train there as a teacher of geography a course that was only added to the programme in 1882 100 he graduated in 1885 and left the gatchina commune when it agreed to exclude him from their ranks so that he could enter state service as a teacher 101 his first job at the vologda gymnasium gave him not only a job but a formal rank in the state bureaucratic system initially he taught both history and geography there must have been challenges for him as a young teacher he was the son of a serf but most of his students 69 per cent of the entire school body in 18867were of noble background 102 nonetheless he seems to have done well there at the end of 1890 he received an award for his service as a teacher at the vologda gymnasium the order of st stanislaus third class 103 fedors success in vologda likely helped him return to st petersburg in 1892 he began to teach at the larinskaia gymnasium on vasilievskii ostrov and for the next two decades he worked at a series of different secondary schools around st petersburg often more than one at a time as a geography 98 o zapisi shubinoi ll 38 5151ob 99 teacher 104 at various points he taught at the larinskaia gymnasium the elizavetinskii institute and the pavlovskii institute in 1895 he took a post at his alma mater the historicalphilological institute as a head tutor of geography and two years later he also began to teach at the gymnasium affiliated with the institute 105 at the same time he rose through the ranks of the state bureaucracy in 1893 he held the rank of court councillor 106 on 1 january 1895 he was given the order of st anna third class and at some point in 1894 or 1895 he was promoted one rank to collegiate councillor 107 by 1898 fedor had been promoted yet again to state councillor 108 he may have had a setback around 1900in the city directory for that year he is listed as holding the rank of collegiate councillor again and only teaching at the larinskaia gymnasiumbut either that was an error or he was back on track by 1901 in that year he was again listed as a state councillor and teaching at three different schools 109 fedor moved house several times but consistently lived on vasilievskii ostrov near several of his places of work in 1894 he lived at no 15 6th lineon the premises of the larinskaia gymnasium by 1896 he had moved to no 30 7th line apparently renting a room or rooms from ivan and sofiia miliugin and in 1900 he lived at 19 malyi prospekt renting from the merchant shmuilo movshevich kibalskii 110 as of 1903 he had moved just down the street to no 21 perhaps because he needed more space for a new expanded household in 1903 evgeniia nikolaevna shubina wife of a state councillor lived there too 111 in 1907 they had moved to a new apartment on the 14th line no 33 fedor was still teaching at several schools now including the vasilevskii ostrov womens gymnasium evgenia now also had an occupation listed masseuse 112 in 1911 evgeniia nikolaevna had either moved out or moved her place of practice to 42 petergofskii prospekt 113 the following year however both had moved to a new address back on vasilevskii ostrov back to the premises of the larinskaia gymnasium 114 the shubins took part in the wider world of voluntary associations then developing in the capital 115 at the time they married evgeniia was a member of the society for the protection of young girlsan antisexwork philanthropic society fedor meanwhile not only taught geography but also published several short pieces and gave public talks on the subject possibly through his longstanding membership in the imperial geographic society 116 that membership may even have led him to one of his apartments the building on the 14th line was owned by evgeniia mikhailovna semënova her husband was dmitrii petrovich semënovtianshanskii who was at this point not only a member of the society but the president of its statistical bureau as well as a state servitor and member of the st petersburg town duma 117 fedor was also a longstanding member of a mutual aid society the burial account associated with the st petersburg pedagogical mutual aid society in 1895 he served as its treasurer 118 one might assume that he was also part of the larger mutual aid society but that may not have been the case given what seem to have been his political leanings the society leaned left discussing not only the material wellbeing of teachers but larger questions of civic activism 119 fedor however had a distinctly conservative bent in 1907 he spoke at a meeting of a wouldbe right block that tried to unify three rightleaning parties including the notoriously antisemitic union of the russian people fedor clearly sympathized with the unions extremist views in his speech he blamed jews for all of the ills facing the empire according to a newspaper account of the meeting his speech was not well received by the audience with workers in attendance in particular trying to shout him down 120 he must have felt increasingly ill at ease in the revolutionary capital perhaps that is why fedor made a huge move in summer 1912 when he took on the initial directorship of the omsk teachers institute 121 this was a bold decision accepting not only a job with significantly more responsibility than he had previously held but also one in a very different place a colonial boom town omsk had been growing extraordinarily quickly as interest in settling siberia developed along with the transsiberian railway it swelled from 37470 residents in 1897 to 133280 in 1912 122 the teachers institute was a new school founded to help meet the growing demand for teachers in the wider region 123 the number of schools in the four regions of western siberia increased 167 per cent between 1894 and 1910in akmolinskaia oblast alone the increase was even higher from 123 schools to 432 in keeping with the growing population of siberia they served ever more students 4353 in 1894 up to 27171 in 1911 124 the move seems to have been a success for fedor the new school in omsk was tiny at firstit lacked its own building so held classes for its initial group of twentythree students in rented rooms it nonetheless had the potential to make real change in their lives those students came from varied backgrounds ten were peasants by origin five townspeople five cossacks the remaining three came from privileged backgroundsone from the church one from the bureaucracy one from the nobility the students were not yet able to take part in practical activities because omsk did not yet have a secondary school this was scheduled to open the following year 125 more students came however and fedor worked to move the institute into better quarters and to get more teachers in budgeted positions one of the students at the institute e g beimanpautova remembered him well describing him as an erudite man a scholar … we loved his interesting lectures he had apparently travelled a lot and he always so clearly vividly and concretely described the countries where he had been 126 on 1 january 1915 fedor was elevated in rank once more to actual state councillorthe fourth rank which brought with it hereditary nobilitythe best security possible for an upwardly mobile subject of the tsar and a definitive recognition of his having transcended his fathers birth in serfdom 127 of course this was also only shortly before the entire system in which he had succeeded came crashing down around him while the first world war probably brought profits to the chikins it created nothing but problems for fedor in 1915 he began to send reports noting that the cost of living in omsk had skyrocketed since the start of the war which meant that students in particular were hit hard living as they did on meagre stipends he continued to write to authorities seeking better funding for his students 128 and then for fedor the end of the tsarist system that had brought him nobility clearly brought fear rather than hope in 1917 first the tsarist government fell and next the bolsheviks seized control bringing civil war to the empire omsk turned out to be at the centre of one of its fronts the famed and feared white general aleksandr kolchak based his alternative russian state in the town given shubins political leanings he may well have supported kolchaks regime clearly too shubin knew that the bolshevik regime would bring him nothing good and took steps to avoid it on the day kolchak left the city in 1919 fedor committed suicide shooting himself in his office at the institute much to the shock of students and staff129 v the history of the russian empires nineteenth century has often been written with a consciousness of its end in revolution and therefore a focus on factors that either led to revolution or failed to prevent it the collapse of the soviet union made that narrative seem less pressing and instead scholars have come to focus on the russian empire among other empires or on topics that seem far removed from the revolutionary world the family histories here demonstrate how difficult it is however to write the history of the nineteenth century without the revolution as an end on one level it should not be hard there is little in these family histories that hints at the coming end of the tsars most of the individuals seem to have been simply living their lives affected by tsarist social regulation but generally not in ways that troubled them politics only show up once and in a conservative not revolutionary form but the fact that i have only been able to find traces of two of these many individual subjects of the empire after the revolution and have uncovered the shocking death of another during the civil war shows the ways in which the revolution was a true disruption in everyday lives that resonated even in documents themselves the new soviet state abolished sosloviiaan act that removed privileges and restrictions based on birth and also changed the ways that lives were documented there will certainly still be records for some if not many of the kosichkins the chikins and the shubins in archives or elsewhere but the ruptures of the revolution have detached them from their tsarist past these histories also show the ways in which the russian empire fits awkwardly into general narratives of europes long nineteenth century and not only because its final cataclysm brought even greater change than the first world war did elsewhere those narratives generally involve both a transformation of technology and culture and also a shift away from a world of autocracy and rigid social stratification to one of greater democracy and the rise of the middle class 130 the russian empire saw many of the global changes of the nineteenth century railways new art forms advertising and striking workers and as these family histories show it had middleclass people of all sorts 131 at the same time however it retained many features that seemed obsolescent if not downright archaic it both started and ended the century long or not as an autocracy it both started and ended with social estates that placed restrictions on individual lives it both started and ended as an empire 132 as alexander martin noted in a roundtable dedicated to the question what is the nineteenth century in russian studies this could be read as meaning that russia skipped the nineteenth century entirely moving from an eighteenthcentury old regime directly to the twentieth century or it could mean that it was a century of coexistence of what were distinct eras in other parts of europe 133 in the histories of the lifantevs the kosichkins the chikins and the shubins this coexistence comes through clearly the very origins of their stories as reconstructed here are in the demands of the archaic structure of social estates individuals came up against the limits of that structure in requests to be allowed to go to school or to leave their status to take on a new professional life they also made use of the potential benefits of that structure in requests for charity some of which were met at the same time the individuals in these families all reflected the wide range of lives possible in the empires middling classes industrialists made more wealthy by new technologies and the engine of war trading merchants teachers bureaucrats clerks tavern keepers lowwage workers looking at these individuals as part of family histories also gives a sense of the larger picture of the nineteenth century only the chikin story is a clear and obvious tale of family success and prosperity but as it begins with prosperity it is hardly a bootstrapping narrative like those popular at the time 134 nor do any of the histories represent a buddenbrookslike tale of bourgeois degeneration though that concept too was part of late imperial discourse 135 instead the family histories reflect the ways in which russias nineteenth century saw archaic and modern institutions and trajectories coexisting there is one final question to take from these stories of everyday lives in tsarist russia their sudden end in revolution is surely particularly russian but what else about them is or to put it another way is the fact that actual family histories do not quite align with either fictional or historians visions of the nineteenth century a peculiarity of russia or something that might hold true in any effort to recreate life stories in this way in her recent exploration of the history of a family in france over the long nineteenth century emma rothschild finds many similar features prosperity and precarity more success through state or church service than through the market she describes this as a history that is disconcerting … in relation to large presumptions about modern times 136 perhaps this would be true in most efforts to trace out real lives few if any grand narratives and instead a multiplicity of variants of the experience of the century competing interests the author declares none twilight of realism pp 1532 daniel beer renovating russia the human sciences and the fate of liberal modernity 18801930 136 emma rothschild an infinite history the story of a family in france over three centuries p 12 cite this article smith ak prosperity and precarity in imperial russias long nineteenth century the historical journal 66 10531078

this article looks at four families living in and around the small town of gatchina not far from st petersburg russia in the long nineteenth century their family histories are recreated from archival files based in tsarist russias system of social estates soslovie supplemented by city directories newspapers and many other sources taken together the four family histories expand our understanding of tsarist russias middle classes in two ways first they highlight the role that women played in families as economic actors and as agents of their own destiny second they demonstrate the role that social mobility did and did not play in maintaining families across the long nineteenth century in addition they demonstrate some of the ways in which the russian empires experience of the nineteenth century differed from a standard eurocentric narrative in particular in the way that archaic and modern worlds existed simultaneously hundreds of files sit in the archives of the tsarskoe selo ratusha holding thousands of documents that trace out the lives of individual subjects of the russian empire over the course of the long nineteenth century 1 the ratusha was an institution of the tsarist system of social estates sosloviia according to which every individual had an official status registered in a specific place as a member of a specific social group a peasant from a particular village a merchant from a particular town a noble from a particular province 2 the documents in the files therefore illuminate moments when that registry mattered in the lives of individuals when they changed their registration when new family members were born died or married when they needed an

19884_0

introduction and short literature review recently much has been written in academia about social media undoubtedly these inexpensive and userfriendly online platforms became extremely popular and widely used around the world with billions of users worldwide we live in a post mass media society where a large part of the population relies on those online applications to get information 1 naturally the popularity of social media has also captured the attention of public administration and different levels of government by allowing their users to generate and share original content within very large and relatively diverse networks social media have opened the door to realtime interaction between public sector officials and citizens 2 understandably this has brought some expectations to improve public administration different levels and sectors of government and more broadly democracy as well amid reports of a steady increase in the last decades of citizens discontent with democratic institutions 3 4 it seems that social media can play an important role in the future of our societies by promoting together with other icts a culture of receptiveness and transparency in public organizations and political institutions 5 indeed under certain conditions the internet and social media can contribute positively to political participation 6 even though despite this recognized capacity they can as well lead to the exact opposite effect 7 in the end this perceived potential of social media to mitigate important challenges in established democracies make the study of the adoption and usage of those platforms by political and public organizations extremely relevant in this paper we focus on social media use by local government regardless of the reasons behind their adoption and use a large number of local governments are nowadays incorporating social media in their communication repertoire 8 the study of local government use of social media has been mainly focusing on frequency of use and levels of citizens engagement with the messages 9 much less attention has been paid to a what are the types of social media adopted by the municipalities and b the communication strategies of the municipalities for those platforms this paper addresses precisely those two untapped aspects of social media use by local governments offering an empirical contribution to the former and providing an initial discussion and hypotheses for the latter there are two fundamental assumptions or social media aspects guiding this study the first one is that there is a great amount of uncertainty in both using and adopting those platforms regarding their use differently from mainstream media the reach and impact of the content generated on social media is extremely uncertain as castells 10 nicely puts it communication on social media is like casting a message in a bottle into the ocean any message can either go viral or unnoticed in the massive ocean of information called cyberspace in other words institutions cannot fully control the visibility and impact of their online communication the uncertainty in the adoption of social media concerns the fact that institutions have an extremely vast and growing catalogue to choose from it is difficult to foresee which applications will become popular and persevere and which ones will abruptly end for this reason institutions must choose carefully those applications especially since being active is a key requirement for their success 11 the second important aspect of social media is that those online applications can be quite distinct in fact the only common aspect shared by all of them is the fact that differently from internet forums they are structured or built around people rather than topics 12 however they can be public semiprivate or private and they differ regarding the type of content that they allow its users to generate and share depending on the type of content allowed on those platforms the costs of adopting a particular social media will vary as well as a consequence not only the users of those platforms vary considerably in terms of volume and characteristics but also partially as a consequence of that social media can be used in different ways and for different purposes it is normal for institutional actors to give different uses to different social media 13 overall besides focusing on usage levels it is important to take a step back and understand why municipalities adopt a particular type of social media while there are relevant benefits from using them the risks associated with their use are equally important the goal of this paper is precisely to explore what factors explain the adoption of a particular social media by the portuguese local governments research question hypotheses and methodology this papers research question is what are the determinants of social media adoption by the portuguese local governments even though our main research hypotheses derive from the literature this study at this stage has a strong exploratory component we investigate this research question by looking at three of the most internationally popular social media facebook twitter and youtube our three dependent variables are dichotomous measures for whether a municipality has a facebook twitter and youtube account additionally a fourth dependent variable is included to assess the presence of municipalities in alternative social media platforms besides those three main ones all variables refer to 2016 concerning our research hypotheses and independent variables the use of social media by different organizations is often associated with efforts to increase both transparency and citizens participation and collaboration with those organizations since it allows dialogic communication 14 indeed studies have found a positive relationship between social media usage levels and the municipalities commitment to transparency 8 9 we therefore expect those two motivations to be associated with the adoption of different social media more concretely we expect that h1 municipalities with higher commitment to participation are more likely to be present on social media h2 municipalities with higher commitment to transparency are more likely to be present on social media in this study we have two variables measuring the municipalities commitment to participation and transparency the former is measured by a dummy variable called participation coded 1 if the municipality has been conducting participatory budgeting initiatives and 0 otherwise commitment to local government transparency is measured with an index ranging from 0 to 100 based on an assessment of the information provided in municipalities websites 15 even though creating a social media account is an easy and usually costless process being active on them which is a crucial aspect for the success of the online communication of any organization is not as easy or straightforward an effective use of social media requires the allocation of important resources in fact lack of resources can be a factor hindering local governments use of those platforms 16 17 this factor is particularly important in the case of less popular social media with higher costbenefit and the ones that only allow more elaboratedcostly content therefore we expect that h3 municipalities with higher administrativeeconomic capacity are more likely to adopt social media particularly the less popular or costlier ones administrative capacity is measured with two different variables the first one is the number of local government employees the second is the proportion of own revenues raised by the municipalities two other aspects examined in this study are the political setting and the media landscape of the portuguese municipalities concerning the first one we expect political participation and political competition to have an effect on municipalities adoption of social media citizens use of social media and political behavior should be positively correlated 18 and political competition should also affect positively governments commitment to transparency and disclosure of information 19 20 21 for this reason we expect that h4 the higher the level of political participation and political competitiveness the more likely municipalities will be to adopt different social media platforms political participation is measured by the average turnout in the last three local elections similarly political competitiveness is the average margin of victory in the last three mayoral elections we use an average of three elections in order to capture longlasting trends of these two variables regarding media landscape we employ the number of local radios and newspapers in the municipality the goal is to explore a possible relationship between the local media environment and the use of social media we expect that local governments might rely more on different social media when the number of local media outlets is lower finally we include a set of control variables in the estimations population size level of education number of parishes proportion of foreign population purchase power and latitude results concerning the adoption of different social media by the portuguese municipalities our analysis shows that facebook is by far the most popular social media platform as displayed in table 1 85 of all portuguese municipalities had in 2016 an official facebook account the second most popular social networking site was youtube more than half of the portuguese municipalities had an account in this platform with respect to twitter only 36 of the municipalities used this platform finally around 33 of the 308 portuguese municipalities had accounts in some other social media applications that were not one of the three majors the results of the logistic regression analyses are presented in table 2 odds ratios and robust standard errors are reported or higher than one indicate a positive relationship between the variables contrarily or lower than 1 imply a negative relationship between variables the only difference between the four models is the dependent variable the first model investigates the adoption of facebook since a large number of municipalities have adopted this platform nothing very relevant can be taken or interpreted from these results the only variable that is statistically significant is latitude which measures the geographical location of the municipality in the country the results suggest that municipalities from the north are less likely than the ones in the south to have a facebook account overall we can just say that facebook is widely popular among portuguese municipalities the results become far more interesting when we look at the other less popular social media sites in the case of twitter five variables display statistical significance again municipalities from the south are more likely to use twitter indeed this was a consistent finding across all dependent variables suggesting that municipalities from the north of portugal are less likely to adopt social media compared to their southern counterparts in addition to that the results show that municipalities more committed to participation initiatives are almost twice as likely as the others to have a twitter account besides that municipalities with a higher number of parishes with more economic resources and more employees are also more likely to be present on twitter overall our analysis shows that twitter is not a popular platform among portuguese local governments and that its adoption is positively associated with the municipalities resources and commitment to engage with the citizens however it is also possible that the use of twitter is not a direct consequence of municipalities wanting to engage citizens but rather a consequence of their efforts to get more visibility to specific eparticipation initiatives the results for youtube are similar to the ones we found for twitter there are only two exceptions the first one is that the difference in participation is not statistically significant the second one is that population size becomes statistically significant with a negative coefficient this means that municipalities with larger populations are less likely to adopt youtube overall these results further confirm that when it comes to the adoption of social media human and financial resources are important for municipalities to venture on alternatives to facebook indeed we can say that having less resources hinders local governments from being present on less popular social media finally when it comes to alternative social media we also get very interesting results the first one is that participation is significant the municipalities with participatory budgeting initiatives are about 70 more likely to have an account in one alternative social media again it might be the case that rather than using them to interact with citizens municipalities are simply trying to expand their online communication channels to give more visibility to those initiatives the municipalities resources are an important factor to explain presence in alternative sns the number of parishes population size the percentage of foreigners and latitude are also statistically significant in the case of population foreign population and latitude their or is lower than 1 meaning that the relationship between the variables is negative however what is perhaps more interesting in this last model is the statistically significant and negative relationship between local media and the adoption of alternative social media to put it in other words municipalities with a higher number of local radio stations and newspapers are less likely to adopt alternative social media this suggests that perhaps portuguese local governments rely on social media to circumvent some limitations to inform their citizens conclusion there are important limitations in this paper due to the fact that it is an ongoing research in specific the nature of our dependent variables does not allow us to explore shortterm factors such as the characteristics of mayors and executives and the institutional configuration of communication departments inside municipalities these are factors that indubitably might play an important role in the adoption of different social media and that allow an indepth study of the determinants of social media adoption by portuguese local governments therefore we exclusively focus on longterm less mutable variables nevertheless our study revealed important aspects regarding the adoption of those platforms by local government and provides grounded clues for further research and methodology perhaps the most important or at least consistent finding of this study was that resources and local government capacity matter and they seem to matter a lot that was the only hypothesis that the quantitative analysis fully confirmed we knew already from previous studies that resources matter for usage levels now we also know that these are important factors for the adoption of less popular social media contrarily political aspects do not seem to affect the adoption of those platforms overall this study suggests that portuguese municipalities are indeed aware of the risks involved in adopting social media they are more likely to adopt more alternative platforms when they have resources to guarantee their successful use we also found that while commitment to transparency does not have any impact on social media adoption municipalities that have participatory budgeting initiatives are more likely to have accounts on alternative less popular platforms we can however interpret this result in two different ways it can indeed be that these alternative sns are more suitable to engage citizens since there is an understanding that twitter is more suitable for sharing ideas while facebook is used for leisure or networking however it can also be that these municipalities are simply using a larger variety of online applications to promote their participatory budgeting initiatives further analyses must be conducted to better investigate these two hypotheses this is indeed the next step of this project that aims with a multimethod approach to better understand the use of social media by local government one final aspect worth mentioning is that we found that municipalities from the north of portugal tend to be more conservative when it comes to social media adoption a difference observed even for the most popular application facebook this is interesting since the north is also more conservative when it comes to local politics and the importance of religion when it comes to the adoption of new communication channels we can say that southern municipalities seem to be trendier than their counterparts in the north 5

what are the determinants of social media adoption by local government this ongoing research provides a tentative answer to this question by analysing the 308 municipalities in portugal extending previous analyses of facebook andor twitter usage levels we examine why local governments adopt a particular social media platform more concretely we explore with statistical analyses the determinants of the adoption of different types of social media we investigate the adoption of three extremely popular social media ie facebook twitter and youtube as well as possible alternatives to those more popular applications since these platforms have distinct natures and can serve diverse purposes we examine to what extent aspects such as local governments commitment to transparency and participation administrative capacity media landscape and sociodemographic and economic factors can explain the adoption of social media platforms the results show that indeed demographic characteristics and administrative capacity are important factors for the adoption of less popular social media surprisingly we also observe a geographical difference in municipalities social media adoption with the south in this regard being trendier or more innovative than the north

19885_0

introduction cardiovascular disease has remained the leading cause of death and disabilityadjusted lifeyears globally over the last 20 years and is killing more people than ever before especially in the western pacific region 1 in china two out of five deaths are attributed to cvd 2 and the rapid ageing of the population further exacerbates the burden of cvd 3 evidence indicates that the deaths from cvd among elderly individuals in china increased by 251 from 1990 to 2019 4 and the burden is compounded when the elderly individuals have one or more cardiac diseases 5 additionally with the rapid changing of chinas socioeconomic structure socioeconomic disparities have contributed to new patterns in cvd prevalence 6 therefore it is crucial to comprehensively understand the epidemiology and socioeconomic characteristics of cvd among the elderly population in china to identify the key issues to be addressed and what is already known on this topic ⇒ there are limited studies examining the temporal trends and regional variations in cvd among the elderly population in china ⇒ socioeconomic status plays a significant role in the occurrence of cvd however with the rapid changing of chinas socioeconomic structure it remains unclear on socioeconomic inequality and its temporal trend concerning cvd among the elderly population in china ⇒ cardiovascular disease has remained the leading cause of death and disabilityadjusted lifeyears in china and the burden of cvd is even greater among the chinese elderly population bmj global health to implement evidencebased health strategies to effectively alleviate the substantial burden of cvd in china although some studies have estimated the prevalence of cvd in china most of them have only provided agestandardised data without specifically addressing the cvd situation among the elderly population 3 6 7 as for those analysing cvd among elderly individuals in china the results have limitations in terms of analysing comorbid cardiac diseases exploring temporal trends and capturing regional variations within the country 8 9 moreover while studies suggest that socioeconomic status plays an important role in the prevalence of cvd 10 the existing studies conducted among chinese elderly individuals focused on the relationship between ses and overall health status 11 12 it remains unclear about the socioeconomic inequality and its secular trend concerning cvd among the chinese elderly population to address the gap we used data from the china health and retirement longitudinal study a nationally representative resource to explore the temporal trends in cvd prevalence to investigate the regional variations and socioeconomic inequalities and to evaluate the association between pivotal demographic factors and incident cvd in china from 2011 to 2018 methods data sources and participants the charls is a nationally representative longitudinal study beginning in 2011 that was designed to provide reliable data for understanding the health status and socioeconomic determinants of individuals over age 45 in china 13 employing a consistent multistage stratified probabilityproportionatetosize sampling strategy samples with national representativeness were selected from 28 provinces in china and then were followed every 23 years 14 three followup surveys were conducted in 2013 2015 and 2018 in each followup survey the original participants were revisited and new participants were selected using the same methods mentioned above to make up for people who dropped out and ensure representativeness data were collected via onetoone interviews with a structured questionnaire and the overall response rate of the charls was 805 a detailed description of the charls has been reported elsewhere 15 the sample selection process is outlined in figure 1 participants were initially extracted from each charls survey wave conducted in 2011 2013 2015 and 2018 missing age and sex data were subsequently imputed using information from other survey waves then in each survey wave individuals were excluded if they had missing age and sex data or if they were aged 60 years furthermore participants with missing cvd data across all survey waves were excluded with any gaps in cvd data filled using information from previous survey waves figure 1 the flow chart of recruited participants for the analysis these participants were not eligible for cohort analyses cvd cardiovascular disease what this study adds ⇒ this is the first study to examine the temporal trends and regional variations in cvd especially comorbid cvd among the elderly population in china we found that there was a significant increase in the ageadjusted and sexadjusted prevalence of cvd and comorbid cvd among the elderly population in china from 2011 to 2018 and the prevalence and changing patterns of cvd and comorbid cvd varied widely among provinces ⇒ this study provides valuable insights into the interplay between ses and cvd prevalence among the chinese elderly population cvd and comorbid cvd tended to be more common among the elderly with higher ses and socioeconomic inequalities were persistent but narrowed from 2011 to 2018 ⇒ this study offers a unique opportunity to evaluate the associaiton between key demographic factors and cvdcomorbid cvd this assessment is particularly valuable given the significant demographic shifts that have transpired in china over recent decades how this study might affect research practice or policy ⇒ more efforts should be taken to optimise the strategy and provide highquality healthcare to prevent and manage cvd for the elderly population in china bmj global health when available finally a total of 5451 7258 8820 and 11 393 participants were eligible for inclusion in the crosssectional analyses examining cvd prevalence temporal trends regional variations and socioeconomic inequalities to examine potential biases due to exclusions related to missing data on cvd a χ 2 test was employed to compare the socioeconomic distribution between excluded and included participants a significant difference existed between the two groups except for the socioeconomic distribution in 2011 considering the potential nonresponse biases stemming from the different distribution between the excluded and included participants we applied individual weights with the household and individual nonresponse adjustments provided by the charls to ensure the generalisability of the estimates to the targeted population measures cvd encompassing a class of diseases predominantly contributes to the mortality burden with heart disease and stroke being the primary causes 16 information regarding heart disease and stroke in the charls was collected through the following questions have you been diagnosed with heart attack coronary heart disease angina congestive heart failure or other heart problems by a doctor and have you been diagnosed with stroke by a doctor in this study we defined cvd as the presence of at least one diagnosed condition of heart disease or stroke and defined comorbid cvd as having been diagnosed with both heart disease and stroke health regions refer to legislated administrative provinces defined by the state council of china to administer and deliver healthcare services to all residents the charls was conducted in 28 out of 34 provinces of china previous studies mostly used education consumption income and occupation to construct ses 17 18 19 considering the studys focus on participants aged ≥60 years the majority of whom were retirees we employed education and consumption as indicators to measure ses education was used as a proxy for conveying a degree of social status and consumption was used as an indicator of economic status 19 in the charls education was harmonised according to the 1997 international standard classification of education codes 20 and coded as three categories corresponding to less than lower secondary education upper secondary and vocational training and tertiary education as for consumption we used the monthly per capita household consumption as the metric data on household consumption were collected from various sources including both food consumption in the past month and nonfood consumption in the past year as investigated in the charls monthly household consumption was calculated by aggregating these data thereafter monthly per capita household consumption was derived by dividing monthly household consumption by the number of individuals residing in each household for analytical purposes monthly per capita household consumption was stratified into quartiles for each survey wave with 14 representing the lowest to the highest following the methodology employed in previous studies 21 22 we constructed ses using a composite score that summed education levels and monthly per capita household consumption quartiles this approach assumed exchangeability between education and monthly per capita household consumption the summed score ranging from 2 to 7 was used to represent ses with smaller values indicating lower ses to further enhance the efficiency of analyses we categorised the summed ses score into four groups low 2 lower middle 3 4 upper middle 5 6 and high ses 7 statistical analyses the statistical analyses were conducted by using stata a twotailed significance level of less than 005 was considered statistically to enhance comparability across diverse subgroups and survey waves ageadjusted and sexadjusted cvd prevalence was calculated through direct standardisation to the 2010 china census population using the joint age and sex groups 23 aligning prevalence estimates with the demographic structure of the entire population temporal trends in cvd prevalence were assessed using multivariable poisson regression analysis 24 25 26 involving adjustments for age and sex in different configurations we adjusted for age and sex simultaneously for overall participants as well as independently adjusted for age within each sex group and for sex within each age group p values for trend were then calculated using the contrast postestimation command in stata temporal variations in regional cvd prevalence from 2011 to 2018 were quantified by computing the difference between the prevalence in 2018 and that in 2011 for each province socioeconomic inequality in cvd was assessed using the concentration index a recognised metric with the dual capacity to reflect health indicators within distinct socioeconomic strata and to adeptly capture shifting inequality trends over time 27 28 29 30 31 the concentration index ranges from 1 to 1 with negative values indicating a higher prevalence of cvd among lower ses groups and positive values denoting concentration among higher ses groups while 0 suggests no sesrelated inequality to visually represent the concentration index we employed the concentration curve which plots cumulative cvd prevalence against the cumulative proportion of the population ranked by ses 28 when the cc lies below the equality line it signifies elevated cvd prevalence among higher ses groups 28 31 the concentration index and cc were computed using the conindex command in stata a joinpoint regression analysis was employed to assess significant changes in socioeconomic inequality trends for cvd prevalence by estimating the average annual percentage change of concentration indices 32 33 the changes in concentration indices bmj global health were determined through permutation test and p values and the 95 ci by monte carlo method 32 33 34 we conducted a cohort analysis to assess the cvd incidence and explore the effects of pivotal demographic factors on cvd from 2011 to 2018 the set of factors investigated in this analysis included age gender region and ses participants without baseline cvd diagnosis and comorbid cvd were longitudinally followed up throughout 2013 2015 and 2018 to track the incidence of cvd and comorbid cvd the incidence density of cvd and comorbid cvd was calculated accounting for participants who remained in the study for all survey waves we employed a generalised estimating equation to examine the temporal association between baseline exposure factors and new cases of cvd and comorbid cvd identified in subsequent survey waves 35 considering provinces with 0 prevalence of comorbid cvd we used firths penalised likelihood logistic regression to reevaluate the association between exposure factors and incident cvd 36 and performed a sensitivity analysis to compare the outcomes of firths approach with those of gee the absence of statistically significant differences between the two methods reaffirmed the stability and reliability of the associations patient and public involvement the data analysed in this study were exclusively sourced from the charls conducted by the china national development research institute of peking university patients or the public were not involved in the design conduct reporting or dissemination plans of our research stringent measures were applied to safeguard data confidentiality and anonymity ethical protocols were strictly followed to protect participant privacy with analyses conducted on aggregated and anonymised data the findings of this study have important implications for the public as they highlight the need for enhanced strategies and highquality healthcare to prevent and manage cvd among the elderly population in china results in total of 5451 7258 8820 and 11 393 participants aged ≥60 years were included in crosssectional analyses in 2011 2013 2015 and 2018 respectively the largest age group was those aged 6069 years the sample size and characteristics of the study sample by age group and sex for each survey wave were presented in online supplemental table 2 a total of 4392 and 5396 participants at risk in 2011 were included in the cohort analyses the cvd prevalence and trend analysis at the most recent wave in 2018 the overall crude prevalence of cvd and comorbid cvd was 3121 and 383 respectively the ageadjusted and sexadjusted prevalence of cvd and comorbid cvd overall and by age group and sex was shown in figure 3 the overall ageadjusted and sexadjusted prevalence of cvd and comorbid cvd was 3101 and 379 in 2018 respectively and both of them tended to be higher among women additionally in 2018 the adjusted prevalence of cvd and comorbid cvd was the highest among participants aged 7079 years followed by the adjusted prevalence among participants aged ≥80 years from the baseline 2011 to the most recent 2018 survey wave there were statistically significant increases in the ageadjusted and sexadjusted prevalence of cvd and comorbid cvd temporal trends in the ageadjusted and sexadjusted prevalence of cvd and comorbid cvd by age group and sex were also shown in figure 3 in terms of cvd the overall ageadjusted and sexadjusted prevalence increased from 2077 in 2011 to 3101 in 2018 in terms of comorbid cvd the overall ageadjusted and sexadjusted prevalence increased from 122 in 2011 to 379 in 2018 from regional variations in 2018 the provincelevel ageadjusted and sexadjusted prevalence of cvd varied widely from 1308 in guangdong to 6466 in heilongjiang between 2011 and 2018 27 out of 28 provinces experienced an increase in the prevalence rate over this period the top three provinces with the most rapid increase in the ageadjusted and sexadjusted prevalence of cvd were xinjiang anhui and shanxi guangdong was the only province experiencing a decline in the ageadjusted and sexadjusted prevalence of cvd the provincelevel ageadjusted and sexadjusted prevalence of comorbid cvd in 2018 ranged from 000 in beijing and shanghai to 1580 in heilongjiang between 2011 and 2018 25 out of 28 provinces experienced an increase in the prevalence rate over this period the top three provinces with themost rapid increase were heilongjiang shaanxi and qinghai in contrast tianjin and beijing experienced a decline in the ageadjusted and sexadjusted prevalence bmj global health the ageadjusted and sexadjusted prevalence of cvd and comorbid cvd in each province in 2011 was presented in online supplemental table 3 more details about ageadjusted and sexadjusted prevalence change of cvd and comorbid cvd in each province between 2011 and 2018 were presented in online supplemental table 4 socioeconomic inequalities the distribution of ageadjusted and sexadjusted prevalence of cvd and comorbid cvd by ses groups and sex was shown in figure 6 in all survey waves both cvd and comorbid cvd tended to be more common among those in higher ses groups trends analysis showed that there were significant increases in the adjusted prevalence of cvd in the low lowermiddle and uppermiddle ses groups from 2011 to 2018 2018 3704 p for trend 0001 as for the adjusted prevalence of comorbid cvd a significant increase was observed across all ses groups for both sexes combined and men while the significant increase for the women was found specifically within the low and lowmiddle ses groups the ccs presented in figures 7 and 8 and online supplemental figures 1 and 2 demonstrate consistent relative socioeconomic inequalities in cvd and comorbid cvd across all survey waves the ccs consistently remained below the equality line from 2011 to 2018 with the 2011 curve furthest from the equality line suggesting that the ageadjusted and sexadjusted prevalence of cvd and comorbid cvd was higher for higher ses groups in addition the gap between the cc and the equality line narrowed over time with decreasing concentration indices in 2011 to 008 in 2018 and the concentration index of comorbid cvd in both sexes combined decreasing from 037 in 2011 to 013 in 2018 the concentration indices presented in figure 9 showed the magnitude of socioeconomic inequalities in cvd and comorbid cvd across all survey waves according to the joinpoint regression analysis the concentration indices bmj global health of ageadjusted and sexadjusted prevalence of cvd and comorbid cvd showed a significantly decreasing trend in both sexes combined from 2011 to 2018 with an aapc of 544 and 2150 respectively the details of aapcs of concentration indices are shown in online supplemental table 5 cohort analysis of cvd incidence from 2011 to 2018 the overall incidence density of cvd and comorbid cvd among the elderly population was 1796 and 265 per 1000 personyears respectively furthermore table 1 and online supplemental table 6 summarise the results of the gee with table 1 showing provinces with statistically significant relative risks of cvd and online supplemental table 6 encompassing the entire array of provinces as shown in table 1 compared with adults aged 6069 years those aged 7079 and ≥80 years displayed a significantly heightened risk of both cvd and comorbid cvd women exhibited an elevated susceptibility to cvd and comorbid cvd when contrasted with men using henan province of central china as the reference sichuan and hunan exhibited a decreased risk of both cvd and comorbid cvd remarkably heilongjiang showcased an elevated risk when contrasting elderly adults with low ses those positioned in the uppermiddle and high ses groups manifested an increased risk of cvd and comorbid cvd while the lowermiddle ses group exclusively displayed a statistically significant association with comorbid cvd discussion this study conducted crosssectional and cohort analyses focusing on examining the temporal trends regional variations ses inequalities and the influence of key demographic factors on cvd among chinese individuals aged ≥60 years from 2011 to 2018 the main findings are the ageadjusted and sexadjusted prevalence of cvd increased significantly from 2077 to 3101 and the adjusted prevalence of comorbid cvd increased bmj global health significantly from 122 to 379 over the study period geographically we observed striking variations among provinces in the ageadjusted and sexadjusted prevalence of cvd and comorbid cvd although the temporal patterns in almost all provinces followed the national trends furthermore we found persistent but decreasing relative socioeconomic inequalities in the prevalence of cvd and comorbid cvd among the elderly across all surveys and a higher prevalence was observed among individuals in higher ses groups moreover the cohort analysis indicated increased risks of incident cvd and comorbid cvd among older individuals women those with higher ses and residents of northern china similar to the global trend the adjusted prevalence of cvd among the elderly tended to increase in china 16 additionally the total number of elderly individuals with comorbid cvd defined in this study as individuals diagnosed with both heart disease and stroke was also on an increasing trend previous studies have shown that heart disease complicated by stroke is associated with great suffering for patients and imposes a substantial burden on society 37 therefore more and higherquality healthcare services for the prevention and treatment of cvd should be required as the number of elderly individuals with cvd and comorbid symptoms is increasing in china concurrently the significance of proactive health promotion initiatives should be underscored such initiatives can empower individuals to adopt healthier lifestyles cultivate cardiovascular wellness and mitigate the risk factors associated with cvd and its comorbidities 38 39 different from other countries such as canada our study reveals a notable gender difference in cvd prevalence with a bmj global health higher incidence observed among women than men among individuals aged ≥60 years 10 this difference highlights the significance of considering unique population characteristics and healthcare contexts in cvd research clinical evidence indicates that as age increases the prevalence of cvd in women significantly rises with older women outnumbering men in cvd patients 40 41 42 43 this phenomenon can be elucidated by the elevated expression of cvd when risk factors are present among elderly women 43 44 for example previous studies have found that in china elderly women who smoked or consumed alcohol faced a 15fold higher risk of cvd but no statistical differences were found in elderly men 45 additionally in china women are at particular risk of suboptimal secondary prevention and this disparity does not diminish among urban residents and those with higher education levels 46 therefore gender differences should be considered to improve the management and treatment of cvd risk factors in women we found that most provinces experienced an increase in cvd prevalence among elderly individuals over a fairly short period in china which indicates the importance of cvd prevention and health promotion strategies because the temporal changes might be driven mostly by modifiable risk factors rather than genetic factors 3 furthermore we confirmed substantial variations in the prevalence among provinces consistent with previous studies cvd prevalence was higher in northern regions compared with southern regions of china 3 47 these findings are particularly useful for local health authorities to assess existing cvd prevention and control programmes and develop more localised prevention strategies targeting key cvd risk factors in different regions the china cardiovascular health index provides a comprehensive dimension bmj global health of cvd risk factors including the smoking rate the physical inactivity rate the salt intake level the intake rate of vegetables and fruit obesity hypertension diabetes hyperlipidaemia and concentration of pm25 48 these factors may provide at least partial explanations for the regional disparities in cvd prevalence and contribute to guiding localised prevention goals and strategies 49 it is notable that within our study certain provinces displayed a 0 prevalence of comorbid cvd among individuals aged ≥60 years between 2011 and 2018 this phenomenon may be attributed to a multifaceted interplay between chinas distinctive cvd occurrence and regional disparities in health factors and behaviours 49 50 chinas cvd occurrence exhibits a significant pattern characterised by a high stroke prevalence with low heart disease prevalence in almost every population 49 51 this national trend sheds light on the observed low comorbidity rates of heart disease and stroke within the country furthermore it is noteworthy that some provinces including those reporting 0 comorbid prevalence in this study demonstrate better health factors and behaviours which may account for their 0 comorbid cvd prevalence for instance provinces in western china such as chongqing qinghai and guizhou exhibited more favourable health factors profiles and those in the southern and eastern regions such as guangdong shanghai and zhejiang demonstrated better health behaviours 50 however it is important to acknowledge that while the charls data we used is a reliable resource the quality of specific cvd information might have limitations due to its secondary nature therefore we recognise the need for further investigations using nationally representative firsthand data to comprehensively explore comorbid cvd prevalence in china according to the fundamental cause theory higher ses is associated with better health outcomes which has been supported by abundant evidence from western countries 10 52 however because the seshealth associations are contextdependent and vary by countrylevel characteristics we suspect the association between ses bmj global health and cvd in china therefore we analysed the cvd prevalence among different ses groups and found that elderly individuals with higher ses had a higher prevalence of cvd which is consistent with findings from another study 53 this is partly because deleterious health behaviours embodying strong cultural meanings are socially accepted and even encouraged among older individuals with higher ses in china as the backbone of chinas rapid economic growth beginning in the 1990s adults aged ≥60 years were among the first to benefit from the sudden increase in personal wealth and the availability of consumer goods in china 54 while their western counterparts became increasingly aware of the negative health impacts of tobacco alcohol and highcalorie foods this group of chinese individuals was enjoying the newly widespread availability of these commodities 55 56 57 58 the critical roles of smoking and alcohol consumption in peoples social lives coupled with the enduring image of affluence attached to excess weight may outweigh the protective effect of higher ses 59 60 61 some studies have found that higher wealth and education levels predict higher tobacco and alcohol use and are associated with higher obesity rates 58 61 therefore the higher prevalence of cvd in the high ses population may be attributed to the higher risk factors present in this group 53 additionally the higher prevalence of cvd among elderly individuals with higher ses may partially be the result of higher healthcare utilisation participants with higher ses may have better access to healthcare services greater capacity and higher health literacy to seek healthcare and undergo regular screening for cvd 62 these contribute to higher diagnosis rates of cvd among elderly individuals with higher ses reflecting higher prevalence the cohort analyses were designed to investigate the dynamic impact of key demographic factorsage sex province and seson cvd incidence over time age as a pivotal risk factor contributing to the escalating burden of cvd has been largely ignored in china 3 sex differences in cvd incidence among the elderly in china remain insufficiently studied while international research indicates that women catch up with men after menopause 63 as for provinces previous studies were limited in their scope primarily focusing on broad geographical analyses across major regions of china 50 which constrained their ability to investigate disparities across provinces although ses is acknowledged as a significant determinant of overall health 11 12 its evolving impact on cvd incidence in elderly chinese populations remained unexplored given the critical importance of these demographic factors and in light of significant demographic shifts occurring in china over recent decades 64 we examined the evolving association between these pivotal demographic factors and cvd incidence the results of cohort analyses align with those identified in our crosssectional analyses specifically the results showed an increased risk of cvd with age increasing this finding is particularly significant in light of the ongoing ageing of chinas population projections indicate an alarming 50 annual surge in cvd incidence between 2010 and 2030 65 emphasising the critical need for a comprehensive understanding of the agerelated dynamics of cvd incidence in china additionally the cohort analyses reaffirmed the significant regional variations in cardiovascular health within china specifically we selected henan province located in central china as our reference point revealing a distinct northsouth gradient in cvd risks the identification of such disparities underscores the critical importance of prioritising increased investments in health promotion as well as proactive strategies for cvd prevention and treatment particularly in provinces where these challenges are more pronounced strengths and limitations this study has several important strengths most importantly its novelty to our knowledge this study addresses a research gap by providing a comprehensive estimation of the temporal trends and regional variations and recognising the importance of ses in cvd especially comorbid cvd among the elderly population in china moreover this study used data from the charls a nationally representative database of high quality therefore the findings of this study exhibit strong national representativeness underpinned by the reliability of the charls survey data additionally the comprehensive crosssectional and cohort analyses provide robust evidence concerning the association between the key demographic factors and cvd several limitations of this study should be properly acknowledged first limited by the charls data cvd only included heart disease and stroke which are the primary causes of mortality burden and did not include other cardiac conditions such as aortic aneurysm and peripheral arterial disease second like other studies based on the charls data the data on cvd in this study were obtained through selfreport questionnaires 9 66 although medical records were not available in the charls its sister survey with similar survey protocols the english longitudinal study of ageing found good consistency between selfreported coronary heart disease events and medical records 67 third to gain insights into broader trends of cvd incidence across provinces we categorised each province as a distinct category however it is noteworthy that beijing and shanghai had no cases of comorbid cvd resulting in empty standard errors in the gee estimates this could potentially affect the models robustness to address this concern and ensure the reliability of our findings we performed a sensitivity analysis which confirmed the associations even in the presence of zero counts fourth while we used individual weights with household and individual nonresponse adjustments and poststratification techniques to enhance generalisability it is important to acknowledge that perfect generalisation is challenging to achieve in largescale surveys due to inherent variability and complexities bmj global health conclusion from 2011 to 2018 there were statistically significant increases in the ageadjusted and sexadjusted prevalence of cvd and comorbid cvd geographically there were substantial variations in the prevalence and temporal changes of cvd and comorbid cvd across provinces furthermore the prevalence of cvd and comorbid cvd was higher among older individuals of higher ses and socioeconomic inequalities were persistent but narrowing during the study period additionally the cohort analysis indicated increased risks of cvd and comorbid cvd among older individuals women those with higher ses and residents of northern china more efforts including robust health promotion initiatives focused on the prevention and management of cvd should be taken to optimise the strategy and provide highquality healthcare for the elderly population in china furthermore future interventions and policies should consider and resolve agespecific and genderspecific geographical and socioeconomic disparities to ensure equitable access and outcomes for all contributors qw contributed to the study concept and design drafting the manuscript data acquisition and statistical analysis yz revised the manuscript ll supervised the study ll is the guarantor who had full access to the data controlled the decision to publish and accepts full responsibility for the work all authors have made contributions to the manuscript and have read and approved the final version competing interests none declared patient and public involvement patients andor the public were not involved in the design or conduct or reporting or dissemination plans of this research patient consent for publication not applicable ethics approval this study involves human participants and the data used in this study were from the charls which was reviewed and approved by peking university biomedical ethics review committee the patientsparticipants provided their written informed consent to participate in the charls participants gave informed consent to participate in the study before taking part provenance and peer review not commissioned externally peer reviewed data availability statement data are available in a public open access repository publicly available datasets were analysed in this study the data can be accessed on the charls database 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

introduction cardiovascular disease cvd continues to pose a significant burden among the elderly population in china there is a knowledge gap in the temporal trends regional variations and socioeconomic inequalities among this vulnerable population methods this study conducted crosssectional and cohort analyses based on four survey waves of the china health and retirement longitudinal study among adults aged ≥60 years spanning 20112018 across 28 provinces crosssectional analyses examined temporal trends regional variations and socioeconomic inequalities in cvd prevalence cohort analyses identified individuals without cvd in 2011 and followed them up until 2018 to calculate cvd incidence generalised estimating equations gee were employed to identify associated factors results a total of 5451 7258 8820 and 11 393 participants were eligible for crosssectional analyses and 4392 and 5396 participants were included in cohort analyses of cvd and comorbid cvd in 2018 the ageadjusted and sexadjusted prevalence of cvd and comorbid cvd was 3121 95 ci 2725 to 3517 and 383 95 ci 285 to 481 respectively trend analyses revealed a significant increase in the adjusted prevalence from 2011 to 2018 p for trend 0001 there were substantial provincial variations in the adjusted prevalence of cvd and comorbid cvd higher socioeconomic status ses participants exhibited higher prevalence and the concentration curves and concentration indices suggested persistent but narrowing inequalities in cvd and comorbid cvd across survey waves cohort analyses from 2011 to 2018 yielded overall cvd and comorbid cvd incidence densities of 1796 and 265 per 1000 personyears respectively gee results indicated increased cvd risks among older individuals women higher ses participants and northern residents conclusion more efforts should be taken to optimise strategies for highquality cvd prevention and management in chinas elderly population future interventions and policies should address agespecific and genderspecific geographical and socioeconomic disparities to ensure equitable access and outcomes for all

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introduction governments and society have accepted and enthusiastically promoted contraception especially contraceptive steroid hormones to facilitate optimal timing and number of births an undoubted health benefit to this end the affordable care act mandates that all contraceptive steroid hormone formulations as well as all other food and drug administration approved contraceptive commodities be made available without cost to any insured beneficiary the american congress of obstetricians and gynecologists echoes and reinforces the recommendations of the centers for disease control and prevention and the world health organization to include contraceptive steroids in their preventive care armamentarium the society for adolescent health and medicine as well as the american academy of pediatrics followed suit stressing larcs particularly for women 1519 years of age larcs include intramuscular injections of 150 mg of medroxyprogesterone acetate every 3 months etonogestrel implants intrauterine devices infiltrated with levonorgestrel and copper iuds recently sayana press a prefilled syringe of 104 mg of medroxyprogesterone acetate for subcutaneous administration was introduced for developing countries none of the above committee opinions or position papers enumerate side effects but suggest counseling of patients before prescribing the modalities the fda list of serious side effects for etonogestrel covers every organ system 1 and is similar to product information for all contraceptive steroids the high rates of discontinuation of contraceptive steroid hormones often led to unplanned pregnancies sadly about half were aborted in britain 66 percent of women who received abortions between 2011 and 2013 at the british pregnancy advisory service were using contraception in the conception month 40 percent of these were using contraceptive pills inconsistently bpas reports that many women are unhappy with the pill because of side effects without specifying a number or proportion the physical side effects of contraceptive steroids are well known and have been well described to counter the high discontinuations the national institutes of health issued a 3 million dollar request for applications to produce nonhormonal contraceptives while the physical side effects of contraceptive steroids on every organ system will be described in other issues of this journal the personal social and spiritual effects of hormonal and in fact any contraception limit the sexual partners commitment this is not primarily a religious issue 2 as youth initiate sexual activity much earlier teen pregnancy and the rising incidence of sexually transmitted infections and diseases are major public health concerns the 2011 youth risk behavior surveillance study reports that 278 percent of female ninthgrade students had experienced sexual intercourse 43 percent of tenth graders 519 percent of eleventh graders and 639 percent of twelfthgrade female students of these 337 percent had intercourse within the past 3 months and 18 percent had used the birth control pill at their last intercourse this level of oral contraceptive use prompted energetic advocacy of larcs and dual methods by practice committees of the american congress of obstetricians and gynecologists the society for adolescent health and medicine and aap to reduce teen pregnancy and sexually transmitted infections and related diseases despite the public perception that all women use contraception the national survey of family growth reports that among women 1545 years of age in union 62 percent were currently using any contraceptive of these 17 percent were using ocs it is clear that every woman in the usa is not currently ingesting contraceptive steroid hormones yet the political debate surrounding the contraceptive mandate of the aca implies that the steroids are essential for womens health regardless of side effects 3 many of the articles reviewed on the effects of contraception on emotional and social parameters equate contraception or any method of birth control with the use of contraceptive steroids while steroidal contraceptives accounted for 42 percent of modalities used an additional 56 percent of women used an iud but the data do not distinguish between hormonal and nonhormonal devices in view of the aforementioned evidence the objective of this article is to review the literature on the psychological social and spiritual impact of contraceptive steroid use the intrapersonal effects nearly always affect a womans social and spiritual functioning the social effects in turn are often grounded in physical and psychological causes we will in turn examine the effects of contraceptive steroid hormones on brain structure emotions and behavior their pharmacological impact on partnerspouse selection the demographics of contraceptive steroid use on marriage family building divorce and career choices of women and religious determinants of usenonuse of steroidal contraceptives search for bibliographic information the following databases were searched fiftyseven studies were reviewed those selected were pertinent to the topic of the paper the data were scientifically documented and were less than 5 years old unless the article was seminal the selected articles had a sample size of at least 100 with the exception of three relevant smaller wellperformed studies whose results were relevant the impact of contraceptive steroids on brain structure pediatric neuroimaging studies beginning in 1990 showed that organizational brain changes such as neural pruning and remodeling of neural pathways among other changes take place rapidly between 15 and 19 years of age while the realignment of executive function pathways from the midbrain to the prefrontal cortex usually is not completed until the midtwenties to resolve inconsistencies in reported sex differences in human brain structure pletzer and her group obtained high resolution structural images of the brains of fourteen young healthy men fourteen young healthy women who did not use hormonal contraception and fourteen women who used contraception the women who were cycling naturally were scanned in midfollicular and midluteal cycle phases while the contraceptive users and the men were scanned once voxelbased morphometry was used to determine regional gray matter volumes the following differences emerged men had larger hippocampi parahippocampal and fusiform gyri amygdalae and basal ganglia than women the gray matter of the prefrontal cortex and the preand postfrontal gyri of the normally cycling women were larger than the mens but these sexdependent effects were modulated by menstrual cycle phases and hormonal contraceptives the right frontal fusiformparahippocampal gyrus contained larger volumes of gray matter during the early follicular than during the midluteal phase suggesting the influence of higher amounts of estrogens contraceptive users showed significantly larger prefrontal cortices preand postcentral gyri parahippocampal and fusiform gyri and temporal regions compared to the women who were not using contraceptives relating morphological changes to behavior is still largely based on animal studies however in human fmri studies the fusiform and parahippocampal gyri have been implicated in spatial navigation abilities the decrease in volume in these gyri during ovulation might explain hormonedependent changes in women pletzer et al offer no further interpretation but hormones especially sex steroid hormones play important roles in the pubertal pruning and neural remodeling exogenous and endogenous hormones can retard or arrest it in view of the emotional lability of the teen years with their alternating impulsive and rational behaviors the choice of whether when and with whom to engage in sexual activity can be profoundly influenced by the addition of contraceptive steroids and can lead to lasting consequences effect of steroid hormones on mate selection the highly polymorphic genes of the major histocompatibility complexes found in house mice and humans not only control immunological selfnonself discrimination which is important in tissue rejection and immune recognition of infectious diseases but also play a key role in odor preferences the latter was significant when fortynine women whose mhc types were known were presented with tshirts which had been worn by fortyfour men whose hlaa b and dr mhc types were also known the women were presented with six tshirts the odors of shirts worn by men of divergent mhc types were judged more pleasant than those worn by mhcsimilar men this supported the hypothesis that mate choice is designed by nature to avoid inbreeding a subsequent study reported in the same article found similar outcomes among nonmedicated subjects but women who were using the contraceptive pill were attracted to the odors of the shirts of men with similar rather than complementary mhcs in other words use of the contraceptive pill reversed the expected attraction to mates with divergent mhc types to those with similar mhc types while the role of pheromones in mediating the perception of smells is generally accepted their role in chemical communication is still controversial as hormonal contraceptives affect partner choice which impacts subsequent relationship satisfaction offspring quality and the wellbeing of women and mothers alexandra alvergne and virpi lummaa behavioral anthropologists urge drug companies to investigate these parameters on a large scale they believe that women have dual sexuality conceptive which dominates during the fertile phase and nonconceptive which is dominant during times of infertility they cite increasing evidence that women are more motivated to engage in extrapair copulation at midcycle with resultant 35 percent extrapair paternity while these can lead to genetically superior offspring the social costs of infidelity are high for both the woman and the child these behaviors are also dependent on social situations ie arranged marriages polygamous unions or in cultures in which a widow must marry the deceased husbands brother while another male may be more attractive especially when the attraction is hormonally enhanced the family planning literature is largely silent about the effects of contraceptive steroids on the behavioral and personal antecedents which affect the choices to engage in sexual intercourse on entering into temporary or permanent liaisons and on reaching emotional maturity during estrus normally cycling women have increased preferences for more facially and vocally masculine men men whose scents signal dissimilar mhc these preferences are voided by pill use which also leads to shortterm as opposed to longterm relationships favored by nonpill users men in turn find women most attractive during estrus the consequence of maladaptive mate choice of an mhcsimilar pair may lead to a higher rate of spontaneous abortion due to compromised immune function andor decreased heterozygosityrelated problems of offspring as there has been no research to evaluate the quality and stability of relationships when contraceptive steroids are no longer influencing attractions alvergne and lummaas plea for manufacturers of contraceptive steroids to undertake such a study makes eminent sense as the woman may discover that the partner she chose or accepted while ingesting contraceptive steroids is not compatible with her when the effect is no longer present the impact of contraceptive steroids on emotions and behavior for decades it has been suspected that hormonal contraceptives produce psychological alterations in user women eg depression mood changes changes in libido and in the stability of affective relationships even though hormonal contraceptives such as oc are the most extensively studied drugs in the history of medicine little research has focused on determining the consequences of using these drugs on psychological wellbeing thus both the users as well as healthcare professionals are quite misinformed regarding these consequences among the few studies conducted in this line the most relevant are described as follows in 1969 udry and morris formally reported the prevalence of two side effects of hormonal contraceptive preparations on the lives of users a decrease in the libido and depressive symptoms several years later oinonen and mazmaniam studied the relationship between affect and duration of oc use in ninetysix women they compared early late and neverusers of oc regarding positive affect variability and personal and family psychiatric history triphasic contraceptive users experienced greater variability in positive affect across the menstrual cycle likely due to the variable steroid hormone levels withdrawal of constant level of hormones during early use was associated with greater variability in positive affect than withdrawal of changing hormonal levels a personal or familial psychiatric history enhanced the variability and negative effects of the oc while many women using oc experience positive effects the subgroup experienced a negative mood change later a group of italian researchers studied the psychological effect of a different oc formulation in a group of ten users compared to a control group in the third month of treatment they found that certain psychological symptoms evaluated by a psychometric scale had decreased significantly in users of oc the effect was attributed to the anxiolytic action of drospirenone sulfate when comparing with the control group this led these researchers to propose the benefits of this formulation in reducing some psychological disorders the association between hormonal contraceptive use and mood disorders was studied in a random sample of 498 norwegian women of the total sample 185 women were using contraceptive formulations at the time of assessment of these 152 were using combined formulations of estrogens and progestins whereas thirtythree were using progestinonly contraceptive formulations among users with mood disorders six were taking progestinonly formulations while five were taking combined contraceptive formulations the women taking progestinonly contraceptive formulations had an increased likelihood of a current mood disorder compared with women taking combined contraceptive formulations who had a lower likelihood of a current mood disorder as a whole current users of progestinonly contraceptives were found to have a threefold increased risk of a current mood disorder compared to nonprogestin contraceptive users a randomized doubleblinded placebocontrolled trial was performed to determine whether the combined oc induce more mood disorders than placebo in users who had previously suffered from mood disorders induced by combined oc thirtyfour women participated in this study fourteen received a placebo while fourteen received a combined oc an emotional facematching task was administered during fmri prior to and during the combinedoc treatment cycle throughout the trial users recorded daily symptom ratings on the cyclicity diagnoser scale during the last week of the treatment cycle combinedoc users had higher scores of depressed mood mood swings and fatigue in comparison to placebo users combinedoc users also had lower emotioninduced reactivity in the left insula left middle frontal gyrus and bilateral inferior frontal gyri compared to placebo users in comparison with their pretreatment cycle the combinedoc group had diminished emotioninduced reactivity in the bilateral inferior frontal gyri whereas placebo users had diminished reactivity in the right amygdala authors concluded that combinedoc use in women who previously had suffered emotional side effects resulted in mood deterioration and combinedoc use was also accompanied by changes in emotional brain reactivity despite the uninterrupted availability of nonreproductive intercourse provided by contraception more and more women without antecedent psychiatric history experienced a reduction in libido the syndrome of hypoactive sexual desire made its way into the dsm iv while few noted that it was most prevalent in women who were taking contraceptive steroids it is known that combined oc reduce levels of androgen especially testosterone by inhibiting ovarian and adrenal androgen synthesis and by increasing levels of sex hormonebinding globulin the explanation for this is that the principal function of shbg has traditionally been considered to be that of a transport protein for sex steroids regulating circulating concentrations of free hormones and their transport to target tissues considering that free and total testosterone are thought to be mainly responsible for libido it is not a surprise that treatment with testosterone is usually offered and considered helpful but the binding effect of the steroids on shbg continues even after discontinuation of the contraceptive steroids regrettably some clinicians are not yet persuaded of the above association and maintain their patients on contraceptive steroids while offering antidepressants and counseling to alleviate the complaint oinonen and mazmaniam whose review was cited above acknowledged that depression was the most frequently cited reason for discontinuation of the drug which may be attributed to the abolition of the natural hormonal cycle by monophasic contraceptives robinson et al examined studies of increased depression anger anxiety fatigue use of tranquilizers sexual dysfunction divorce and suicide and other accidental or violent deaths with current use of different hormonal formulations of contraceptive steroids and inert iuds they questioned whether the emotional disturbances resulted directly from the pharmacologic changes introduced as different steroid formulations and the inert iuds had similar effects even a study of weak female hormones vs a placebo which was labeled as a contraceptive yielded a similar sideeffect profile suggesting that it is the practice of contraception itself which is responsible for the psychological effects a populationbased study of west german women yielded mixed findings which did not attempt to distinguish physical from psychological effects a questionnaire administered to current or past users of oc condoms iud and 428 nfp users and sterilization showed both positive and negative effects fears of anticipated side effects of pills and iuds concerns about unplanned pregnancies with nfp and condoms were negatives satisfaction was reported by 92 percent of sterilized women 68 percent of oc ever users 59 percent of iud users 43 percent of nfp users and 30 percent of condom users nearly 33 percent of nfp users had experienced an unplanned pregnancy compared to 5 percent of condom users negative mood changes were reported by 16 percent of oc users 23 percent of condom users and 30 percent of nfp users suggesting that many effects were a combination of fear anxiety and confidence in the method or its lack it is possible that either the women andor their partners had not received sufficient followup support to become comfortable with their use of nfp this interpretation was borne out by the authors followup study which found that additional counseling allayed health concerns and led to improved compliance in the use of reversible methods the effects of contraceptive steroids on the cardiovascular nervous gastrointestinal skeletal immune and genitourinary systems will be described in other issues of this journal it is worth noting that graham and sherwin found no beneficial effects of oc in women suffering from moderate to severe premenstrual symptoms such as mood disorders women who received oc reported decreased sexual interest after starting treatment and this effect was independent of any adverse influence on mood the demographic impact of contraceptive steroid hormones on womens careers conjugal relationships and family building the literature is replete with studies linking the effects of the pill on facilitating womens achieving higher education either by delaying marriage and childbearing or avoiding marriage altogether the pill allowed women to engage in sexual relations without fear of pregnancy thus precluding expected interruption of careers or life plans curiously bailey refers to this as family planning services even though the goal is to avoid starting a family passage of the twentysixth amendment to the us constitution in 1971 reduced the legal age of majority from 21 years of age to 18 this change was soon reflected in state laws and allowed younger women to obtain contraceptives without parental consent soon most college health services were prescribing the pill for their undergraduate students the availability of the pill was seen as a supplyside explanation for the change in career plans an increase in age of first marriage and an increase in the numbers of women entering professional schools chiefly law and medicine despite the widespread availability of the pill and a ratio of 81 of pill use vs abortion the abortion rate among 18and 19yearold college students who took the pill went from 53 percent in 1971 to 60 percent in 1976 the pill is not necessary for demographic change at least it is not the sole agent in japan there was a decline in the fertility rate and increase in age at first marriage beginning in the early 1970s while the pill was not legally available until 1999 the authors were apparently unaware that japanese women made extensive use of abortion in that time frame after abortion was legalized in 1948 nearly 40 percent of married women had at least one abortion the number has since stabilized between 20 and 30 percent the recent review by the guttmacher institute of relevant papers from 1980 to march 2012 details the positive effects of hormonal contraception on womens freedom to decide whether and when to have children on educational attainment workforce participation economic stability union formation and stability mental health and happiness and the wellbeing of children via adequate birth spacing in the authors view obtaining reliable contraception was the gateway to achieve all the above benefits and theoretically to counter the economic ill effects of single teenage childbearing and failure to complete high school both are acknowledged to keep lowincome teens impoverished and tend to reduce women from higher income groups to poverty at least for some time while access to the pill is credited with increased workforce participation and the amount of time spent in the paid labor force including the professions the results for mothers of small children vary in dualincome households married women have more flexibility to reduce their paid work or leave it entirely to care for small children income disparities are closely linked to ability to participate in the workforce which is contingent on the need to care for one or more children while some job categories value experience more highly than educational achievement over all the family gap perdures the gender gap for childless women still exists at age 30 childless women average 90 percent of the wages a 30yearold man earns in comparable occupations women with small children average 73 percent as much as men in similar jobs both men and women benefit financially from delaying family formation until later adulthood but highly educated women are estimated to lose 2133 percent of their lifetime earnings when they have children delaying childbirth until the late twenties and thirties raises income 4 percent but does not address the nonmonetary value of the satisfaction or the challenges of being a parent marriage and family building would need to be delayed to achieve the above economic advantages but needs for love and relationship often take precedence and behaviors are more often driven by impulse than rational choice despite cultural messages to teens and young adults that sexual activity is normative as long as it is protected currently 40 percent of pregnancies in the usa are unplanned when couples conceive while using contraception this is always stressful among cohabiting couples contraceptive failures are not infrequently associated with disharmony and abuse sadly many times the baby is aborted despite attempts to make abortion appear to be of no consequence women must deal not only with the loss of the child but with their responsibility and guilt for the act some women can grieve openly but many choose psychologically destructive means of coping substance abuse depression suicide these often result in posttraumatic stress disorder psychosomatic symptoms or family dysfunction according to the national survey of family growth in 20062010 40 percent of first premarital cohabitations among women transitioned to marriage by 3 years 32 percent of these marriages remained intact and 27 percent dissolved nearly 20 percent of women experienced a pregnancy in the first year of their first premarital cohabitation pregnancy clearly elicited a range of reactions from the parents depending not only on their economic aspirations but also on their maturity and commitment to their union according to sonfield et al both married and cohabiting couples relationships dissolve more often when there is an unplanned pregnancy this effect becomes stronger if there is an additional unplanned birth or when parents disagree on the number of children they wish while unplanned pregnancy was an independent factor for union instability personality traits such as ability to communicate clearly affected the relationship the higher rate of unintended pregnancy among teen parents affected union dissolution even more strongly legal access to the pill coincided with a 30 percent reduction in new marriages and greatly increased cohabitation by 2011 60 percent of marriages were preceded by cohabitation while fewer women married those who married later were better educated and had fewer divorces conversely the education of teen mothers is often interrupted or stopped by the need to care for the child many public and private assistance programs aim to support single teen mothers with financial personal and educational assistance to become selfsupporting currently teen mothers are especially targeted by the larc programs sponsors of which consider prevention of repeat pregnancy by teen mothers of paramount importance yet motivation for conception is far from uniform and ranges from unintended to highly intended highly intended pregnancies are conceived for a variety of reasons desire for a baby can be highly immature similar to wanting a doll to wanting to punish ones mother or father for real or imagined slights to wanting to marry the babys father to feeling inadequate as a person until one is a mother to wanting a baby before biological motherhood becomes impossible as marriage had receded as an option to search for community sonfield et al view too early or unwanted childbearing to be associated with maternal depression anxiety and a lower level of happiness citing analyses of longitudinal studies of motherchild pairs such as barbers the terms unwanted and unplanned are used interchangeably and statically overlooking the commonly found ambivalence about both planned and unplanned pregnancy in the first trimester which often changes to positive acceptance by the time of birth studies cited show that early parenthood and low quality of life are associated with lower income and a lower quality of life later even extending to poor mental health among us and british women in menopausal years children born to teen mothers or whose birth was unintended too often suffer from the lack of competent and consistent nurturing on the part of immature economically deprived or depressed mothers resulting in poor developmental educational and economic outcomes the antidote offered for these and for too close birth intervals is contraception preferably larcs while poor developmental outcomes of children born to teen mothers or born unwanted is well known these vary with the quality of support which the mothers and children receive from family and community sonfield et al clearly view contraception as a panacea to avert all the bad outcomes described but do acknowledge the positive role of antidiscrimination laws which make attainment of better education and subsequent careers possible for teenage mothers mothers whose children are spaced too closely or who are in other economically deprived situations or are discriminated against on the basis of ethnicity for all these categories contraception more often than not by contraceptive steroids is offered as the preventive the basis of the mothers relationship with the babys father only enters peripherally when either marriage violence or abuse are discussed the economic benefits of delaying pregnancy until the mother has completed her education and is established in a career are lauded as positive outcomes for womens reproductive health while acknowledging that abortion must always remain available as a secondary method to help women achieve the goals which the authors consider desirable but few acknowledge that oocytes begin to lose potency by age 30 and that many women who have missed their optimal window of fertility resort to assisted reproductive technology to attempt pregnancy while the business of art is highly remunerative in the best hands the success rate is 40 percent this has led to a variety of surrogacy arrangements which have reduced the child to a product while sonfield et al and many others attribute to contraceptive use the fact that women can delay pregnancy and cite the positive effects of the pill on womens education and lifestyle choices few link the concomitant rise of divorce to contraceptive use in 1960 the us divorce rate was 221000 compared to 851000 couples who married that year in 2009 35 1000 couples divorced compared to 68 1000 who married in that year while the rate of divorce has increased fewer couples marry as the rate of cohabitation has also risen even though the rate curves for divorce and contraception can easily be superimposed the academic community has not drawn the obvious conclusion nor has it adverted to the enormous social costs of divorce on the former spouses their children or society at large once a marriage is legally dissolved the state enters into many decisions concerning not only alimony but also the education and healthcare decisions for minor children what was once the private decision of parents now involves the legal system and imposes constraints while child custody arrangements vary from joint to sole custody all children are impacted by the loss of the secure home which they had taken for granted until their parents separated some children are resilient others develop emotional andor physical illnesses but no child is unaffected similarly children who are raised by a single parent or cohabiting parents fare less well economically and personally than those raised by their married biological parents shaunti feldhahn states that divorce among churchgoing couples is 25 percent compared to 50 percent among couples who do not attend church but does not address denominational differences in respect to approval or disapproval of contraception among catholics ever use of the contraceptive pill had no effect on divorce rates while sterilization doubled the risk of divorce fehring believes that the finality of sterilization suggests an inability to live with ones fertility but data to support this belief are not available a more refined qualitative and quantitative study of spiritual wellbeing selfesteem and intimacy of couples compared twenty randomly selected creighton model nfpuser couples from a private university nursing center with twenty couples from another nfp center who had switched from nfp to artificial contraception at least 1 year prior to the study eight of the comparison group were currently using ocs six used condoms two used diaphragms two used the contraceptive sponge and two had been sterilized while students t test results showed no significant differences between nfp users and contracepting couples in selfrated selfesteem and intimacy scores the nfp couples had statistically higher scores on spiritual religious and existential wellbeing a survey of 1131 longterm users of the roetzer symptothermal method of nfp in austria germany and switzerland yielded a 43 percent return rate the 37item questionnaire was sent to current and former users it covered gender age education employment finances civil status number of children religious confession religious practice and practice and consequences of living the stm method ninety percent of respondents had secondary or higher education more than 30 percent had chosen stm because they wanted a natural method 22 percent had done so on the advice of friends the same number chose nfp for ethicalreligious reasons while 15 percent feared side effects of hormonal methods consistent use of the roetzer stm method was reported by 83 percent of respondents who also reported high levels of church attendance and prayer as a couple the twentyfive persons who were divorced after a median 12 years of marriage had fewer children than the couples who remained married religious confession was not related to the occurrence of divorce but was related to nonoptimal religious practice and a 77 percent use of artificial birth control at some point in their marriage compared to 40 percent use of those who remained married impact on spirituality spirituality is personal but as many religious faiths have taken positions for or against the use of contraception when the use of contraceptives conflicts with ones religious groups teaching one would expect to see effects the anglican church formally approved the use of contraceptives by married couples with resolution 15 at the 1930 conference of anglican bishops at lambeth most other protestant groups did not take formal positions but accepted the practice tacitly the catholic church is the largest religious group to oppose the use of any method which renders the sexual act sterile either temporarily or permanently thanks to widespread opposition by clergy and laity many were placed into a crisis of conscience when the encyclical humanae vitae was issued in 1968 as many had already begun to use barrier contraceptives withdrawal or the pill the pill now provided easy access to a noncoital method given the too often minimal clerical teaching the question has become moot for many who consider themselves faithful practicing members of their denomination since the advent of the pill nfp use according to the national survey of family growth is no higher than 008 percent of the 62 percent of the population who are using any method of family planning and has not changed significantly in the last 20 years there appears to be cognitive dissonance between catholic use of artificial family planning methods and periodic abstinence as at least two thirds of each group of users consider the practice of their faith important and more than half of these attend church services weekly or more often a study of us hispanic catholic women 1544 years of age compared the influence of faith on their choice of family planning methods while hormonal pills male condoms withdrawal and vasectomy were used significantly less often the iud and depo provera were used more frequently than by nonhispanic women in the 20062010 nsfg the percentage of hispanic women who used periodic abstinence was 194 percent double the 053 percent of white women and 0 percent for black women there was no difference in reported rates of abortion the variation in method mix may well reflect the generally lower income levels of the hispanics and their subsequent use of publicsector family planning providers clearly the goal to separate sex from procreation was paramount while noncoital means were preferred the study was not able to specify the motivation directing the choices as there was no information about the womens knowledge of church teaching an analysis of the nsfg data on contraceptive use by religious affiliation by hill siwatu and robinson postulated and demonstrated a preference for noncoital methods by members of religious groups predominantly catholic who desired to avoid conception as well as prevent feelings of shame and condemnation by their communities while feelings of shame about contraceptive use by catholics were voiced more frequently after humane vitae was issued in 1968 attempts at justifying its use by theologians such as rev charles curran former professor of moral theology at the catholic university of america not only muted these expressions but have seemingly removed them concurrently membership in the catholic church in the us has increased from 463 million in 1965 to 666 million in 2013 while weekly mass attendance declined from 55 percent to 24 percent today nearly 27 percent of couples are cohabiting of these over 90 percent are using contraceptives the data do not discriminate about participants religious practice because catholics were slower to accept contraceptives than their protestant neighbors their fertility was higher prior to the advent of noncoital methods but with acceptance of current contraceptives the differences have disappeared except for the hispanic population whose fertility has remained higher than the nonhispanics for mainly religious reasons which tend to disappear with changes in income and education similar conclusions about contraceptive use among collegeeducated mexicanamerican women were reached by alvarado and nehring hirsch conducted a qualitative study of older and younger catholic women in rural mexico and observed that the older women resisted the modern methods as they were heavily promoted by the government in order to obtain us funds for fertility reduction while the younger women persuaded themselves that use of the modern methods was approved by god to ensure that they did not have more children than they could support some obtained permission from priests to that effect interestingly a significant number of the younger women who tried to space children relied on natural methods presumably calendar rhythm and withdrawal while the older women had used prolonged lactation to lengthen birth intervals often concluded by tubal ligation hirsch concluded in mexico catholicism is not just something women practice with their heads and not their hearts they practice it with their whole bodies but they employ cultural creativity to justify their reproductive practices currently 85 percent of churchgoing catholic women in the us are more open to additional children than their noncatholic sisters but believe that they are compliant with catholic church teaching while using contraceptives hasson suggests that catechesis on sex and procreation as well as conscience formation has lagged since humanae vitae while oc are consumed by women who are in relationships with men mens attitudes have significant effects on whether women make use of the drugs hoga et al found sixteen qualitative studies eligible for inclusion in their systematic review undertaken to facilitate the recommendation of the un conference on population and development held in cairo in 1994 which sought to increase contraceptive access globally and also attempted to legalize universal access to abortion the review found that religion family and social background are strong influences on contraceptive use and that mens acceptance of contraceptive responsibility was highest among protestant christians who were most likely to make use of condoms and vasectomy from a sense of responsibility for their families these usages were not without ambivalence which healthcare providers must deal with if contraceptive use is to expand in conclusion the availability of predominantly hormonal contraception has affected society profoundly by facilitating the separation of sex from procreation it has changed womens life styles to facilitate completion of their education or engaging in careers while either marrying but delaying childbirth or cohabiting or simply engaging in nonprocreative intercourse this freedom has also led to fewer or later marriages more divorce low sexual desire and depression for those whose religion proscribes the use of contraceptives it has often led to diminished religious practice all these changes were predicted by pope paul vi in humane vitae number 17 discussion in restricting payment for family planning services to fda approved contraceptives and commodities or procedures which exclude fertility from any sexual encounter the alleged healthserving goal of the acas contraceptive mandate our government has legislatively decoupled sexual intercourse from procreation evidently the administration assumes that women want to include or exclude their fertility from any heterosexual encounters at will and that they can do so without any personal physical emotional or spiritual sequelae the regulations which our department of health and human services has issued only consider reproductionfree sexual relations as significant the means to achieve this end are of no consequence apparently as only commodities are reimbursed the national institutes of health which are part of dhhs have recognized that the high number of women who discontinue the alleged boon of hormonal contraceptives because of the side effects which they encounter and have unplanned pregnancies as a result call for different approaches they have issued a request for research for nonhormonal contraceptives but they need look no further than nfp and will save taxpayer funds in the process the natural biomarkers of fertility and infertility are not even considered in the regulations yet these offer well documented reliable costfree and sideeffect free options for procreative choice fertility is not a disease using a drug with the many untoward effects described in this article to sterilize sexual encounters in not only irrational it is not good medicine acknowledgments we want to express our thanks to dr william e williams editor in chief of the linacre quarterly for helpful comments and to dr anthony caruso and laurel graham for provision of valuable library references and resources endnotes 1 food and drug administration product warnings and information side effects inflammation at the insertion site symptoms of cerebral pulmonary cardiac or peripheral thrombotic or embolic episodes or hypertension breast mass icterus or depressionclinical trials with 942 women from several countries preceded approval of implanon adverse reactions leading to discontinuation of treatment reported by more than 1 of subjects included irregularities of menstrual bleeding 111 percent emotional lability 23 percent weight increase 23 percent headache 16 percent acne 13 percent depression 1 percent in the subset of 330 us subjects 61 percent experienced emotional lability and 24 percent reported depression adverse reactions which did not result in discontinuations reported by more than 5 percent of subjects included headaches 249 percent vaginitis 1455 weight increase 137 percent acne 135 percent mastodynia 128 percent abdominal pain 109 percent pharyngitis 1055 percent leukorrhea 96 percent influenzalike symptoms 76 percent dizziness 72 percent dysmenorrhea 72 percent back pain 68 percent emotional lability 65 percent nausea 64 percent pain 56 percent nervousness 56 percent depression 55 percent hypersensitivity 54 percent and insertion site pain 52 percentas postmarketing experience is based on voluntary reporting the fda cannot estimate their frequency or establish a causal relationship but the list encompasses every organ system warnings and precautions in uk literature not mentioned in us sources for etonogestrel include ectopic pregnancy in the event of contraceptive failure which is considered to be more likely than intrauterine gestation as progestins slow transport of the embryo in the fallopian tube implantation normally begins when the embryo is 55 days old if the movement of the embryo is slowed it will begin to implant in the tube 2 some years ago a psychologist from the nih who had no religious affiliation came to me for instruction in the billings ovulation method of nfp she had already used mechanical and hormonal contraceptives but responding to a comment i had made at an nih meeting decided to seek a natural method after using the method for three months she told me this method is so differentnow i can be all there now i am not holding anything back the contrast between contraception and fertilityacceptance methods has never been explained more simply 3 the far greater incidence of thromboembolic episodes discovered subsequently and multiple lawsuits for over 19 billion have dampened enthusiasm for this drug which was heavily marketed as lacking the negative effects of the androgenderived levonorgestrel contraceptives despite the numbers of women who have suffered or died from pulmonary emboli myocardial infarction or strokes yaz yasmin and ocella are still on the market

governments and society have accepted and enthusiastically promoted contraception especially contraceptive steroid hormones as the means of assuring optimal timing and number of births an undoubted health benefit but they seldom advert to their limitations and side effects this article reviews the literature on the psychological social and spiritual impact of contraceptive steroid use while the widespread use of contraceptive steroid hormones has expanded life style and career choices for many women their impact on the womens wellbeing emotions social relationships and spirituality is seldom mentioned by advocates and negative effects are often downplayed when mentioned at all depression and hypoactive sexual desire are usually treated symptomatically rather than discontinuing their most frequent pharmacological cause the contraceptive the rising incidence of premarital sex and cohabitation and decreased marriage rates parallel the use of contraceptive steroids as does decreased church attendance andor reduced acceptance of church teaching among catholics lay summary while there is wide societal acceptance of hormonal contraceptives to space births their physical side effects are often downplayed and their impact on emotions and life styles are largely unexamined coincidental to the use of the pill there has been an increase in depression low sexual desire hookups cohabitation delay of marriage and childbearing and among catholics decreased church attendance and reduced religious practice fertility is not a disease birth spacing can be achieved by natural means and the many undesirable effects of contraception avoided

19887_0

introduction the covid19 global pandemic is ongoing caused by the sarscov2 virus the first outbreak of infection was in china in december 2019 which was followed by spread to many other countries the first case was detected in australia on 25th january 2020 this case was in melbourne the capital of the state of victoria in the absence of vaccines at the time the victorian government attempted to control the spread of the virus using lockdowns beginning on the 30 th march 2020 victoria and the city of melbourne in particular was the region of australia most impacted by the pandemic and by series of lockdowns which are summarized in table 1 as in the rest of the world the initial concern about the pandemic was the effect on mortality and hospitalizations however as the pandemic progressed the potential effects on mental health have also been recognized 1 given the strong evidence for increased psychological distress and mental disorders after disasters 2 the prevalence of mental health problems was expected to rise due to infection and fear of infection as well as the impacts of lockdowns including social isolation loss of employment and income and intensification of pressures on families there is now an extensive international literature exploring the mental health consequences of the pandemic early studies involved crosssectional comparisons of the prevalence of symptoms of distress anxiety and depression during the early months of the pandemic compared to prepandemic data they found that the prevalence of symptoms was higher than prepandemic 56 subsequent studies used stronger longitudinal designs and repeated crosssectional surveys of representative samples systematic reviews and metaanalyses of these studies found that symptoms of distress anxiety and depression increased during the early months of the pandemic in 2020 but returned to prepandemic levels by the middle of that year 78 while longitudinal studies with frequent waves have been proposed as the best methodology for investigating pandemicrelated mental health impacts 9 survivorship bias has been raised as a limitation of these studies czeisler et al 10 analysed a 4wave longitudinal study from the usa and found that people who participated in only 1 or 2 waves had a higher prevalence of depression and anxiety symptoms this selective pattern of retention could lead to an overly optimistic interpretation of mental health over time czeisler et al 10 therefore recommended the simultaneous use of independent crosssectional data along with longitudinal data as these approaches have different strengths and weaknesses and facilitate the investigation of distinct research questions most studies of the impact of the pandemic have assessed symptoms of mental disorders however keyes 11 argued that a complete assessment of mental health should take account of a dimension of positive mental health as well as symptoms relevant to this twodimensional concept there have also been some studies on the effects of the pandemic on positive mental health including subjective wellbeing life satisfaction and positive affect there has been less research carried out on positive mental health than on symptoms but one systematic review and metaanalysis of studies up to june 2020 found no significant effect of covid19 pandemic lockdowns on measures of life satisfaction positive affect wellbeing and quality of life 12 in addition to research examining changes in mental health measures there have been studies of factors table 1 chronology of covid19 restrictions in victoria up until the second survey sources 34 dates events and restrictions that may impact any changes found a particular focus of pandemic studies has been social isolation and loneliness as these are potentially adversely affected during lockdowns while there was some evidence of an increase in these factors during the early phases of the pandemic 13 other systematic reviews found a lack of effect 712 one explanation of these findings is that there was an initial impact of restrictions and lockdowns on social relationships but people soon adapted by finding alternative online means of social contact 1213 and that the shared experience of the pandemic may have increased social cohesion 12 studies from other types of disasters have also indicated that social factors such as access to social support and sense of social solidarity are associated with more positive mental health outcomes 14 however it was also shown that these factors can deteriorate over time the above findings mainly come from studies in europe and north america and may not be generalizable to all countries we focus on the studies with stronger methodologies involving more systematic and representative samples from early in the pandemic the australian bureau of statistics has monitored the health and social impacts 15 it found that symptoms of psychological distress increased in april 2020 when the nation was first affected by lockdowns declined to prepandemic levels by june as restrictions eased and then increased again in august when there was another wave of lockdowns another source of longitudinal data has come from the life in australia panel 16 this study found that the prevalence of severe psychological distress rose in april 2020 compared to prepandemic but then fell in may it worsened again from may to august mainly due to the effects of a second lockdown in the state of victoria this impact subsequently declined with victoria showing little difference from the rest of the country by november 2020 a third longitudinal panel study is the australian national covid19 mental health and risk communication survey which involved fortnightly online surveys from march to june 2020 17 this study found that any changes in depression and anxiety symptoms were generally transitory the study also found that while suicidal ideation was high it did not vary over time 18 later work from this study reported greater psychological distress in parents and caregivers who were home schooling but no effect on wellbeing 19 overall the australian data show a worsening of mental health which was associated with lockdowns but this effect diminished over time australian studies of mental health outcomes from other types of disaster are also of relevance including an epidemiological study showing increased risk of psychiatric disorders post disaster 20 crosssectional analyses demonstrating a complex relationship between social networks and individual mental health post bushfires 21 and longitudinal analyses indicating moderate involvement in community groups can be a protective factor for mental health following bushfire exposure 22 in the present study we report new repeated crosssectional and longitudinal data from the australian state of victoria which was the region of australia most affected by pandemic lockdowns the capital city of melbourne was particularly affected and by 2021 was one of the most lockeddown cities in the world 23 consistent with keyes 11 twofactor concept of mental health the study aimed to assess both symptoms of psychological distress and life satisfaction we aimed to investigate crosssectional factors associated with higher psychological distress and life satisfaction at each survey and also social connection factors associated with longitudinal changes between the two surveys method this paper builds on the descriptive findings of the victorian coronavirus wellbeing impact study surveys 24 which showed significantly higher rates of lowmedium life satisfaction over time and a nonsignificant trend towards higher rates of psychological distress over time study design the current analysis has a twopart study design a repeated crosssectional study of respondents who participated in survey one and survey two followed by a longitudinal nested cohort study of these same respondents the surveys were undertaken by the victorian health promotion foundation a statebased government agency in victoria australia with a remit to promote health and prevent illness the vichealth coronavirus victorian wellbeing impact surveys of victorian residents aged 18 years and over were conducted via an optin research only online panel the surveys were designed to track the impact of the pandemic and associated lockdowns on a range of behavioural and attitudinal health risk factors during the first two waves of the pandemic in victoria from march to june in 2020 and from july through to october 2020 survey one commenced on 31 may 2020 and concluded 8 june 2020 the total achieved sample size was 2000 survey two which was conducted during the second pandemic wave commenced on 10 september 2020 and concluded on 21 september 2020 survey two included 1008 respondents who were recontacted from survey one and 992 new respondents to boost the total sample size to 2000 survey questionnaire the 20min survey questionnaire covered a range of health and wellbeing factors including life satisfaction subjective wellbeing psychological distress and social connection as well as sociodemographics the selection of health and wellbeing indicators for the questionnaire was guided by several key principles previously used in population surveys conducted by vichealth 25 these principles included sensitivity to change across person place and time strong psychometric properties being amenable to action at a range of jurisdiction levels including local government nonduplication of other victorian population surveys and brief questions that could be feasibly used in local program evaluations thus allowing the population measure to act as a comparator for local evaluations different question styles were used to minimise respondent fatigue and enhance engagement with the survey such as likert scales closedended questions and openended questions current guidelines were followed to ensure questions were as userfriendly as possible for respondents regardless of the device being used to access the survey 26 respondents were also asked to provide their nearest crossstreet to enable the application of geocodes to participants identification codes and their question responses no formal pilot testing of the survey was undertaken however a soft launch was undertaken to confirm the integrity of the questionnaire the soft launch involved inviting a small number of participants to complete the survey with the aim of securing approximately 20 completed surveys the data from these surveys were carefully checked against the microsoft word version of the survey to ensure the survey was error free and had been scripted as expected no errors were detected as a result of this process and the survey was launched in full without any amendment the average completion time of the questionnaire was 20 min measures our primary outcomes were psychological distress and life satisfaction and the primary exposures were feeling connected with others staying connected with family and friends and social solidarity psychological distress was measured using the kessler psychological distress scale6 which has excellent internal consistency reliability 27 the k6 is a combined score across 6 areas of psychological distress each person can score a minimum of 6 and maximum of 30 scores of 19 or more are classified as probable serious mental illness while scores of 6 to 18 are classified as no probable serious mental illness null responses to 2 or more of the 6 statements were excluded from the mean calculation with adjustments made for those who gave a null response to 1 statement life satisfaction 28 was derived from a rating of satisfaction with life as a whole using a scale of 0 to 10 where 0 is completely dissatisfied and 10 is completely satisfied the measure correlates highly with the personal wellbeing index measure of life satisfaction 29 low to medium life satisfaction was defined as a score between 0 and 6 out of 10 null responses were excluded from mean calculation the measure of feeling connected with others 30 uses a six item likert scale to assess level of agreement with the statement i feel connected with others the measure has a high positive correlation with the social connectedness revised scale and a high negative correlation with the ucla loneliness scale 30 for analysis responses were divided into the percentage of people who selected strongly disagree disagree mildly disagree mildly agree and those who selected agree or strongly agree staying connected with family and friends was a question developed for the survey and to the best of our knowledge it is the first time that this measure has been used it measures the extent to which people find it easy or hard to stay connected with those close to them for analysis the fivepoint likert scale was coded as the percentage of people who reported it was 1 very easy or easy 2 neither or 3 hard or very hard the social solidarity measure 31 was designed to determine how close people feel with their communities using a combined score across six questions and has good reliability across samples these questions ask respondents whether they agree with statements regarding their connection with their local community responses for all six questions were assigned the following values strongly disagree 1 disagree 2 neither agree nor disagree 3 agree 4 strongly agree 5 any respondent providing a dont know or prefer not to answer response to any of the six questions was excluded from the analysis the final score was calculated by summing the values of the six categories out of a maximum of 30 and minimum of six in addition to the above the variables age gender disability income the main activity in september region and household composition were used as covariates in the longitudinal analysis the covariates used for each analysis are shown in the corresponding tables ethics ethics approval for survey one was provided by the australian national university human research ethics committee on 20 may 2020 ethics approval for survey two was provided by the australian national university human research ethics committee on 8 september 2020 all methods were carried out in accordance with relevant guidelines and regulations online written informed consent was obtained from study participants as this survey was carried out as an online survey statistical analysis data were analysed using stata v17 32 and r software 33 categorical data were summarised using frequency with percentages continuous data using means with standard deviations and skewed data using medians with interquartile ranges our primary outcomes exposures and covariates are described in the measures section to assess differences in dependent means and proportions paired sample ttests and mcnemars tests were used respectively using logistic regression modelling we explored the associations between our exposures and primary outcomes of psychological distress and life satisfaction with and without adjustment for covariates the results from the multivariable models were summarised using adjusted odds ratios 95 confidence intervals and pvalues to identify confounding variables for the regression analyses we used information from previous literature and directed acyclic graphs 3435 for each outcome we conducted three separate analyses a crosssectional analysis at the first lockdown a crosssectional analysis at the second lockdown and a longitudinal analysis exploring the change in outcome measures between the two lockdowns we tested for exposureoutcome associations that may have been modified by other covariates using interaction terms and likelihood ratio tests and used measures of fit for logistic regression 36 to test model assumptions we used completecase analysis and investigated the baseline firstlockdown characteristics of those missing and notmissing at the second lockdown using summary statistics results cohort characteristics the cohort characteristics for the 1008 participants who completed the survey at both lockdowns are shown in table 2 table 2 indicates that this sample consists of a higher proportion of female participants compared to male a higher proportion living in melbourne compared to regional areas and a higher proportion reporting not having a disability approximately 56 were employed in february 2020 and 55 employed in september 2020 while the rest consisted of retired student and other in february and september 2020 approximately 32 of the household composition consisted of couples with children and the rest consisted of couple living alone person living alone single parent with children and other compared to the first lockdown at the second lockdown participants had lower life satisfaction felt less connected with others had a harder time connecting with family and friends and had lower social solidarity the cohort characteristics are summarised separately at the first and the second lockdowns in supplementary file 2 table s1 the participants characteristics at the first lockdown for those who were missing and not missing at the second lockdown are shown in supplementary file 2 table 1 supplementary file 2 table s2 shows that those who were missing at the second lockdown compared to those who were not missing had higher psychological distress and were more likely to be male live in melbourne and be employed in february 2020 crosssectional results at the first lockdown crosssectional results from logistic regression modelling at the first lockdown with psychological distress and life satisfaction as outcomes are shown in table 3 at the first lockdown participants who found it hard to stay connected with others had 186 times higher odds of psychological distress compared to those who found it easy to stay connected after adjusting for covariates participants who did not feel connected with others had 38 times higher odds of psychological distress than those who felt connected higher social solidarity was associated with lower odds of psychological distress melbourne residents had higher odds of psychological distress compared to those who lived outside melbourne psychological distress was higher for younger participants participants who reported a disability had higher odds of psychological distress compared to those who did not report disability in addition lower income was associated with higher psychological distress a similar range of variables were found to be associated with life satisfaction at the first lockdown participants who did not feel connected with others had 03 times lower odds of life satisfaction than those who felt connected after accounting for covariates those who found it hard to stay connected with others had 05 times lower odds of life satisfaction compared to those who found it easy to stay connected higher social solidarity was associated with higher odds of life satisfaction life satisfaction was lower for younger participants participants who reported disability had lower odds of life satisfaction compared to those who did not report disability lower income was associated with lower life satisfaction crosssectional results at the second lockdown crosssectional results at the second lockdown for the outcome variables psychological distress and life satisfaction are shown in table 4 the crosssectional results at the second lockdown were comparable to the first lockdown participants who did not feel connected with others had 26 times higher odds of psychological distress than those who felt connected after adjusting for covariates higher social solidarity was associated with lower odds of psychological distress psychological distress was higher for younger participants participants who reported a disability had higher odds of psychological distress compared to those who did not report disability melbourne residents had higher odds of psychological distress compared to those who lived outside melbourne participants who did not feel connected with others had lower life satisfaction compared to those who felt connected the participants who found it hard to stay connected with others had 03 times lower odds of life satisfaction compared to those who found it easy to stay connected higher social solidarity was associated with higher odds of life satisfaction participants who reported a disability had lower odds of life satisfaction compared to those who did not report disability participants who were unemployed in the september had lower odds of life satisfaction compared to those who were employed longitudinal results longitudinal results for psychological distress and life satisfaction are presented in table 5 the results showed that participants who did not feel connected with others at the second lockdown had 33 times higher odds of psychological distress at the second lockdown after controlling for their psychological distress status at the first lockdown and other covariates the younger participants aged less than 35 years had higher odds of psychological distress compared to participants over 65 years of age participants who did not feel connected with others and found it hard to stay connected with the family and n number sd standard deviation statistically significant differences between the two lockdowns are highlighted in grey background using an arbitrary pvalue cutoff of 005 37 paired ttests and mcnemars tests were used for comparing means and proportions respectively data consists of the participants who completed both surveys a unless otherwise stated friends at the second lockdown had lower life satisfaction at the second lockdownwith or 02 and or 04 respectivelyafter accounting for their life satisfaction at the first lockdown and other covariates no significant associations between social connection at the first lockdown and psychological distress or life satisfaction at the second lockdown were found after controlling for covariates discussion this study aimed to investigate psychological distress and life satisfaction during the first and second lockdowns in the state of victoria in 2020 as well as social factors that may be affected by lockdowns and which could affect mental health the main finding was that adults aged 18 years and over who did not feel connected with others at the second lockdown had 33 times higher odds of psychological distress at the second lockdown after controlling for their psychological distress status at the first lockdown and other covariates this odds ratio is considered to be a small to medium effect size 38 crosssectional findings using life satisfaction as an indicator of positive mental health we found that the percentage of participants with low life satisfaction was significantly higher in the second survey sample compared to the first survey sample because the survey samples are not representative these percentages could be biased figures as estimates for prevalence however a previous descriptive analysis that weighted the data by population characteristics found a similar significant change for prevalence of low lifesatisfaction from 49 to 53 24 this result differs from a previous systematic review and metaanalysis of studies up to june 2020 which found no significant effect of covid19 pandemic lockdowns on life satisfaction however these studies examined the effects of single lockdowns whilst the results of this study indicate that a second lockdown led to a decrease in life satisfaction by contrast the percentage of participants with high psychological distress was not significantly different between the two survey samples with high distress found in 143 in the first survey sample compared to 156 in the second survey sample in comparison to the prevalence percentages reported previously where weighted data had been used the prevalence percentages were higher but again there was no change across surveys 24 these results are different to other studies that have found that psychological distress reduced after initially increasing during the early months of the pandemic 78 as the first survey was conducted in mayjune 2020 it may be that this study did not capture the initial peak in psychological distress whilst this study did not have a precovid baseline we can get some indication of the impact of lockdowns in general through examining the melbourne region which was subjected to greater restrictions than the rest of victoria particularly during the second lockdown in the crosssectional analyses from both lockdowns residents of melbourne had a higher level of psychological distress after adjusting for other factors indicating that greater lockdown is likely to be a risk factor these findings are consistent with studies internationally showing that lockdowns have a negative impact on symptoms of mental health problems 56 on the other hand we found no effect of living in melbourne compared to the rest of the state on life satisfaction whereas there was a decrease in life satisfaction across the state as a whole from the first to the second lockdown when the social connection factors were examined there was a higher proportion of participants in the second survey reporting not feeling connected to others and finding it hard to stay connected to family and friends there was also a lower social solidarity mean score these findings are consistent with the international literature results using longitudinal data are presented statistically significant associations are highlighted in grey background using an arbitrary pvalue cutoff of 005 37 unadjusted modelling is shown in supplementary file 2 table s5 aor adjusted odds ratio ci confidence interval model adjusted for the covariates shown in the table that there was an increase in social isolation and loneliness in the early phase of the pandemic 13 but are not consistent with suggestions that the effect of social isolation diminished over time as people adapted by finding alternative online means of social contact 1213 however the findings are consistent with the broader literature on disasters showing a potential deterioration in social support and social solidarity over time following a critical incident 14 a n 1 591 b n 2 592 longitudinal findings the longitudinal analysis facilitated the investigation of factors associated with changes in life satisfaction and psychological distress from the first to the second lockdown lower social connectedness was associated with worsening of both psychological distress and life satisfaction not feeling connected with others was associated with both mental health variables while finding it hard to stay connected was specifically associated with lower life satisfaction this is consistent with the research following the black saturday bushfires which showed the relationship between social networks and mental health post disaster 21 and identified connection to community groups as a protective factor 22 these associations point to interventions targeting social connectedness as a potential response to future lockdowns while lower social connectedness was associated with both increases in psychological distress and decreases in life satisfaction there were also some differential associations a notable longitudinal finding was that younger adults had a greater increase in psychological distress across lockdowns this association was found even after adjustment for social risk factors and indicates that young people should be a particular target for intervention to reduce the psychological impact of lockdowns this has been shown in other postdisaster studies and may reflect lower maturity and life experience 39 however by contrast the younger adult age group was not associated with greater declines in life satisfaction unemployment at the time of the first survey was also associated with declines in life satisfaction although the association with psychological distress was not statistically significant at our preset significance level there was a trend in the same direction however any negative impact on mental health in the second lockdown may have been ameliorated by changes to australian government policy in march 2020 that came into full effect after the first lockdown this policy increased welfare payments to people who were unemployed in an effort to stimulate the economy there was also a jobkeeper scheme to subsidize wages of people in employment where the pandemic was adversely affecting the business of their employer which may have reduced distress associated with fear of unemployment in the longitudinal analysis we found no effect of living in melbourne on changes in either psychological distress or life satisfaction indicating that any worsening of mental health across lockdowns was not greater in melbourne despite the greater restrictions on the city in the second lockdown at the time of the second survey melbourne had been in lockdown for two months and had been under curfew for one month whereas the rest of victoria had been in lockdown only for approximately one month it may be that the difference in accumulated lockdown dose between melbourne and the rest of victoria at the time of the second survey was not significant enough to show a difference in psychological distress and life satisfaction alternatively given that the crosssectional analysis did show a difference in victorian regions the lack of effect in the longitudinal analysis may be an indicator of survivorship bias with those experiencing higher psychological distress not participating in the second survey consistent with the limitations of longitudinal studies reported previously 10 limitations an important limitation is that the samples were taken from an optin online panel with complex recruitment strategies which is unlikely to be representative some subgroups are likely to be excluded by the survey method such as people without digital access andor without digital literacy or english literacy while representativeness is not required for the longitudinal analysis of risk factors it potentially affects prevalence estimates in the crosssectional analyses however prevalence changes between surveys were similar when there was weighting of the sample by population characteristics 24 which adds to confidence in the findings in their longitudinal study of mental health during the pandemic czeisler et al 10 found that there was a high dropout rate in people with worse mental health which could lead to an overly optimistic interpretation of mental health over time our data are consistent with this finding with the proportion of participants with high psychological distress in the first survey being greater for those who did not participate in the second survey compared to those who did thus the proportion of people with high psychological distress is likely to be underestimated at the second survey however we did not find a significant difference between these groups in the proportion of participants with low life satisfaction conclusion the state of victoria and the city of melbourne in particular was the area of australia most impacted by covid lockdowns the crosssectional data collected in the first and second lockdowns reported here facilitated an investigation of the factors associated with higher psychological distress and life satisfaction consistent with keyes 11 twocontinua model of mental health while the longitudinal data enabled an exploration of the change between the two lockdowns the data showed that lower social connectedness was associated with worsening psychological distress and life satisfaction and that the young adults had a greater increase in psychological distress across the lockdowns the results in this study support and expand on findings of other international studies they also indicate that in any future pandemics or lockdowns interventions designed to maintain social connectedness may ameliorate the risk of decreased wellbeing and increased psychological distress this is particularly important for younger adults routine promotion of involvement in community groups may be protective 22 abbreviations additional file 1 vichealth coronavirus victorian wellbeing impact survey questionnaire s1 cohort characteristics at the first lockdown the second lockdowns table s2 baseline characteristics of the cohort with and without missing at the second lockdown table s3 results from univariable logistic regression modelling with psychological distress and life satisfaction asoutcome at the first lockdown table s4 results from univariable logistic regression modelling with psychological distress and life satisfaction as outcome at the second lockdown table s5 longitudinal associations of change in psychological distress and life satisfaction between the first and the second lockdowns additional file 2 table competing interests the authors declare they have no competing interests

background population surveys across the world have examined the impact of the covid19 pandemic on mental health however few have simultaneously examined independent crosssectional data with longitudinal data each of which have different strengths and weaknesses and facilitate the investigation of distinct research questions this study aimed to investigate psychological distress and life satisfaction during the first and second lockdowns in the state of victoria australia and the social factors that may be affected by lockdowns and could affect mental healththe vichealth victorian coronavirus wellbeing impact study included two 20min optin online panel surveys conducted in may and september 2020 in victoria each with a sample of 2000 adults aged 18 a twopart study design was used a repeated crosssectional study of respondents who participated in survey one and survey two followed by a longitudinal nested cohort study the primary exposures were social solidarity social connectedness and staying connected with family and friends using logistic regression modelling we explored the associations between our exposures and primary outcomes of psychological distress and life satisfaction with and without adjustment for covariates both crosssectionally and longitudinally the results from the multivariable models were summarised using adjusted odds ratios aor 95 confidence intervals ci results crosssectional results indicated that the percentage of participants with low life satisfaction was significantly higher in the second survey sample 53 compared to the first 47 the percentage of participants with high psychological distress was higher but not significantly different between the two survey samples 14 first survey vs 16 second survey longitudinal study results indicated that lower social connectedness was significantly associated with higher psychological distress aor33 95 ci 1384 and lower life satisfaction aor02 95 ci 0104 younger adults had higher psychological distress compared to older adults aor68 95 ci15311 unemployment at the time of the first survey was significantly associated with lower life satisfaction at the second survey aor05 95 ci 0309

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introduction the longitudinal aging study amsterdam is a prospective cohort study among older adults in the netherlands the study started in 1992 initiated by the dutch ministry of welfare health and culture and is still ongoing the primary objective of lasa was to study the determinants trajectories and consequences of functioning in four domains physical cognitive emotional and social functioning 12 lasa is one of the few longitudinal studies of older adults in the netherlands 34 and worldwide among the few studies covering a broad range of functional domains the main strengths of the study include its multidisciplinary character the availability of over 25 years of followup and the inclusion of refresher cohorts of young older adults at 10 and 20 years after the start of the study this structure provides unique opportunities to investigate longitudinal trajectories cohort differences and time trends in functioning of older adults 56 in this paper we briefly describe the design of lasa and provide an update of the methods in particular this paper describes the additional data collections that have not been described in detail previously such as data collected in telephone interviews additional ninemonthly measurements among the oldest old genetic data environmental data and the inclusion of a migrant cohort the design of lasa the lasa cohort was initially based on a representative sample of older adults aged 5584 years from three regions in the netherlands these three regions were selected to obtain an optimal representation of the dutch older population the regions cover the predominantly protestant northeast the largely catholic south and the more secularized western part of the netherlands and include both urbanized and rural areas the initial lasa sample consists of people who first participated in the nestor study on living arrangements and social networks of older adults 7 the sample for the lsn study was randomly selected from municipality registers in 1992 with an oversampling of the oldest old and men this oversampling was done to ensure that there would be reasonable numbers of oldest old and very old men even after several years of followup the initial sample of the lsn study consisted of 3805 persons which corresponds to a response rate of 60 the cooperation rate was 62 on average 11 months after the lsn interview respondents were invited to participate in the first wave of lasa the response rate was 85 and the cooperation rate was 89 since the 1992 lsn measurement wave there have been nine lasa measurement waves to date at the eighth measurement wave approximately 23 years after the start of the study a total of 500 respondents from the original cohort were still participating two refresher cohorts were added to the original sample in 20022003 and 20122013 exactly 10 and 20 years after the start of the lasa study figure 2 and table 1 show the sample sizes for the three cohorts across all measurement waves and by interview type the second cohort consisted of 1002 men and women born between 1938 and 1947 and the third cohort consisted of 1023 men and women born between 1948 and 1957 in followup measurements after the baseline measurement respondents from these new cohorts were merged with those from the original cohort at the end of 2019 the data collection of the most recent measurement wave consisting of the remaining respondents from all three cohorts will be completed the lasa study is conducted in line with the declaration of helsinki and received approval by the medical ethics committee of the vu university medical center data collection facetoface interviews respondents are visited every 3 to 4 years at home by trained interviewers who collect the data all interviews are audiorecorded for quality checks measurements are performed for each of the four domains of functioning physical cognitive emotional and social functioning the data collection includes both questionnaires and clinical tests an overview of the main predictors and outcome measures in lasa has been published fig 2 lasa study flowchart before 2 detailed descriptions of the measurements can be found on the lasa website the data collection consists of three elements a main interview a selfadministered questionnaire and a medical interview the main interview takes on average almost 2 h to complete an abbreviated interview may be offered to the respondent when a full interview is too burdensome to complete at the end of the main interview respondents are asked to fill out a selfadministered questionnaire which is left at the respondents home in print or can be accessed online respondents are asked to hand in this questionnaire during the medical interview to return it by postal mail or to complete the questionnaire online respondents are also invited to participate in a subsequent medical interview after consent a separate visit is scheduled in which additional questions are asked and clinical measurements are performed this medical interview takes on average 1 h and a half to complete respondents who score highly on the symptom checklists of depression or anxiety are invited for an additional diagnostic psychiatric interview at specific measurement waves blood samples were obtained from respondents who participated in the medical interview 2 telephone data since lasa measurement wave c a telephone interview is offered to those respondents who refused to participate in a full or an abbreviated facetoface interview the telephone interview takes approximately 15 min and includes a selection of key indicators of functioning while this interview mode was initially intended to obtain information from proxy respondents it turned out that quite a few respondents were willing to answer the telephone questions themselves even though they could not participate in the facetoface interview across all measurement waves up to 20152016 the majority of telephone interviews was in fact conducted with respondents 44 of all interviews were done by telephone with respondents versus 33 by telephone with proxies across all measurement waves respondents with telephone data were older than respondents with facetoface data less often lived with a partner and more often lived in a care institution net of age there were no differences in level of education respondents with telephone data were also less healthy in terms of number of chronic diseases functional limitations and selfrated health than those with facetoface data besides being too frail one reason for respondents to refuse a facetoface interview is that they may be too busy in 20152016 respondents aged 74 years or younger were asked about paid work and number of hours of work it turned out that telephone respondents indeed had paid work relatively often and that those who worked also worked relatively long hours both differences were however not statistically significant in order to better reflect the variation in the population it is recommended that telephone data are used in addition to facetoface data whenever the research question allows it this helps to minimize selection bias attrition and representativeness attrition of respondents over time is a key concern for longitudinal studies which may affect the representativeness of the sample 1 the main reason for dropout in lasa is mortality 128 if mortality in the lasa study differs from mortality in the general population this could be a threat for the representativeness of the study as it could lead to an increasingly selective sample therefore analyses were performed to compare mortality among lasa respondents with mortality in the dutch general population data on mortality in the general population by sex year and age group were obtained from statistics netherlands 9 the results show that mortality was slightly higher in the general population than in the lasa sample but for most groups differences did not exceed 1 percent point thus it can be concluded that mortality in the lasa study is not substantially different from mortality rates in the dutch general older population a further indication of the representativeness of the lasa cohorts is obtained by comparing the frequency of work participation between lasa and the general population as assessed by statistics netherlands for the age group 5564 years we performed this comparison for the baseline wave of the second and third cohort for men and women and for three levels of education work participation was defined as having paid work for 1 h or more the difference between frequencies in lasa and the general population was 26 percent points on average thus showing good correspondence across subgroups the differences ranged from 02 to 69 percent points the larger deviations were observed for women and the lower educated which may be attributed to the greater precariousness of work in these groups so that their work participation is more likely to fluctuate over time methods update additional ninemonthly measurements among the oldest old the oldest old are in a stage of life in which changes in functioning can occur more rapidly and more catastrophically than earlier in life for example cognitive decline markedly accelerates during the last years of life 10 therefore it is important to accurately monitor trajectories of functioning and changes in functioning in this age group at the same time there have been recent changes in policy in the netherlands that may particularly affect the oldest old as of 2015 the social support act directs municipalities to provide support for people with functional limitations including instrumental support at home home care and social care which was previously regulated by the national government this may lead to variations in care provision between different municipalities in addition the longterm care act for residential care and the care insurance act for personal and nursing home care at home were implemented in these acts thresholds for access to care were raised making it more difficult to be eligible for residential care which can lead to an increased reliance on informal care and privately paid care the absolute increase in the number of oldest old in the community the rapid changes in functioning among the oldest old and the recent policy changes were the main reasons for conducting an ancillary study among the oldest lasa respondents with increased density of measurements three additional ninemonthly measurements were performed between the regular lasa measurements in 20152016 and 20182019 thus together with these regular measurement waves data from five consecutive ninemonthly measurements will become available for studying changes and trajectories of the four domains of functioning all persons aged 75 years and over were invited to participate in this ancillary study in total 601 persons agreed to participate at the first additional measurement 442 participated in a facetoface home interview and 159 participated in a telephone interview the topics included in the interview as well as the response rates for each additional ninemonthly measurement are presented in table 4 respondents who had a facetoface interview were asked to fill out a oneweek calendar to study changes in pain use of pain medication mood sleep social contacts and appetite on a daily basis respondents were asked to return the calendar by postal mail genetic data blood samples from respondents participating in the lasa medical interview in 19951996 20022003 20082009 and 20122013 were used to obtain genetic data in the first and second cohort dna was isolated from buffy coats in wave c and wave 2b and from full blood samples in wave g for respondents from whom both full blood samples and buffy coats were available the full blood samples were used to extract dna in the third cohort full blood samples drawn at baseline were used for dna isolation in all samples dna was extracted using standard procedures in 20162017 genotyping array data were generated for respondents who had blood samples available first a batch of around 600 samples was genotyped using axiomnl array 11 at the avera institute for human genetics sioux falls sd usa then another 1880 samples from the first second and third cohort were genotyped using infinium global screening array24v10 at the genetic laboratory department of internal medicine erasmus mc rotterdam the netherlands due to technical differences quality control and imputation were performed separately for each array for both arrays quality control was performed using ricopili 12 an established tool developed by the psychiatric genomics consortium 1314 samples with sex mismatch duplicate samples excess heterozygosity and call rate 098 were removed after quality control single nucleotide polymorphism with call rate 098 and minor allele frequency 001 were also excluded ancestry related principal components for each array were calculated samples of noneuropean ancestry were identified and later removed using the 1000 genome data as reference then 10 principal components were recalculated for each array for european ancestry respondents the data was further checked for relatedness between respondents a expressed in percent point difference all differences were summed and weights were applied for the number of lasarespondents in each group b we estimated 1year mortality in lasa by dividing the percentage that died between subsequent measurement waves by three since the interviews were held with 3year intervals exceptions were the interval between wave e2b and wave f which was on average 37 years and the interval between wave h3b and wave i which was on average 36 years for each year the percentage that died in each age group between two successive waves in lasa was calculated as follows number of deaths in age group x between the two waves number of deaths number of survivors in age group x overall genotyping array data are available for europeanancestry nonrelated respondents from cohort 1 from cohort 2 and from cohort 3 after quality control both arrays were separately used to impute the data using as reference the haplotype reference consortium panel version 11 15 imputation for autosomal chromosomes was done using minimac 3 and was facilitated by the michigan imputation server 16 genotyping data available in lasa can be used in candidate gene studies to build polygenic risk scores for complex traits and in genomewide association studies in combination with the rich pool of physical cognitive emotional and social phenotypes in lasa genotyping array data are a valuable resource for geneenvironment interaction studies lasa has been included in gwas metaanalyses from the charge and gefos consortia recently as well as other collaborations 17 18 19 exome chip data and a number of snps in candidate genes are available for a subsample of respondents in the first cohort furthermore genotyping of apolipoprotein e gene is also available for a subset of respondents in the second cohort an overview of the exome chip data and candidate snps has been previously published 2 chronic disease and composite algorithms in lasa various sources of data on chronic disease are available including selfreported chronic diseases medication use in the two weeks before the interview and diagnoses from general practitioner records since none of these data sources are the gold standard to measure disease status chronic disease ascertainment algorithms were developed in these algorithms data from different sources are combined 21 algorithms were constructed for seven cardiovascular diseases diabetes mellitus and osteoarthritis 22 23 24 using these algorithms respondents were categorized as definitely possibly or not having a disease contradictory data or as missing when there are no data available an illustrative example of diabetes mellitus disease status according to the chronic disease algorithm and other sources is shown in table 5 an advantage of the algorithm is that it reflects the degree of uncertainty related to the use of medication diagnoses reported by gps and selfreport of disease or symptoms as measures for disease status moreover combining data from various sources in an algorithm reduces the number of cases with missing data in 2018 the previously developed algorithms for cvd and diabetes mellitus were revised for several reasons first the algorithms could only be constructed for the b c and d waves as some items on selfreport of disease differed in content in later waves second the use of certain medications is very disease specific yet the diagnosis of the gp carried more weight in the former algorithms this resulted in counterintuitive diagnoses for example a respondent who uses insulin was classified as possibly having diabetes mellitus for angina pectoris cardiac arrhythmia and diabetes mellitus the use of disease specific medication was given precedence over the other variables in the revised algorithms third we have included data from the telephone interviews in the revised algorithms in order to reduce the number of cases categorized as missing chronic disease ascertainment algorithms are available for lasa waves b c d e 2b f and g and will be developed for more recent waves as well furthermore algorithms for composite indices were constructed for the metabolic syndrome allostatic load and frailty 25 26 27 28 29 metabolic syndrome and allostatic load algorithms are currently available for wave c only but the metabolic syndrome algorithm can also be constructed for waves b and 2b and for wave g algorithms for two widely used frailty constructs the frailty phenotype and the frailty index have been established from wave c onwards combining selfreported and performance data 30 31 32 33 lastly an algorithm for persistent cognitive decline was developed to identify participants with probable dementia 34 for wave c to h this was determined on the basis of reported by the gp andor specialist and psychogeriatric nursing home admittance and the presence of dementia as a cause of death based on this algorithm 3year incidence of pcd in lasa was estimated to be about 3 34 more details on the disease and composite algorithms have been published on the lasa website environmental data the lasa study has been included in two cohort consortia that focus on the relationship between the environment and health outcomes the geoscience and health cohort consortium 35 and the mindmap project 36 in gecco various largescale and ongoing cohort studies in the netherlands have been enriched with a variety of existing objectively measured environmental data that were collected from different sources 35 the mindmap project aims to identify the opportunities and challenges posed by urban environmental characteristics for the promotion and management of mental wellbeing and cognitive function of older adults 36 this consortium brings together cohort studies across cities in europe canada and the united states of america and links these cohorts with databases of arealevel environmental exposures and social and urban policy indicators the environmental data collected for the gecco consortium and mindmap project can be linked to individual lasa respondent data using their 4digit postal codes or where possible 6digit postal codes as the identifier the main environmental data that are currently available in lasa are shown in table 6 and include urbanization grade population demographics household characteristics educational level income socioeconomic status social security air pollution noise crime rates availability of facilities physical environmental characteristics and daily average weather parameters several of these variables have been used in recent lasa studies 35 37 38 39 40 41 migrant cohort in 20132014 a sample of older adults born in turkey and morocco was included in lasa these migrants comprise the third and second largest groups of older nonwestern migrants living in the netherlands 42 in the 1960s and 1970s predominantly male turkish and moroccan migrants arrived in the netherlands to perform physical manual labor 43 later waves of migration from these countries took place in the 1980s when many wives and children from turkey and morocco rejoined their husbands living in the netherlands it was expected that these groups would face a number of additional challenges in older age relative to their dutch agepeers many face language barriers 44 unemployment 45 poverty 46 discrimination and prejudice 47 on average they are expected to experience more rapid health decline than their native peers 4849 have higher levels of loneliness and depression 50 and are in greater need of care 46 by including a sample of turkish and moroccan migrants living in the netherlands we aimed to investigate functioning in the domains of social physical emotional and cognitive functioning in these groups and to compare their functioning to that of dutch agepeers in addition we aimed to study how characteristics of migration contributed to functioning in these domains migrant cohort sample and measurements data were collected among 478 older adults from turkish and moroccan origin with birth years between 1948 and 1957 the cooperation rate was 45 because turkish and moroccan migrants in the netherlands predominantly live in urban areas data collection took place in 15 dutch cities with population sizes between 85000 and 805000 inhabitants specifically the cities were amsterdam zwolle oss alkmaar almere amersfoort breda eindhoven enschede haarlem helmond hilversum nijmegen tilburg and zaanstad trained interviewers of the same ethnic background conducted facetoface interviews in dutch turkish moroccan arabic or berber language if available translated questionnaires were obtained from prior studies such as the de jong gierveld loneliness scale 51 and the center for epidemiologic studies depression scale 52 if questionnaires were not available in moroccan arabic berber or turkish questions were translated by two professional translators according to the backandforth method all questionnaires were evaluated and tested in pilotinterviews data were collected in a main interview and in a subsequent medical interview of the respondents who participated in the main interview a large part was also interviewed in a medical interview the main measures are listed in table 7 no followup data have been collected among respondents included in the lasa migrant cohort data on mortality may become available in the near future as vital status can be retrieved from municipality registers in the past few years various studies using data from the lasa migrant cohort have been published two studies were conducted on transnational belonging 5354 one study found that those feeling marginalized were lonelier and that transnational belonging was not protective of loneliness 53 the other study investigated determinants of transnational behavior and transnational belonging familyinlaws location and gender explained transnational belonging subjective income explained transnational behavior and cultural distance and selfrated health explained both 54 a study on wellbeing investigated whether private and public religious activities reduced the negative effects of a lack of physical social and socioeconomic resources on wellbeing private religious activities were positively associated with wellbeing but negatively associated with wellbeing in the context of lacking resources 55 three studies were performed in which the lasa migrant cohort was compared with native dutch agepeers at wave 3b first a study on resilience in the disabling effect of physical impairments indicated that sense of mastery buffered against disability in those with physical impairment in the turkish group income acted as a buffer against disability in those with physical impairment in the dutch sample but not in the migrant groups 56 second measurement variance of the cesd was studied among older people of dutch turkish and moroccan origin and the levels of depressive symptoms were compared if the four subscales were used scores were measurement invariant which means that they measure the same construct across ethnic groups however migrants reported more depressive symptoms than native dutch older adults on all subscales 57 finally explanations for higher rates of loneliness among turkish and moroccan older adults compared to native dutch older adults were examined less social participation lower satisfaction with their income poorer selfrated health and a higher number of depressive symptoms partially explained the higher rates of loneliness among migrants 58 qualitative data collections the rich resource of quantitative data in the lasa database provides the possibility to purposively select and approach subsamples of older adults for indepth qualitative research capitalizing on this strength several ancillary qualitative data collections have taken place to answer specific research questions for example indepth interviews about the meaning and experience of control in health care have been conducted 59 in addition to providing new insights into the factors that may enhance older adults sense of control the conceptual model emerging from this qualitative study was subsequently used to develop a questionnaire measuring perceived control in health care 60 another qualitative study investigated resilience in older adults who aged successfully despite a low lifetime socioeconomic position 61 previously calculated 16year longitudinal trajectories of social mental and physical functioning and three available indicators of sep were used to identify the target group that was most likely to possess the experiences relevant to the research question furthermore experiences of older turkish and moroccan migrants have been examined 62 the life course experiences captured in the qualitative interviews provided insights into the aging experiences of migrants in the netherlands and the resources they use to cope with migration and aging related challenges finally a photovoice study has been conducted among a purposively selected sample of lasa respondents living in the city of amsterdam who were asked to photograph aspects of their living environment that were important for their wellbeing photographs were then discussed in indepth interviews to investigate the importance of the living environment for their wellbeing this method enabled the researchers to capture a richer picture of the lived experiences and perceptions of older people besides having participants decide for themselves what aspects they photographed gave them control over the contents and the direction of the interviews which may empower participants 63 these examples indicate that embedding qualitative ancillary studies in cohort studies such as lasa has several advantages first it enables researchers to answer questions on lay perceptions of aging and offers a thick description of a topic of interest second the results from qualitative studies can illustrate complement and help to understand results from quantitative studies for example it may aid in developing new research ideas to be tested with quantitative methods or in the development and implementation of new quantitative research instruments in the total lasa cohort one potential drawback of the ancillary qualitative studies is that they increase the burden on the participants and this might negatively affect their subsequent participation in the ongoing study however our impression is that respondents welcome the variation in the mode of data collection additionally the qualitative studies usually take place in a very small portion of the total sample and are thus unlikely to substantially affect overall response rates data availability lasa data are available for research the lasa steering group has adopted a policy of sharing of data with interested researchers for specific research questions on agingrelated issues to obtain data researchers need to submit an analysis proposal that is evaluated by the lasa steering group data are available for investigation under the condition that results of analyses will be made available to the research community through scientific reports or research papers regardless of the results of the study more information on data requests can be found on the lasa website forms to request assessment of biomarkers are also available here we are open for collaborations in gwas metaanalysis and geneenvironment interaction studies a specific analysis proposal format for gwas metaanalysis is available on the website as well compliance with ethical standards conflict of interest all the authors declare that they have no conflicts of interest open access this article is distributed under the terms of the creative commons attribution 40 international license which permits unrestricted use distribution and reproduction in any medium provided you give appropriate credit to the original author and the source provide a link to the creative commons license and indicate if changes were made publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

the longitudinal aging study amsterdam lasa is a prospective cohort study of older adults in the netherlands initially based on a nationally representative sample of people aged 5584 years the study has been ongoing since 1992 and focuses on the determinants trajectories and consequences of physical cognitive emotional and social functioning strengths of the lasa study include its multidisciplinary character the availability of over 25 years of followup and the cohortsequential design that allows investigations of longitudinal changes cohort differences and time trends in functioning the findings from lasa have been reported in over 600 publications so far see this article provides an update of the design of the lasa study and its methods on the basis of recent developments we describe additional data collections such as additional ninemonthly measurements inbetween the regular threeyearly waves that have been conducted among the oldest old during 20162019 and the inclusion of a cohort of older turkish and moroccan migrants

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introduction sport has become increasingly globalized in the current world sporting teams professionally have grown in popularity attracting fans supporters and media attention from all around the world with diverse broadcast contracts that have given them greater worldwide recognition the major reason for the sports industrys continued internationalization in recent years has been the substantial integration of new digital media technologies social platforms have developed into crucial elements of branding and advertising and can be timely and accurate platforms twitter facebook and instagram in particular are the most popular channels for brand recognition and following and several fans have made it a tradition to follow professional sports teams online broadcasts the rise in popularity of social media users has produced an atmosphere in which reporters frequently use private accounts to share data generated by their employers companies despite the fact that journalists own this comparatively recent private space the data they broadcast on these sites is subject to company regulations in this context its critical to look at how correspondents as guardians act as online community account owners building personal labels while simultaneously representing their news agencies because of their sense of obligation and cultural consequences social media has received much interest from academia and practice consumers can employ social media for a variety of reasons including data gathering policymaking and the purchase usage and scrapping of goods and services for internet users using social media is becoming extremely prevalent sport brands invest a large number of resources and time in engaging on social media due to its popularity professional clubs and brands devote significant resources to adopting social media methods in their branding plans such institutions confront problems in creating socialmedia rules that maximize the benefits of new technologies while minimizing the risks related to athlete and consumer use of social media with the increasing use of smartphones and easy access to internet services worldwide social media is playing a crucial role in modern communication today most of the global population is highly inclined towards social media platforms making them a part of their daytoday lives it has become an exceedingly interactive tool that has resulted in effective communication and a platform where one can put forward their own opinion associating with various social media platforms numerous organizations are branding their own houses seamlessly in the world of sporting ventures social media has become a pathway for global outreach various sports houses employ social media platforms to interact with their fans and embarking on their global presence in this review paper an indepth study has been carried out to review the impact of social networking usage in the world of the sporting industry along with its recent global trends and future aspects background study professional athletes represent their country and serve as role models for youngsters although many children have been involved in sports since childhood the majority of the population still regards sports as a hobby or a kind of physical activity traditional advertising such as tv ads billboards and newspaper ads was the only way to market sports before digital marketing it has altered the sports sector and assisted businesses in reaching out to a diverse and targeted audience fans experiences have been transformed by watching sports information on social media and on any digital platform with the help of social media sports companies can now advertise themselves their products and their players much more easily they develop handles for their organizations so that they may identify who consumes their information and prepare similar advertising trends for the target demographic this database brings sports company marketing to a whole new level ai systems which connect with fans via instagram skype whatsapp and facebook are also an intriguing kind of marketing strategy a huge portion of the worlds population uses social media facebook is the most wellknown social media platform with nearly 2500 million active users ahead of youtube with 2000 million users instagram with 1000 million users and other platforms with comparable numbers owners of social networking sites succeed in engaging with supporters which improves brand loyalty and attraction among prospects and followers additionally a large number of athletes use social media to communicate with their followers and promote their brands through interactive tools social media has evolved and assisted sports companies in interacting with customers and maximizing profits social networking has taken on a separate role from traditional marketing tactics peoples engagement habits have changed due to this online social community social media has become so integral to any sports marketing strategy that it can no longer be ignored entrepreneurs can benefit from social media initiatives in terms of planning strategizing and executing impact of social media in sports instagram is being extensively used by top clubs in poland to interact with their supporters and fans worldwide in this work threefold research has been executed and indepth data has been analysed the data analysis was carried out in 2014 2015 and 2016 respectively most of the information was gathered mainly from a literature review and extensive data gathering from webpages in this work indepth research on instagram was executed along with all its attributes spearmans rankcoefficient test and wilcoxon signedrank test were employed and a mathematical model was created to govern the interdependence of different factors and differences among various factors respectively in his research peter english has demonstrated that journalists who have used social media to represent their media organizations may confront a conflict between their personal contributions and their work roles with the arrival of one more publication platform the reporters function as gatekeeper has altered more with judgments to be made about branding options on traditional online and social platforms the research compares gatekeeping impact at the personal and organizational zones among sports correspondents in australia and india it combines indepth conversations with 22 journalists of sports backgrounds with an analysis of 2085 tweets from sports media personalities etc the findings established multimedia gatekeeping as a factor for todays writers in sports reporting in both countries in a nation like india noncricketing sports are quickly growing various sports marketing houses are utilizing social media platforms to promote the sports leagues due to the availability of web 20 more research is required however to have knowledge of how to use online communication platforms in sports branding the prokabaddi league has become one of the most fruitful noncricket sports leagues in india the effect of communications on social media in promoting supporters sports engagement resulting in greater game viewership is examined in this study the study was performed using a definitive research methodology with data collected from 444 respondents a structural model was used to examine the hypotheses the research found that online social platform communications have a greater impact on fan online community participation which leads to increased viewership and sponsorbased product purchase intent sports marketing is shifting as a result of the internet and social communication media historically major sports clubs leagues and organizations relied heavily on television coverage for revenue this will emerge as the internet opens up new avenues for producing sporting tournaments and events social media is allowing fans athletes teams and sponsors to connect in new and unexpected ways fans intake of sports content in general as well as at live events is altering as a result of communication devices many strategic problems and opportunities arise as a result of these shifts the ecosystem of sportsbased model event branding star campaigning and worldwide variances in viewership for certain sports are among the theories and ideas presented in this case study sports branding information from various sources are used to demonstrate these ideas a framework for developing a strategy for social media is presented which can be used to assess a sports organizations current situation as well as to aid in the evolution of a socialmedia plan a set of questions is presented to help outline the discussion of the tactics and technological problems that a big sports teams commercial director faces the ecosystem of sportsbased models event branding star campaigning and worldwide variances in viewership for certain sports are among the theories and ideas presented in this case study sports branding information from various sources is used to demonstrate these ideas a framework for developing a strategy for social media is presented which can be used to assess a sports organizations current situation as well as aid in the evolution of a socialmedia plan a set of questions is presented to help outline the discussion of the tactics and technological problems that a big sports teams commercial director faces in his study holly thorpe demonstrated that participants in action sports have long been active consumers and producers of specialized cultural media on the other hand the procreation of new media advancements is gaining importance in the ongoing development of expertise among athletes and in imparting a sense of association among audiences in international national and local contexts such communication is leading to new partnerships among companies action athletic organizations and communities rather than simply reproducing existing patterns the article shows a research methodology for understanding action sports new media directions in a better way researchers explain how athletes individuals and companies are using digital platforms to transform networking and relationships within action sports this article provides a set of crucial challenges and questions for scholars passionate about contributing to new perceptions of the current technologies in the sector of actionsport cultures in addition to revealing upcoming difficulties philip c rothschilds research aimed to learn how sports and entertainment venue managers manage utilize and identify social media while there is evidence that top 500 firms have successfully used social media little is known about how administrators of event venues administer and perceive social media researchers used tools to survey 383 professionals in venue management all members of the international association of venue managers in the findings many venue managers consider their social media efforts excellent and a tactic for social media researchers analyzed to provide insight into the use of social media as an online marketing device by various associations of sports the goal of the study is to figure out how the use of social media enhances viewer engagement and audience attraction website and socialmedia interactions of the football clubs in the 201415 european champions club were analyzed by two integrated approaches including one novel scale the scale consisted of six sevenpoint items measuring a persons belief that a website allowed unrestricted information the strength of the association between two variables was investigated using a correlation by pearson of social platform pages which was utilized to analyze spectator interactivity it was discovered that increased client interaction via social media might be appealing and can improve spectatorship the research also discovered that a football clubs level of website interactivity is unrelated to their performance in the competition the researcher noted that previous research has looked at how businesses react publicly in times of crisis the findings use a dilemma in sports the ncaas investigation into the university of miami as an example of how supporters might act as backup for organizational responses to crises using the social media platform twitter scrutiny of 75 important identifiable miami supporters with numerous twitter followers using reputation repair strategies showed that fans engagement in ingratiation reminder and redirect contemplation were key strategies to endure the affair the study discovered different ideas for reputation rehabilitation with ramifications for businesses sports research crisis communication theory and academic institutions according to the studys findings the expansion of social media has significantly impacted how sports are presented and appreciated by viewers in the current evaluation researchers assessed the existing body of knowledge regarding social media in the sports authority sector from a servicedominating perspective with a focus on relationship marketing researchers looked at articles on management in englishlanguage sports journals that looked at new media technologies that allow for creating and distributing usergenerated material there was a need for conceptual practical and usercentered social media research the findings of the paper suggest that social media perception research in sport management is consistent with servicebased thinking and highlights the role of social media in developing affiliations within and between enterprises and entities interaction and engagement are required to cultivate these partnerships each topic is reviewed as is the possibility for future research and recommendations for the best methodologies context and research design sada reed has a study in which he works the rise of social media has provided new avenues for sports journalists to collect information this practice raises ethical considerations in an industry that is already undergoing technological transition journalists from minnesota were interviewed about their use of social media the impact of twitter and facebook on their news clusters the ethics of obtaining quotes from social media platforms and how these platforms have blurred the traditional lines between personal and professional relationships in the lead study researchers investigated what characteristics influence sport twitter consumption when it comes to following sportsmen on twitter in the study furthermore the study attempted to build a realistic and valid technique for academics and practitioners to examine twitter consumptionrelated motives and constraints the suggested combination model included twelve items with four incentive measures and twelve with four constraint measures the structural equation modeling method was used to examine the conceptual framework and properties of the scale 14 the respondents motivations for stc were favorably and significantly associated with their twitter use in terms of following athletes whereas their restrictions were negatively and significantly related the findings and their implications for future practical and theoretical sport marketing research are reviewed conclusion this study shows the correlation between the application of social media in the world of sports and its acceptance among the public it has been noticed that various researchers have employed different strategies to carry out some indepth research on establishing a link between the use of social networking platforms and the branding of the sports industry as mentioned in the introduction the use of these platforms is constantly growing among the masses which the sports houses are exploiting in a very creative and innovative way to promote their content yet there are certain challenges to date it has been observed that organizations are using these online platforms for some limited applications like fan interaction and promotion of businesses in the upcoming times a road lies in front of these organizations to utilize and manipulate the technology in achieving all means of communication beyond promotional and interactional purposes

figure 6 diagram showing all the variable in the study waldburger et al nd

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explored whether social context affects patterns of assimilation among adolescent children of immigrants and their families this paper explores the relationship between school context and the extent to which immigrant families assimilate one prominent attempt to describe contemporary immigration experiences is segmented assimilation theory which argues that there are many possible pathways of assimilation for immigrants to follow while classical assimilation theory assumed that immigrant families would eventually settle among and assimilate into the native middle class segmented assimilation theory identifies this traditional type of assimilation as only one possible assimilation trajectory for contemporary immigrant families this traditional assimilation trajectory entails increasing access to educational and economic opportunities as immigrants become incorporated into the american mainstream segmented assimilation theory argues that assimilation does not always entail such benefits an immigrant family assimilating in an impoverished innercity area may become incorporated into the urban underclass leading to stagnant or decreasing educational and economic outcomes whether assimilation has positive or negative consequences is thus dependent on the particular native group with whom immigrants assimilate which in turn will be influenced by the immigrant familys local residential context finally an immigrant family may choose not to assimilate fully this third possible assimilation trajectory sometimes referred to as selective acculturation involves deliberate preservation of the immigrant groups culture and values accompanied by forms of assimilation necessary for economic integration the segmented assimilation perspective suggests that this third path may be the most beneficial for immigrants who settle in disadvantaged contexts as it may allow them to avoid assimilating into the urban underclass a recent study by xie and greenman tested segmented assimilation theorys implication that the outcomes of assimilation may differ by local context they found no evidence that assimilation had different consequences in lowpoverty neighborhoods than in highpoverty neighborhoods however this result should not necessarily be interpreted as a rejection of segmented assimilation theory such an interpretation would require an unrealistic assumption that assimilation itself is a given condition exogenous to both expected consequences and the local context in this paper i avoid such an assumption by examining assimilation behaviors local context and assimilation consequences jointly my argument draws on not only segmented assimilation theory but also the literatures on social context parenting and peer effects on adolescent development together these literatures suggest that immigrant parents and their children may actively modify their assimilation behaviors in response to local contexts immigrant families that settle in economically disadvantaged areas are likely aware of the dangers that impoverished communities and schools pose for their children however given the modest financial means of many immigrant families upon arrival in the us they may find it difficult to avoid settling in such areas they may instead make efforts to protect their children from assimilating into the surrounding school and community contexts framed in terms of the above discussion this means that if an immigrant family realizes that full assimilation may entail downward mobility it may try to follow the third assimilation pathway of only limited or partial assimilation these insights suggest an alternative interpretation of segmented assimilation theory rather than the consequences of full assimilation differing according to local context the theory can be construed to imply that assimilation behavior differs by local context immigrant families in lowses contexts may have reason to avoid full assimilation immigrant families in higherses contexts by contrast may not be as concerned about the potentially deleterious effects of the surrounding environment on their children it follows that immigrant families choices about whether and how much to assimilate may depend on the local context this paper explores the relationship between social context measured in terms of school characteristics and the assimilation of adolescents in immigrant families regardless of the adolescents birthplace differences between foreignborn and usborn youth will however be accounted for in the analysis the goals of this research are threefold first in contrast to previous literature i develop a measure of assimilation that is explicitly grounded in the local context by comparing the delinquency and substance use behaviors of immigrant adolescents with those of their native peers within the same school second using this measure i investigate the hypothesis that immigrant adolescents degree of assimilation varies systematically according to school socioeconomic status third i explore the potential role of parental and adolescent behavior in creating such variation i test the hypothesis that both immigrant parents and adolescents adjust their behavior in response to social context so as to diminish the potential negative effects of assimilating into disadvantaged contexts theoretical motivations and hypotheses assimilation sociological studies of the adaptation and incorporation of immigrants into american society have generally been framed in terms of assimilation scholars of the great wave of immigration that ended in the 1920s typically viewed assimilation as a process through which immigrants gradually shed the cultures and customs of their home countries and adopted the language expressive habits and eventually the spatial distribution and socioeconomic characteristics of mainstream americans usually defined as white middleclass protestants modern perspectives on assimilation such as that expounded by alba andnee have refined the idea of assimilation to recognize that immigrant groups can also influence mainstream society in a definition that remains neutral about direction of the influence alba and nee describe assimilation as the decline and at its endpoint the disappearance of an ethnicracial distinction and the cultural and social differences that express it the critical aspect of assimilation in this definition however is still the decline of ethnic distinction that is a process by which two distinct groups become more similar to each other this idea is at the heart of the concept of assimilation most recent empirical research on assimilation has focused on change over time or across generations in immigrants language usage labor market outcomes residential patterns friendship or marriage preferences or on the consequences of such changes for educational economic or health outcomes while these investigations are important to our understanding of immigrant adaptation as studies of assimilation they leave a crucial gap if assimilation is the decline of differences between groups how can we understand immigrants assimilation without also looking at nonimmigrants to know if differences between immigrants and natives are declining it is necessary to compare the two groups this however raises another problem to which natives precisely shall we compare immigrants classical assimilation perspectives assumed that middleclass protestant whites were the natural reference group against which to evaluate immigrants assimilation one valuable contribution of segmented assimilation theory is the recognition that american society is very diverse and that there are multiple possible native groups with which immigrants may assimilate segmented assimilation theory points to the diversity of residential settlement patterns of new immigrant families as one source of variation in the assimilation pathways they experience there is considerable variation in both the ethnic and socioeconomic makeup of receiving communities and their associated schools and therefore in the native americans with whom immigrants will come into contact for this research i conceptualize assimilation as the degree of difference between immigrants and natives within the local context this conceptualization recognizes that opportunities for intergroup interaction are largely dependent on spatial proximity presumably intergroup interaction is necessary for assimilation to occur that is for differences between groups to decline thus the appropriate group of natives to which to compare immigrants is one with which they have frequent contact such as natives who attend the same school for some immigrants this native comparison group will be middleclass whites while for others it may be multiracial or composed primarily of minority individuals or workingclass whites regardless i measure immigrants degree of assimilation as the difference between immigrant adolescents and their native counterparts within the same school under this definition assimilation must be defined with respect to a particular outcome that affords a comparison between immigrants and natives while there are many possible choices here i examine differences between immigrant and native adolescents with respect to the risk behaviors of serious delinquency and controlled substance use these outcomes are appropriate for several reasons first previous research has established that they are among the outcomes that concern immigrant parents as their children become americanized second previous research has indicated that recent immigrant children do well relative to natives with respect to both substance use and delinquency but that their advantage tends to fade over time and in later generations this implies that the behaviors of immigrant children converge to those of natives as they experience assimilation but this proposition has not been explicitly tested finally these outcomes are social behaviors as adolescents usually engage in them while with others therefore i can expect these outcomes to be particularly influenced by adolescents peer groups such peerinfluenced outcomes are especially likely to reveal assimilation in the form of declining differences between groups i use the term behavioral assimilation to refer to these measures of assimilation behavior differences between immigrants and natives fall under the rubric of cultural assimilation or acculturation in milton gordons classification of assimilation variables i prefer the term behavioral assimilation for this analysis due to its greater specificity and the fact that it emphasizes the focus on a specific behavioral comparison between immigrants and natives within the local context readers should be aware however that this type of assimilation is only one of many possible forms specific hypotheses contextual parenting and peer effects several bodies of literature inform the hypotheses tested in this research an extensive literature on the effect of social context on adolescent development suggests that adolescent outcomes differ depending on school and neighborhood characteristics in turn social contexts are linked with interpersonal relationships that are crucial to adolescent development particularly relationships with parents and peers this paper integrates the arguments of segmented assimilation theory with those of the social context parenting and peer effects literatures below i briefly review these literatures and draw on them to derive specific research hypotheses while there are various ways to conceptualize social context the majority of research on contextual effects on youth outcomes has examined neighborhood contexts for the central question of this paper does the degree of behavioral similarity between immigrant adolescents and their native peers vary by social context it is preferable to examine school contexts schools provide the majority of adolescents opportunities for friendship and social interaction meaning that intergroup interactions that facilitate assimilation take place more frequently within schools than in other social contexts furthermore previous studies of contextual effects on immigrant youth have contended that theoretical arguments developed with respect to neighborhood contexts also apply to school contexts as a practical matter schools also have the advantage of being discrete social units with clear boundaries while neighborhoods lack such boundaries schools are therefore the preferred definition of social context for this analysis previous literature on the effects of school context has primarily examined educational outcomes studies of contextual influences on adolescent risk behavior have instead tended to use neighborhoods as their definition of context because much of the current knowledge about this topic comes from neighborhoodbased research both school and neighborhood effects literature will be reviewed briefly here many empirical studies have assessed the relationship between socially or economically disadvantaged neighborhood or school environments and adolescent delinquency or violence such research has typically found that neighborhood or school disadvantage is associated with higher levels of delinquency andor violence controlled substance use has been examined less frequently in relation to school and neighborhood contexts and findings from such studies have been less consistent while some studies have found that neighborhood disadvantage is related to higher substance use other research has found either no relationship or that youth in highses neighborhoods or schools are actually somewhat more likely to use controlled substances past studies have not always concluded that associations between school or neighborhood characteristics and youth outcomes are causal for example rankin and quane find that neighborhood disadvantage is associated with higher delinquency and substance use rates but that this association is due primarily to the sorting of families with disadvantageous characteristics into poor neighborhoods despite the lack of consensus about causality an extensive literature documents correlations between contextual characteristics and youth outcomes including risk behaviors for a comprehensive review of the literature on neighborhood effects these correlations are a key motivation for the present research according to modern assimilation perspectives and segmented assimilation theory immigrants will influence and be influenced by the natives with whom they have contact thus if risky behaviors are more prevalent among native youth in lowses contexts than in highses contexts the peer groups of immigrant adolescents will include more problematic peers in lowses contexts behavioral assimilation in such contexts would imply a greater level of risky behavior on average than behavioral assimilation in highses contexts this implication is an important motivation for segmented assimilation theory which suggests that immigrant youth who assimilate into disadvantaged school and neighborhood contexts are at risk of adopting oppositional youth cultures the theory does not take into account that both immigrant parents and adolescents may foresee the negative consequences of this type of behavioral assimilation and deliberately take steps to avoid it if so immigrant adolescents attending disadvantaged schools may assimilate less than those attending more advantaged schools it follows that differences between immigrant adolescents outcomes and those of their native peers will be smaller in highses schools than in lowses schools the first hypothesis is therefore h1 behavioral assimilation the gap in risk behavior between immigrants and natives will be larger in lowerses schools than in higherses schoolsnote that although previous literature indicates that there is likely a stronger relationship between school ses and delinquency than between school ses and substance use the behavioral assimilation hypothesis applies to behavioral assimilation in terms of substance use as well as delinquency as long as parents and teenagers observe high levels of at least some risk behaviors in lowerses schools whether these include high delinquency rates teen pregnancy school dropout gang activity etc perception of a riskier social environment may cause them to take steps to avoid assimilating thus parents responses to risk behaviors other than substance use may produce the anticipated effect on substance use and the behavioral assimilation hypothesis is meaningful regardless of whether this analysis finds higher average substance use in lowses schools the remaining hypotheses tested in this research concern mediating factors that may explain the relationship between school context and the behavioral assimilation of immigrant adolescents the first potential mediator is the peer group adolescence is commonly recognized to be a time when family relationships become less salient and peer relationships take on increasing importance violence and delinquency have been frequently studied with respect to peer effects the extensive literature on this topic has found a consistent and strong correlation between individuals delinquency and that of their friends 1 moreover the effect of peers is not limited to close friends felson et al find that school peers average values regarding violence and delinquency have an influence on the behavior of individual boys even controlling for the boys own attitudes peer influences have also been studied as potential mediators between disadvantaged social contexts and youth outcomes rankin and quane and haynie silver and teasdale both find that some of the effect of neighborhood disadvantage on adolescent violence is due to lowerquality peer groups in poor neighborhoods this suggests that for immigrant families in disadvantaged contexts limiting childrens assimilation into negative peer groups could be an effective protective strategy one way to limit assimilation is for adolescents to forge friendships primarily within the immigrant ethnic community thus limiting friendships with native peers this strategy is likely to be successful in reducing negative behaviors that are less prevalent among immigrants than natives including substance use and delinquency it would not be likely to be helpful in reducing negative behaviors more prevalent among immigrants than among surrounding natives interethnic friendship may thus mediate the hypothesized relationship between school context and behavioral assimilation the second research hypothesis is therefore h2 interethnic friendship interethnic friendship will be less common for immigrant students in lowerses schools than for immigrant students in higherses schoolsanother way of avoiding assimilation into problematic peer groups is for immigrant adolescents to limit friendships according to friends behavior rather than their ethnicity selecting friends who are not as engaged in risk behavior is one way that immigrant adolescents can create a buffer between themselves and the surrounding social environment thus limiting the potential negative influence of social assimilation however it would be unrealistic to expect immigrant students friends to engage in fewer 1 to what extent peers have a causal influence on adolescent behavior has been the subject of debate however it is theoretically possible that the tendency toward homogamy in friendship is sufficient to explain the association between individual and peer behavior risk behaviors in schools where those behaviors are more prevalent instead the key prediction is that immigrants friendship groups are less affected by the school environment than those of natives thus an interaction is implied between being an immigrant and being in a lowerses school andor a school with higher levels of student involvement in risk behavior the third research hypothesis is therefore h3 peer behavior interaction attending a lowerses school or a school with higher average levels of student risk behavior will have a smaller impact on the risk behavior of immigrant students friends than on the risk behavior of native students friendsparenting practices are the second proposed mediating factor between school context and behavioral assimilation parents are likely aware of the dangers of friendships with deviant peers and they may take action to protect their children from such influences for example furstenberg et al and jarrett both found that parents in disadvantaged neighborhood contexts were highly aware of the dangers that such contexts posed for adolescents these parents strategies to protect their children included restricting childrens friendship choices and their freedom of movement in the neighborhood increasing parental supervision and encouraging children to participate in activities that take place outside rather than within the neighborhood while the above studies were based on native families there is reason to think that immigrant parents may be even more concerned about contextual dangers because many immigrants come from countries in which parents and teachers authority over the young is stronger and standards for behavior are much less lenient than in the united states they are likely to have stricter standards for adolescent behavior while native parents may be no less fearful of extreme outcomes such as children using hard drugs or being involved in gang violence they may perceive less serious behaviorssuch as drinking alcohol or acting rowdy with friends in public places as more normal for adolescents therefore immigrant parents may a lower tolerance for youth risk behavior and be more proactive in shielding their children the limited empirical evidence in this area supports this idea portes and rumbaut found that the perceived permissiveness of us culture made immigrant parents especially fearful of the dangers americanization posed to their children perreira et al found that latino immigrant parents were specifically concerned about the potential negative consequences of their childrens friendships with native peers the parents feared that such friendships increase their childrens risk of drug use violence and teenage pregnancy parents efforts to protect their children from such influences included increasing parental supervision and discouraging children from socializing with native peers many studies have shown that parenting behaviors have an important influence on adolescent outcomes including risk behavior several studies have found that parental supervision is related to lower levels of delinquency friendships with deviant peers have also been shown to be reduced by increased parental monitoring if immigrant parents do indeed increase supervision and control in response to disadvantaged social contexts they may reduce their childrens risk behavior both directly and through reducing their affiliations with problematic peers parenting behaviors are therefore potentially important mediators between school disadvantage and behavioral assimilation of immigrant adolescents the fourth research hypothesis is thus h4 parental control parental control will be higher for immigrant youth in lowerses schools than for those in higherses schoolsif parenting and friendship do indeed serve as mediators between social context and behavioral assimilation they must explain part or all of the observed relationship between social context and behavioral assimilation therefore assuming the empirical analysis supports the behavioral assimilation hypothesis by showing a lower degree of behavioral assimilation for immigrant adolescents in lowerses schools i will test one final hypothesis h5 mediation characteristics of immigrant adolescents friends and the behavior of immigrant parents explain the lower degree of behavioral assimilation for adolescents in lowerses schools data and methods this study uses data from wave 12 of the national longitudinal study of adolescent health add health is a schoolbased survey of adolescents who were in grades 712 in 19941995 the inschool portion of the survey was administered to all students in the sampled schools who were present on the day of the survey the inschool questionnaire covered such topics as demographic characteristics parental education health status academic grades and friendships and was completed by more than 90000 adolescents a smaller core sample of add health respondents was selected to complete more indepth interviews at home additional topics covered by this portion of the survey include nationality of students and of their parents language spoken in the home and many detailed measures of health risk behaviors family dynamics and psychosocial adjustment add health is a good data source for this study because not only is its sample large and nationally representative it also contains oversamples of chinese cubans and puerto ricans as a result i have adequate sample sizes of both asian and hispanic firstand secondgeneration adolescents unfortunately i do not have adequate sample sizes of other groups so i limit my analysis to asians and hispanics variables school sesadd health has limited options for measuring school ses a survey given to school administrators included some potentially useful questions but high rates of missing responses preclude their use instead i measure school ses by aggregating students responses to a question on parental education from the inschool survey aggregated responses to this question have been used by past researchers as an indicator of school ses for example pong and hao measure school ses using the percent of students parents who have a college degree or higher i take a similar approach in this study i measure school ses as the percentage of students mothers who did not finish high school which ranges from less than 1 to 44 the continuous version of this variable is used in all regression models i also experimented with several categorical versions of this variable all yielded very similar results to the continuous version adolescent risk behaviorthe add health inhome survey provides detailed information on participation in risk behaviors from which i construct my dependent variables i consider two types of risk behavior delinquent behavior and controlled substance use my measure of delinquent behavior is based on a series of questions asking respondents to report whether or not they have participated in particular undesirable illegal or violent activities in the past year the behaviors asked about range in seriousness from acting rowdy in a public place to shooting or stabbing someone because the less serious behaviors are not uncommon among adolescents i focus here on more serious behaviors i construct a scale measuring the number of such behaviors the adolescent reports having engaged in during the past year the specific behaviors are used or threatened to use a weapon to get something from someone pulled a knife or gun on someone shot or stabbed someone carried a weapon to school sold illegal drugs broke into a home or building to steal something stole something worth more than 50 got into a serious physical fight hurt someone badly enough in a fight to need medical attention got hurt in a fight badly enough to need medical attention and took part in a fight of one group against another the scale ranges from 0 to 11 because these behaviors vary by age i agestandardize the measure by taking the respondents agespecific percentile score on the delinquency scale the final variable thus potentially ranges from 0 to 100 i derived the measure of controlled substance use from the selfreported frequency of use of tobacco alcohol and marijuana as expected use of controlled substances varies highly with age and by substance therefore i agestandardized the three items by calculating the respondents agespecific percentile score for each substance i then combined the information from the three items into a single scale by taking the average percentile score across all three mediating variablesthe inschool survey is used to measure friends ethnicity and participation in risky behaviors the survey asked each student to name up to 10 close friends in the same school making it possible to link each individuals survey responses with those of hisher friends it is thus possible to measure friends characteristics and behavior directly from their own survey responses the inschool survey included ordinal scales measuring frequency of fighting and use of alcohol and tobacco the fighting scale ranges from 0 to 4 i treat the average score on this scale among a students friends as an indicator of friends delinquency unfortunately the inschool survey did not measure other types of delinquent or violent behavior so it is not possible to construct a delinquency scale for respondents friends that is equivalent to the scale used for the main sample the ordinal scales for alcohol and tobacco use range from 0 to 6 i create a single substance use scale for each friend by summing the responses to the two questions i use friends average score on this scale as a measure of friends substance use as with delinquency it is not possible to create an exact equivalent of the substance use measure constructed for the main sample which also includes marijuana use i also examine the ethnic composition of friendship groups by constructing a measure of the propensity of an adolescent to make friends within hisher ethnic group opportunities for interethnic friendship are heavily influenced by relative group size that is the more coethnic peers available the higher the likelihood of having coethnic friends here i wish to focus on friendship choices which are controlled by the individual rather than school ethnic composition which is not under individual control therefore i use a measure of friendship composition that is purged of opportunity structure and instead reflects immigrant students degree of preference for coethnic friends 3 this measure which i refer to as f is the difference between the proportion of coethnics found among the adolescents friends and the proportion of coethnics in the adolescents school if there is no ethnic preference in friendship we would expect these two proportions to be equal a negative value indicates a tendency to choose coethnics as friends a value of zero indicates that the respondent has no ethnic preference in friendship and a positive value indicates that the respondent tends to choose friends outside hisher ethnic group the inhome survey contains series of questions designed to measure parental supervision of and control over adolescents which i use to operationalize parental monitoring one series of questions asks whether a parent is home at certain times of day including before school after school at dinnertime and at bedtime because the after school and early evening hours are the times adolescents are thought to be most prone to engaging in risky behaviors i construct a measure of very low parental supervision at these times of day the measure is a binary variable coded 1 if a parent is almost never or never present after school and a parent is present during dinner less than three evenings a week several other measures of parental monitoring were also constructed based on these questions but because all provided similar results only one is presented in the tables another series of questions measures parental efforts to control adolescent behavior these questions which are answered by the adolescent consist of seven items measuring whether or not the parent allows the adolescent to make hisher own decisions about curfews friendship choices what to wear how much television to watch which programs to watch bedtime and what to eat i construct two measures of parental control from these questions because the item about friendship choices is the most directly relevant to my research questions i construct a binary indicator equaling 1 if the adolescent makes hisher own decisions about friends 0 otherwise the second measure is a count of the number of own decisions an adolescent is allowed to make finally a parent was interviewed whenever possible during the inhome survey 4 although parents were not asked about supervision or specific rules for their children they were asked how often they make decisions with the reference child i create a binary indicator of parental decision participation equaling 1 if the parent reports always or often making decisions with the adolescent 0 otherwise for brevity i refer to this group of supervision and decisionmaking items as parental control measures control variablesadd health provides an array of information on family background and demographic characteristics the following variables are used as controls in the analysis age gender family structure logged family income parent interview missing parental education immigrant generation and length of stay first generation with greater than 5 years in the us and second generation school racial composition speaks english at home and specific hispanic or asian ethnicity methods due to the approach i take to defining and measuring behavioral assimilation the primary dependent variable in my analysis is the difference in risk behavior between an immigrant adolescent and nonimmigrant adolescents in the same school in addition to measuring the respondents own delinquency or substance use it is therefore necessary to measure average school levels of the same behavior a potential problem arises from the relatively small sample sizes in many schools for the inhome survey from which the measures of risk behavior are taken because the behaviors in question are strongly influenced by sex and age it is preferable to calculate a school average of risk behavior net of the sex and age composition of the respondents sampled in that school which is largely a function of chance therefore instead of simply taking the average level of behavior i regress risk behavior on sex age and a series of school dummy variables for nonimmigrant adolescents i use a modeling strategy in which i adolescents are clustered within j schools in the following models the superscript 0 refers to nonimmigrants while the superscript 1 refers to immigrants the equation used is thus where y 0 i j is natives risk behavior a 0 ij is a vector of variables including age and sex and is the schoolspecific intercept term measuring average behavior differences across schools i then apply the coefficients from the resulting regression model to the sample of immigrant students and generate a predicted value for each student based on hisher age gender and school under the assumption that school differences in risk behavior among native youth do not depend on sex or age this predicted value is equivalent to a measure of the average behavior of natives of the same age and sex as the immigrant adolescent within a particular school i then define my dependent variable as the difference between the immigrant adolescents level of risk behavior and the school average level of risk behavior which will be referred to as d this twostep estimation strategy in which differences between immigrants and nonimmigrants are incorporated into the firststep calculation of the dependent variable allows me to later restrict my sample to immigrants without losing the ability to model differences between immigrants and nonimmigrants this is preferable because effects for covariates included in the models may differ for immigrants and natives particularly those having to do with assimilation restricting the model to immigrants ensures that the results are accurate for the main group of interest immigrant adolescents5 i run all analyses separately for hispanics and asians specific models are explained more fully when they are presented in the results section due to the high data requirements for making withinschool comparisons i do not have a sufficient sample sizes to examine specific national origin groups separately i include national origin as an additive control in my analytical models in all statistical analyses i use appropriate weights to account for stratified sampling nonproportionate nonresponse and nonproportionate attrition observations without sample weights were dropped from the analysis in regression analyses i also appropriately correct standard errors for add healths complex survey design including its use of clustering and stratification the total sample sizes are 1451 hispanic immigrant youth and 810 asian immigrant youth due to small numbers of missing values analytic sample sizes vary somewhat for models with different dependent variables sample sizes for each specific model are included in the tables the sample is spread across 96 schools all of which contain at least one sampled asian or hispanic immigrant adolescent of these 96 schools 16 schools contain no hispanic immigrants and 25 schools contain no asian immigrants the average number of sampled hispanic immigrants per school is 176 while the average number of sampled asian immigrants per school is 97 results descriptive results appendix a gives descriptions and averages by raceimmigration status of all variables used in the analysis past work has revealed that risk behaviors should be lower for immigrants than natives and indeed appendix a shows that both immigrant groups have somewhat lower substance use rates than natives although hispanics have higher average delinquency rates than natives this is most likely due to differences in socioeconomic status appendix a also reveals that hispanic immigrants attend lowerses schools and come from families with lower incomes and lower parental education than natives the same is not true for asian immigrant youth who come from families with incomes and parental education similar to those of natives appendix b presents descriptive statistics showing the relationships between school ses risk behavior and traditional assimilation measures that have been used in previous literature with one exception the average school percentage of mothers lacking a high school diploma is higher for the less assimilated but in most cases the difference is small risk behavior differences are generally consistent with previous literature in showing lower levels of substance use and delinquency for firstgeneration and less assimilated youth although there are exceptions for both asians and hispanics the interrelationships among traditional measures of assimilation school ses and risk behavior indicated by appendix b point to the importance of relying on multivariate models which can estimate the effects of these different factors simultaneously to test the papers main hypotheses table 1 presents descriptive statistics on the relationship between risk behaviors school ses and raceimmigration status for descriptive purposes school ses has been coded into a 3category variable where the top category includes schools whose percentage of mothers who did not graduate from high school is at the 25 th percentile or below the moderate category includes schools between the 25 th and 75 th percentiles and the low category includes schools at or above the 75 th percentile there are 24 lowses schools 48 moderateses schools and 24 highses schools in order to ease interpretation the information is also presented graphically in figure 1 and figure 2 for substance use being in a lowerses school is related to a more favorable outcome for both asian and hispanic immigrant adolescents while immigrant students in highses schools have substance use levels very close to the median substance use levels among those in lowses schools are only at the 38 th percentile or 45 th percentile this pattern does not hold among either white or black natives for whom there is no consistent relationship between school ses and substance use but is similar among the small group of other natives this lack of a clear relationship for natives is consistent with previous literature on contextual effects on youth substance use for asian immigrant youth delinquency is significantly lower in lowses schools than in highses schools for hispanic youth there is no obvious pattern for all three groups of native youth by contrast delinquency levels appear to increase as school ses goes down the results for both substance use and delinquency suggest a different relationship between school ses and risk behavior for immigrants than for natives while suggestive these results are not definitive due to the possible confounding influence of familylevel ses and assimilation factors which are likely related to school ses i therefore turn to regression models to test the papers main hypotheses multivariate results table 2 presents results from models predicting d the measure of behavioral assimilation due to the way the dependent variable was constructed correctly interpreting the regression results in table 2 requires an examination of the constant from the model including only school ses and no covariates recall that the dependent variable d is defined as the difference between an immigrants risk behavior and the mean risk behavior for natives in the same school adjusting for age and gender a negative average value of d thus indicates that immigrants engage in lower levels of risk behavior than natives in the same school the school ses coefficient tells us whether immigrants are engaging in less risk behavior relative to natives as the proportion of students mothers without a high school diploma increases a negative coefficient would indicate that immigrants compare more favorably to natives in lowerses schools however the sign of the coefficient alone cannot inform us about the central research question of this paper whether the behavior of immigrant and native youth is more or less similar in lowerses schools to make this interpretation we need to know how the risk behaviors of immigrant and native youth compare in the highestses schools if there is no difference in highses schools or if immigrants have lower risk behavior than natives in these schools then a negative coefficient on school ses indicates an increasing behavior gap as school ses declines thus for each model it is necessary to first examine the sign and significance of the constant term if the constant term is negative or not significantly different from 0 it is valid to interpret a negative coefficient on school ses as evidence of an increasing behavior gap6 h1 behavioral assimilation hypothesish1 is tested in models 1 and 2 in table 2 model 1 includes only school ses without any covariates the intercept terms in the first panel of table 2 for both outcomes and both ethnic groups are not significantly different from 0 we may therefore interpret negative school ses coefficients as indicators of increasing behavior gaps model 2 adds an extensive set of control variables including familylevel socioeconomic and assimilation indicators because of the possibility that the bivariate relationship between school ses and behavioral assimilation could be driven by either family ses or family assimilation level model 2 rather than model 1 provides the key test of the behavioral assimilation hypothesis for substance use the school ses coefficient for asian youth is only marginally significant in model 1 but becomes significant at the 05 level following the addition of the control variables in model 2 the coefficient of 31 in model 2 indicates that for every 1 percentage point increase in the schools percent of students mothers who did not graduate from high school the difference between asian immigrants and natives substance use scores increases by about a third of a percentile point for hispanic youth the results are similar while there is no significant relationship between school ses and substance use in model 1 model 2 reveals that the substance use gap is larger in schools with a greater percentage of mothers who did not finish high school results for delinquency are presented in the second panel of table 2 for asians the coefficient of school ses in model 1 is negative and statistically significant at the 05 level after the addition of control variables in model 2 its magnitude more than doubles growing from 45 to 95 model 2 thus reveals a sizeable relationship between school ses and the delinquency gap for asians after controlling for family background and school ethnic composition for every 1 percentage point increase in the schools percent of students mothers who did not graduate from high school the delinquency gap between asian immigrant and native youth increases by almost a full percentile point for hispanics by contrast there is no significant relationship between school ses and the delinquency gap in either of the models overall the findings support the behavioral assimilation hypothesis for both groups when the outcome is substance use but only for asians when the outcome is delinquency 7 h2 interethnic friendship hypothesiswhat explains this relationship between school ses and immigrantnative differences in risk behavior h2 and h3 proposed immigrant adolescents friendship choices as a possible explanation while h4 proposed parenting behaviors table 3 presents results from the tests of these three hypotheses the first panel shows results testing h2 the interethnic friendship hypothesis the coefficients in this panel are from ols regression models in which f the propensity for interethnic friendship is the dependent variable the unadjusted model shows no significant relationship between school ses and propensity for interethnic friendship for asians and an only marginally significant relationship for hispanics for asian youth but not hispanic youth the adjusted model shows a small but statistically significant relationship in the expected direction lower school ses is related to a lower likelihood of interethnic friendship the analysis therefore provides support for the interethnic friendship hypothesis for asian immigrant youth although the effect size is small for hispanic youth the interethnic friendship hypothesis is not supported 3 test h3 the peer behavior interaction hypothesis which states that risky behaviors of immigrant students friends will be less influenced by school social context than risky behaviors of native students friends for asians the sample in these two analyses includes only native youth and youth in asian immigrant families while for hispanics the sample includes only native youth and youth in hispanic immigrant families thus the immigrant interaction terms give differences specifically between either asian or hispanic immigrant youth and natives table 3s second panel shows results from models in which the average level of fighting among students friends is the dependent variable the coefficients for school peer fighting show that it is positively related to friends fighting as expected the main 7 these models as well as the models in table 4 were run separately for first and second generation adolescents as a sensitivity check the results indicated that while overall there were fewer significant coefficients school ses remained significant in some models for both generations and effect sizes were typically similar even when statistical significance was lost pooling first and second generation adolescents is therefore justified and also yields greater statistical power h3peer behavior interaction hypothesisthe next two panels of table effects of school ses are statistically insignificant and close to 0 indicating that there is no relationship between school ses and friends fighting for native youth the negative coefficient on the immigrantschool ses interaction term in the unadjusted model for asians however indicates that being in a lowerses school is related to lower levels of fighting among friends for asian immigrant youth but it is only marginally significant however after adjusting for covariates there are no remaining significant interactions for asian youth by contrast the interaction between being a hispanic immigrant and school peer fighting is positive and significant in both the unadjusted and adjusted models this indicates that while higher levels of school peer fighting are related to higher fighting among friends for nonimmigrant youth this effect is actually stronger for hispanic immigrant adolescents the models shown in the third panel of table 3 treat friends average substance use as the dependent variable in both unadjusted models the positive and significant main effect of school peer substance use for natives is 95 indicating that higher substance use among students in general predicts higher substance use among natives friends for both immigrant groups the significant negative interaction terms between being an immigrant and school peer substance use show that this effect is only about half as strong for immigrants these results are also apparent in the adjusted models although the effect for asians drops to the 1 significance level the interaction term between being an immigrant and school ses is also negative and significant for asians in the adjusted model indicating that although school ses has no relationship with friends substance use for natives asian immigrants friends have lower average substance use in lowerses schools the peer behavior interaction hypothesis is thus supported for both asian and hispanic immigrant youth when the outcome is friends substance use and partially supported for asian youth when the outcome is friends fighting behavior though with marginal statistical significance on the other hand the results for friends fighting behavior among hispanic immigrant youth were exactly opposite of those predicted by the peer behavior interaction hypothesis 3 presents four models testing the parental control hypothesis the number of decisions the youth is allowed to make for himherself is modeled using ols regression while the other three parenting measures are modeled using logit regression both the unadjusted and adjusted results for asians show that as the percentage of students mothers without a high school diploma rises the odds of youth having low afternoonevening supervision levels or lacking rules about friendships decline while the unadjusted model indicates that asian students in lowerses schools are allowed to make fewer of their own decisions this result disappears after addition of control variables the parenting results for asians thus provide limited support for the parental control hypothesis for hispanics the results do not clearly support the parental control hypothesis while being in a lowerses school is related to hispanic immigrant adolescents being allowed to make fewer own decisions after adjusting for covariates it is also related to a higher probability of low parental supervision h4 parental control hypothesisthe bottom half of table h5 mediation hypothesisanalyses testing the behavioral assimilation hypothesis revealed significant relationships between school ses and the substance use gap for both ethnic groups and between school ses and the delinquency gap for asian youth models 3 and 4 of the behavior gaps presented in table 4 now test whether these relationships can be attributed to friendship or parenting factors respectively table 4 model 3 adds the friendship variables to the variables included in table 2 model 28 there is no significant effect of interethnic friendship on the substance use gap for both asians and hispanics the positive effects of friends behavior on the substance use gap show that immigrant students whose friends engage in more substance use compare less favorably with their native peers than do immigrant students whose friends have lower levels of substance use for asian students after taking these friendship factors into account the effect of school ses is considerably smaller than in table 2 model 2 and no longer statistically significant this suggests that the tendency of asian immigrant students in lowses schools to choose friends who engage in lower levels of substance use is an important part of the explanation for the larger immigrantnative substance use gap in lowses schools the same is not true for hispanic students the school ses coefficient changes very little between table 2 model 2 andtable 4 model 3 while friendship factors are part of the substance use story for asian students they do not appear to have a similar effect on delinquency neither interethnic friendship nor friends behavior has any effect on the difference in delinquency between asian immigrant and native youth correspondingly the addition of these variables does not explain the relationship between school ses and the delinquency gap table 4 model 4 adds the parenting variables to those included in table 2 model 2 for asians low parental supervision was the only parenting variable significantly related to school ses at the 05 level after adjusting for controls therefore it is most likely candidate to explain the relationship between school ses and the behavior gaps table 4 model 4 shows that low parental supervision is also the only parenting measure that is significantly related to the substance use gap for asians asian immigrant students who lack parental supervision in the afternoon and early evening hours compare less favorably to their native peers than students who are supervised at these times of day more importantly for the mediation hypothesis the effect of school ses is reduced by about half compared to table 2 model 2 the larger substance use gap for asian youth in lowses schools can thus be attributed in part to the higher levels of parental supervision for students in lowses schools there is no similar pattern among hispanics however the school ses coefficient actually becomes somewhat larger after the addition of the parenting variables to the substance use model that parenting does not contribute to the larger substance use gap in lowses schools for hispanics is perhaps not surprising given the lack of a consistent relationship between school ses and parenting shown in table 3 turning to the results for delinquency we see that parenting behaviors are more successful than friendship factors at explaining the relationship between school ses and the delinquency gap for asians although the school ses coefficient remains significant at the 1 level it drops in magnitude from 95 to 74 between table 2 model 2 and table 4 model 4 thus it appears that parenting factors explain at least some of the relationship between school ses and the delinquency gap overall the results for asian immigrant youth support the mediation hypothesis friendship and parenting factors do appear to explain at least in part the relationships between school ses and the behavior gaps the results for hispanic immigrant youth do not support the mediation hypothesis 9 discussion and conclusion this paper explored the relationship between social context and patterns of assimilation among asian and hispanic immigrant youth although the degree of difference between immigrants and natives is at the core of the concept of assimilation most previous work on immigrant assimilation has failed to make specific comparisons between immigrants and natives the question of which group of natives form the appropriate comparison group for a given group of immigrants has also been understudied in the literature by contrast this paper conceptualized assimilation as behavioral similarity between immigrants and natives within the local context this behaviorallybased approach to defining and measuring assimilation in contrast with other frequentlyused measures of assimilation such as immigrant generation and length of stay allows me to develop insights into aspects of the assimilation process that can potentially be controlled by immigrant families i argue that immigrant families are active and deliberate participants in shaping their own assimilation trajectories the analysis confirms findings from previous investigations of the relationship between immigrant assimilation and the risk behaviors of substance use and delinquency but the research strategy and results also differ in several important ways like previous research including other studies based on add health data the current analysis shows that immigrant children tend to have lower rates of both substance use and delinquency than natives however these findings have typically been based on comparisons between immigrant children and the average outcomes of all native children despite large differences in the geographic dispersion of and schools attended by children of different immigrant generations i argue that it is more informative to compare immigrant and native adolescents within the same school using this strategy this analysis demonstrates that the previously documented immigrant advantage in risk behavior is not constant across schools but rather is larger in lowses schools than highses schools it also sheds light on potential mechanisms linking school ses to differing levels of substance use and delinquency among immigrant youth previous research has examined whether 9 the sample size is smaller in table 4 model 4 than in table 2 model 2 due to missing values on one of the parenting measureswhether the parent makes decisions with the adolescent the model shown in table 4 model 4 is thus computed over only a subsample of the cases used to compute table 2 model 2 in order to make the two strictly comparable an alternate version of table 2 model 2 was computed using only the subsample of nonmissing cases used in table 4 model 4 the results were very similar and the conclusions reached regarding h5 remained the same differences between immigrant and native families in parentingrelated factors contribute to generational differences in youth delinquency but sources of variation in such mechanisms among immigrant families have not been examined this analysis explored school context as a potential influence on both parenting behaviors and youth friendship choices among immigrant families the papers main hypothesis stated that immigrant adolescents will be less assimilated in social contexts in which behavioral assimilation is more likely to have negative consequences i tested this hypothesis by examining the relationship between school ses and the degree of behavioral similarity between immigrant and native youth within the same schools the results for asian youth and to a lesser extent for hispanic youth support this hypothesis while in the highestses schools there are few differences in risk behavior between native youth and either immigrant group in lowerses schools asian immigrant youth tend to engage in less delinquency than their native peers and both asian and hispanic immigrant youth tend to engage in less substance use these results particularly for asians are consistent with a scenario in which immigrant families anticipate the consequences of assimilation and therefore avoid assimilating in disadvantageous social contexts where these consequences are more likely to be negative however this leaves us with an unsatisfying black box connecting social context to behavioral assimilation for the above scenario to be plausible it is necessary to demonstrate concrete intermediary factors under the control of immigrant families that would allow adolescents in disadvantaged contexts to avoid being drawn into risky behaviors two such mediating variables were proposed parenting behaviors and adolescent friendship choices both of these factors contributed to the relationship between school ses and behavioral assimilation for asian immigrant youth asian immigrant adolescents in lowses schools tend to choose friends with betterthanaverage risk behavior profiles and their parents tend to supervise them more closely for hispanic youth however neither parenting nor friendship helped to explain the relationship between school ses and the substance use gap why would parenting behaviors or friendship choices have stronger effects on risk behavior assimilation for asians than for hispanics the theoretical perspectives discussed earlier give us no reason to suppose that hispanic families would be any less concerned about the deleterious effects of assimilation on their children than asian families on the contrary past work has shown that hispanic immigrant parents are often concerned about the influence of american peers on their childrens behavior it is more likely that the explanation lies in other differences between asian and hispanic immigrants one potentially important difference may lie in the resources asian and hispanic families can muster to effectively guide childrens assimilation as portes and rumbaut point out parental setting of rules is not the same as enforcing them since external factors can prevent effective guidance of children while there is wide variation by ethnicity among both hispanics and asians asian communities may in general offer more support to parents seeking to delay their childrens acculturation or assimilation into native peer groups the relatively high proportion of highses immigrants within many asian ethnic groups leads to greater availability of community cultural institutions to assist parents in maintaining their childrens connections to the culture of origin for example zhou and kim describe the prevalence of language schools which are accessible to workingclass and professional immigrants alike in both chinese and korean communities on the other hand portes and rumbaut found that of all the immigrant groups they surveyed mexicans and nicaraguans were among the least likely to report that coethnics in the neighborhood help each other and are supportive of each other such lack of community support puts families at risk of dissonant acculturation in which differences between parents and childrens pace of acculturation results in intergenerational communication and relationship difficulties and erodes parents ability to guide their children thus asian families may on average have more means than hispanic families to influence their childrens assimilation and their efforts to do so may be more likely to meet with success another difference between asians and hispanics is the history of immigration because largescale immigration from most asian countries did not commence until recently the third generation for most asian groups is small sometimes almost nonexistent for hispanics by contrast there has been a longstanding steady flow of immigration to the united states for many generations leading to a sizeable population of thirdplus generation hispanics thus there is a substantial samerace native peer group in schools for hispanic immigrants but not for asian immigrants indeed of the sampled add health respondents there are approximately equal numbers of firstgeneration and thirdgeneration hispanics while there are nearly three times as many firstgeneration as thirdgeneration asians adolescents tendency to choose friends of the same race coupled with the lower availability of samerace native peers for asian immigrants may make it easier for asian than for hispanic parents to discourage their children assimilation into native peer groups10 overall the analysis is more successful at illuminating assimilation patterns among asian than hispanic immigrants while the above factors may explain why parenting and friendship factors operate differently for the two groups the papers inability to explain why there was a significant relationship for hispanics between school ses and substance use but not delinquency is an additional limitation both gender and religious participation were explored as factors that may relate differently to substance use and delinquency for hispanics but neither appears to play a role in this finding another limitation of the analysis is the inability due to sample size to conduct separate analyses for different asian and hispanic ethnic groups there is a great deal of diversity among asian and hispanic ethnic groups and the processes reflected in this paper may not apply equally to all subgroups it is especially important to note that the findings for hispanics are driven primarily by mexicans as they make up a large majority of the add health hispanic immigrant sample finally the analysis would be stronger if it were based on longitudinal data the ideal design would be to follow a sample of immigrant youth over time as families move between schools however due to several key variables being measured by only by the crosssectional inschool portion of add health a longitudinal design was not possible for this current analysis finally the issue of selectivity into neighborhoods and schools deserves comment as discussed above the current study is based on crosssectional observational data in absence of being able to randomly assign respondents to neighborhoods or schools there is the danger that the results are biased by respondents ability to choose their social contexts like most other studies of contextual effects based on nonexperimental data this study makes the implicit assumption that such selection occurs only on the basis of observable characteristics which are then controlled in the regression models however this assumption is not testable and may not be realistic this potential endogeneity of social context would be particularly problematic if immigrant parents residential choices are more affected than those of native parents by how well their children are doing for example immigrant parents who suspect problematic behavior among their children may make a greater effort to move to a better neighborhood even in the absence of having greater financial means to do so this would imply the selection of immigrant children with higher levels of problem behaviors into better schools which could contribute to their lower behavioral advantage in highses schools while the present study lacks the necessary data to address such possibilities the potential endogeneity of school ses is an interesting avenue for future exploration in conclusion i emphasize the importance of recognizing immigrant families as active agents in shaping their assimilation pathways modern theoretical perspectives highlight the importance of social context for immigrant assimilation segmented assimilation theory in particular argues that the effects of assimilation on socioeconomic health and other outcomes depend on social context the results of this study affirm that this emphasis on context is justified but also suggest a significant extension that social context may not only moderate the effects of assimilation but may also affect whether and how much immigrant families choose to assimilate in the first place future studies of immigrant families should therefore take care to recognize that patterns of assimilation reflect at least in part immigrant families deliberate adaptations to the surrounding context note omitted categories for the independent variables are as follows age 13 male 2biologicalparent family parent interview not missing first generation with length of stay less than 5 years speaks nonenglish language mexican ethnicity chinese ethnicity substance use by school ses delinquency by school ses table 3 the parenting and friendship as mediators between school ses and adolescents behavioral assimilation in addition to the variables shown models 34 control for age gender specific asian or hispanic ethnicity parent interview missing family income average parental education family structure length of stay in us for foreignborn immigrants immigrant generation whether english spoken at home and school black school asian and school hispanic and whether adolescent has 1 or 2 immigrant parents full results are available from author upon request appendix a variable descriptions and means

this paper explores the relationship between social context measured in terms of school characteristics and the assimilation of immigrant adolescents first it develops a measure of assimilation based on comparing immigrant adolescents to native peers within the same school second it investigates whether immigrant adolescents degree of assimilation varies systematically according to school ses third it explores the role of parental and adolescent behavior in creating such variation results show that both asian and hispanic immigrant youth are less assimilated to native youths substance use and delinquency patterns in lowerses schools this association can be explained by parenting behaviors and adolescent friendship choices for asian youth but not hispanic youth the recent renewed wave of mass immigration to the united states us has sparked attempts to rethink theories of immigrant adaptation and assimilation many scholars have argued that the experiences of immigrants currently entering the us differ in fundamental ways from the experiences of those who arrived in the early twentieth century immigrants settlement patterns upon arrival constitute one such difference earlier cohorts of immigrants typically settled in central cities often in ethnic enclaves alba and nee 2003 and did not disperse into suburban and less ethnically segregated areas until later generations whereas todays immigrants often settle directly in the suburbs alba et al 1999 moreover economic and social changes have brought about deterioration of many central cities meaning that immigrants who do settle in these traditional areas may find themselves in economically isolated highly segregated neighborhoods suarezorozco and suarezorozco 1995waldinger 2001 for immigrants children residential location carries additional importance because it typically determines the schools they attend those whose families settle in central cities often attend educationally and socially disadvantaged innercity schools while their peers in more affluent suburbs also have the advantage of betterfunded suburban schools thus there is a great deal of variation and inequality in the types of school and community contexts that immigrants encounter in the us the implications of such diversity in social contexts for immigrant adaptation are not yet fully understood but many scholars have suggested that adolescents in immigrant families who must cope simultaneously with developing independent identities and issues of acculturation may be particularly influenced by the surrounding environment

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introduction the outbreak of the covid19 pandemic has brought a sharp decline in the tfr in late 2020 and early 2021 though this negative trend reversed for some countries in the second half of 2021 several studies attempted to explain the mechanisms behind extended author information available on the last page of the article these developments referring to the apparent increase in economic uncertainty job and income loss or deterioration of career prospects sudden termination of infertility treatment and access to external childcare no study however has yet looked at the role of homebased work which became widespread during the and fertility this is quite an oversight since the massive spread of hbw has been one of the major and most universal changes that the covid19 pandemic has brought to workers lives on average the share of employees working from home in the eu in 2020 more than doubled compared to 2019 and within the group of 1834 year olds exceeded 50 of employees this enormous and rapid increase in hbw together with lockdowns and school closures has completely changed the conditions of combining paid work and care during the pandemic and could have consequently affected workers fertility intentions and further their realizations the possibility to work from home is potentially an important determinant of fertility since it affects the conditions of combining paid work and care and career opportunities of homebased workers on the one hand homebased work may facilitate fertility as it may support the reconciliation of paid work and care by allowing workers to save on commuting time or organizing paid work more flexibly around family obligations on the other hand however it may also work in the opposite direction exacerbating workfamily conflict by blurring the boundaries between paid work and family life and having negative consequences for workers career opportunities by influencing their productivity interaction with colleagues and promotion opportunities the only two studies that have been conducted so far on the topic in the prepandemic period suggest that the possibility to work from home at least some time is indeed important for fertility decisions though its influence strongly depends on womans family and work context most importantly hbw was found to be positively correlated with childbearing but under the condition that it was really helpful for workfamily reconciliation eg enabled substantial savings on commuting time or was used by those mothers whose partners perform relatively little childcare in light of these arguments the rapid spread of hbw since march 2020 might have opened new opportunities for childbearing at the same time the pandemic and the related lockdowns and school closures have exacerbated numerous risks related to hbw it has been widely demonstrated that workers who had the possibility to perform their jobs at home during the pandemic had to simultaneously take care of children during school closures which resulted in higher mental load lack of sleep work interruptions and increased risk of multitasking in this paper we investigate how the change in access and frequency of use of hbw that took place between february 2020 and june 2021 are related to changes in fertility intentions of parents this relatively long timespan enables us to assume that people have already had enough time to experience what hbw entails for workfamily reconciliation worklife balance and their professional careers during the specific pandemic period therefore our findings would not reflect peoples reactions to the first pandemic shock but rather a midlongterm consequence of working from home during the pandemic times our focus is on parents of at least one child since they were able to make a fullscale experience of what it means to combine hbw with childcare and thus make fully informed changes in their subsequent fertility plans our study is conducted for poland this country in the prepandemic period was characterized by relatively low fertility rates and in particular low progression to second and higher order births which did not reflect the desired family size of poles moreover it also displayed rare access to and use of home based work this means that the studied population had a considerable potential for change in both aspects beginning to actually work from home as well as increasing their intention to have another child furthermore it is a country with relatively low access to childcare low incidence of parttime work and fairly inflexible work hours consequently the possibility to work from home induced by the pandemic could have been perceived by parents as a convenient solution at the same time however women in poland bear a disproportionately high responsibility for childcare and thus a need to simultaneously work and take care of children at home during remote learning could have been a particular challenge for many of them all this suggests that the opportunity to work from home might be both positively as well as negatively related to changes in fertility intentions of poles during the pandemic this study has several contributions it is the first study to explore the links between hbw and fertility in the pandemic period it also contributes to the scarce literature on these links from before the pandemic it helps to better understand the role of specific circumstances for the direction of the impact of hbw on fertility decisions both at the macro level as well as at microindividual level more specifically it contributes to two major strands in the literature first it is the growing literature on the implications of the pandemic for fertility developments that has already pointed at the role of uncertainty job and income loss or deterioration of career prospects sudden termination of infertility treatment and access to external childcare for fertility decisions but has not yet explored the role of hbw furthermore we also contribute to the literature on the impact of hbw on fertility in general past research examined numerous consequences of this work arrangement for workers life such as workfamily balance psychological wellbeing and health time use working conditions or work careers but has rarely explored fertility as an outcome so far exploring the role of hbw for fertility decisions is particularly important as the expansive use of hbw may not end with the covid19 pandemic but become a new standard or at least an option for a substantial share of employees the consequences of hbw on peoples lives may thus be widespread long lasting and understanding better the conditions that foster positive or negative effects of hbw on fertility decisions surely deserves special research attention theoretical framework and hypotheses working from home and fertility the most straightforward mechanism behind the influence of hbw on fertility decisions are the opportunities this work arrangement creates for combining paid work and family these opportunities can be particularly appreciated by parents if they have the possibility to work from home and experience what it means for combining paid work and care parents may increase their fertility intentions if they are able to work from home as hbw may help to relax time constraints reduce commuting times and allow more time to be devoted to family life working from home may also allow working parents to organize paid work around childcare and housework which would not be possible if they would work from the office ie to perform paid work in parallel to some household tasks after initiating them when children sleep or are old enough to manage on their own without supervision qualitative studies suggest that women who work from home choose this work arrangement to accommodate paid work and family demands some studies also show that hbw may lead to higher worklife balance what is more hbw brings material gains too people who work from home can save money for some future childrelated expenses which they would otherwise spend on transport or office dressing but hbw may also have negative effects on the workfamily nexus and thus negatively impact fertility first of all hbw may exacerbate the workfamily conflict by blurring boundaries between paid work and family life and experiencing higher paid or unpaid workload no clear setting of the beginning and the end of the working day and no physical boundaries between the workplace and the home may result in the negative spillover from one sphere to the other studies showed that hbw can lead to longer working hours more multitasking and time fragmentationparticularly among women and higher mental load all this creates unfavorable conditions for making childbearing decisions and may negatively impact fertility intentions all in all the overall effect of hbw on fertility intentions depends on the circumstances which may foster the dominance of either positive or negative effects or cancel both effects out looking first at the overall specificity of the pandemic we argue that the lockdowns school and childcare closures followed by widespread moves toward remote learning even for the youngest children as well as frequent individual and familial quarantaines created a situation in which the negative effects of hbw on the workfamily reconciliation by parents dominated people were faced with the need to simultaneously combine paid work and childcare orand homeschooling at their homes this resulted in an immense increase in unpaid tasks work fragmentation multitasking and mental load limited possibilities of outsourcing not only childcare but also housework created additional burden on families mothers were the ones to bear the most of it but fathers have also increased their engagement in unpaid work during the pandemic these experiences have been shared by large parts of the population across all countries but they were particularly pronounced in poland due to comparatively longer periods of time that children spent at home due to pandemicrelated school closures these considerations lead us to an expectation that in contrast to the overall positive effects of hbw on fertility intentions or no main effects on second births found in studies conducted before 2020 we will find overall negative effects of hbw on fertility intentions among mothers as well as fathers during the coronavirus pandemic in other words we expect that during the pandemic the negative effects of hbw for fertility intentions among parents wouldon averagedominate over the potential positive effects that hbw could have therefore the first hypothesis we formulate is the following hypothesis 1 the overall relationship between hbw and fertility intentions among polish parents during the covid19 pandemic was negative at least among mothers in other words we expect that fertility intentions of parents who worked from home declined more strongly or increased less strongly than fertility intentions of their officebased counterparts moderating role of changes to financial situation of the family numerous confinement policies that accompanied distortions to childcare during the covid19 pandemic led not only to the widespread use of hbw but also increased employment and income instability and thus put economic strain on families for those parents who suffered financially during this period hbw might have been perceived as a particularly convenient working arrangement that helped them save on commuting and office dressing and thus resist the economic hardship caused by the pandemic and accommodate future childrelated needs it has been shown that money savings have been one of the important advantages of working from home for people during the pandemic and that financial savings from hbw were indeed substantial in poland where living standards are comparatively lower than in western countries these financial savings may have held particular significance for families we therefore expect that hypothesis 2 among polish parents whose financial situation deteriorated during covid19 pandemic hbw might have brought enough positive gains that canceled out or even outweigh the negative effects of hbw on fertility intentions during the pandemic therefore we expect to find no negative effect or even positive effect of hbw among parents whose financial situation deteriorated during the pandemic moderating role of gender division of unpaid work prior to the pandemic in our main hypothesis we expect to find a negative relationship between hbw and fertility intentions among mothers as they were the ones to bear the most of the additional unpaid work during the pandemic however for those mothers whose partners had already been involved in sharing childcare duties before the pandemic the increase in unpaid work during the pandemic was likely smaller than for mothers who shouldered the majority of childcare responsibilities before the pandemic it has been shown that in countries with more equal division of labor women were less burdened with pandemicrelated unpaid work than in other countries as their partners took over part of the new responsibilities which emerged with the closure of childcare centers and schools lower overall increase in unpaid workchildcare in particularwhile working from home would likely mean weaker negative effects on fertility intentions among women living in more egalitarian partnerships we thus expect that hypothesis 3a the negative impact of hbw on fertility intentions during the pandemic was weaker among polish mothers who shared childcare more equally with their partners already before the pandemic than among mothers who were fully mostly responsible for unpaid work at the same time however it could be argued that women who live in egalitarian or nearly egalitarian relationships may be used to the situation in which they share childcare duties equally with their partners or at least receive substantial support from them they may even have more demanding jobs than other women which simply do not allow them to spend much time or energy on childcare andor housework thus a sudden increase in childcarerelated duties which they had to carry out during the pandemic while working from home might have discouraged women living in egalitarian relationships particularly strongly from thinking about enlarging their families this might have been the case even if their partners took over some of the additional childcare and housework numerous studies have shown that the additional housework and childcare which emerged during the pandemic was primarily carried out by women regardless of whether they previously lived in egalitarian relationships or not mothers from more traditional families in contrast to those from more egalitarian ones might have been more used to the situation in which they have to carry out most of the childcare and housework and could more easily accept an increase in familyrelated responsibilities without questioning it for them the possibility to work from home could emerge as a convenient solution for combining paid work and care in fact a study by osiewalska et al from the prepandemic period in the uk showed that hbw is more likely to increase fertility of women who are primarily responsible for childcare we thus formulate a competing hypothesis to the previous one hypothesis 3b the negative impact of hbw on fertility intentions during the pandemic was stronger among polish mothers who shared childcare more equally with their partners already before the pandemic than among mothers who were fully mostly responsible for unpaid work moderating role of occupational characteristics finally while for some women work may be perceived as a parallel career to childbearing for other women it may seem as an alternative life path to employment particularly temporarily when their jobs are unsatisfactory consistently with the new home economics resigning from an unsatisfactory job in such circumstances may imply low opportunity costs and enlarging the family size may provide a woman with better selffulfillment and in fact higher satisfaction lockdowns and confinement policies during covid19 pandemic have enforced hbw across different sectors branches and occupations but not for all occupations working from home is a convenientsuitable working arrangement while for managers and professionals working from home is amenable for other occupational groups working from home may not be equally convenient professional and managerial positions are characterized by high levels of job autonomy in contrast to other occupational groups and according to a metaanalysis by gajendran and harrison the effect of hbw on job satisfaction is to be fully mediated via autonomy at the same time intensity frequency of hbw may also have an impact on job satisfaction extensive use of hbw can increase isolation and frustration which in turn leads to lower job satisfaction referring to the effect of hbw intensityfrequency on job satisfaction golden and veiga argue that with little autonomy the increase in job satisfaction for low levels of hbw intensity would be weaker while the decrease in job satisfaction for higher levels of hbw intensity would be stronger compared to hbw users with more autonomy therefore we can expect that for nonmanagerial and nonprofessional workers frequent and prolonged hbw arrangement could have been particularly detrimental for job satisfaction for mothers holding jobs characterized by low autonomy which do not profit them or are not suited to be executed from home being stuck at home working intensively for a long period of time and combining this effort with childcare might have resulted in significant drop in their work satisfaction and lead to increased fertility intentions with a hope to temporarily opt out from working actively through subsequent childbearing in poland such a strategy could be particularly tempting as poland offers relatively long and generous maternityparental leave entitlements for nearly all working women furthermore employment of pregnant women as well as women on maternityparental leaves is protected as a result of these considerations we expect that hypothesis 4 among polish mothers holding nonprofessionalnonmanagerial positions prolonged frequent work from home will be positively related to fertility intentions country context our study is located in poland which has been the lowest low fertility country for more than two decades with the total fertility rate oscillating between 13 and 14 throughout the 2000s and 2010s low fertility has been largely driven by low progression to second and higher order births it persisted despite the fact that the economic recession which took place in europe between 2008 and 2012 was relatively mild in poland and that the country entered a track of fast economic growth in the following years while other postsocialist countries experienced substantial improvements in their fertility rates the tfr in poland hovered below 14 till 2016 when it rose to 148 to start declining gradually in the following years household financial needs are one of the important reasons for this persistence of low fertility low salaries insufficient for purchasing a larger apartment and covering childcarerelated expenses have been repeatedly enumerated as important barriers to family formation the introduction of generous family transfers in 2016 under the 500 programme might have eased some of these financial tensions the program complements the heavily meanstested family benefit which is only granted to families in the highest need with a universal cash transfer of 500 pln paid monthly for each child in the family nonetheless economic activity remains one of the most important sources of income for families importantly womens earnings substantially improve households economic situation the disposable income of the single earner household constituted only around 60 of the income of the dual earner household and the proportion of female breadwinner couples in poland is one of the highest in europe despite the fact that womens economic activity may substantially improve households financial situation and thereby improve the conditions for family formation the conditions for work and family reconciliation in poland are very poor and were often mentioned as an important barrier to partners reproductive choices poland has one of the lowest enrolment rates in creches and kindergartens among the oecd countries with only slightly more than 10 of children below 3 attending creches just before the pandemic in the absence of places in childcare centers parents often benefit from the support of their relatives mostly grandparents at the same time it is uncommon to combine childcare with parttime employment until the pandemic employees had relatively little flexibility when it comes to the organization of their working time or working from home specifically in 2019 ie just before the outbreak of the pandemic less than 10 of employees in poland worked from home at least occasionally while in nordic countries this proportion was already exceeding 25 on top of that poland is characterized by a relatively traditional division of childcare duties while social surveys consistently show that polish women are expected to work for pay they are also deemed mainly responsible for either providing or organizing childcare in these circumstances the possibility to work from home which emerged during the pandemic could on the one hand become an important solution for combining paid work and care for some polish mothers and increase their fertility intentions on the other hand however the pandemic disorganized childcare arrangements of many parents and made combining paid work and care much more difficult those parents who received childcare support from grandparents suddenly had to give it up to protect the health of older family members moreover access to childcare facilities became more difficult all childcare facilities were fully closed during the first three months of the pandemic this changed in june 2021 but the facilities for the youngest children below 3 were opened only partially and it was up to the director to decide how many children could be admitted to the childcare center and at which hours so that the social distancing rules were respected schools in particular for children aged 10 remained closed for most of the time and children had to attend classes remotely during the entire period under the analysis any covid19 cases which were reported resulted in sending all the children from the class or kindergarten group into a quarantine which lasted 1014 days children who displayed any symptoms of sicknesssuch as a running nosewhich would usually go unnoticed were asked to stay home parents of children aged 8 or less were offered a care allowance at 80 of their earnings if the childcare center was closed and the parent had to take time off from work in order to take care of the child because of the school closures both parents reported spending more time on childcare though women more often than men data and research sample in order to investigate the links between hbw and fertility intentions during the pandemic we make use of unique representative data from the polish familydemic survey the data were collected in june 2021 on a sample of women and men aged 2059 drawn from the national research panel ariadna in poland which hosts over 150000 active panelists aged 15 and over with verified profiles the opba holds a certificate from the interviewer quality control programme and works according to the standards of iccesomar international code on market and social research respondents in opba are given points for completing online surveys which further may be exchanged for gifts we have used quotarandom sampling ie random samples with additional quotas applied to secure adequate representation of the population in the sample by crucial sociodemographic characteristics in case of nonresponse another person was sampled fulfilling certain sociodemographic characteristics a total of 11183 respondents aged 2059 completed the online survey of which 4188 were parents of children aged under 12 the polish familydemic survey collected comprehensive information on the lives of respondents and their families over the time period starting just before the outbreak of covid19 till the time of the interview among others it provides detailed information on the socioeconomic characteristics and health status of respondents and their partners partners performance in the labor market before and during the pandemic with detailed information on whether the person had the possibility to work from home partners division of childcare and housework availability of external childcare time spent by children out of school in remote schooling data on respondents attitudes toward work and family gender role ideologies satisfaction with family life and relations with the partner and obviously partners fertility intentions precovid and at the survey time having this rich information we were able to investigate the links between hbw and fertility plans after accounting for the fact that the pandemic turned many other aspects of respondents lives upside down this includes among many sudden changes in health status of respondents and their family members labor market situation and ways of working increase in difficulties in combining paid work and care experience of school closures or difficulties with arranging external childcare to study the change in fertility intentions of mothers and fathers during the pandemic we focus on respondents at reproductive age we select only those who were in heterosexual unions at the interview as their fertility intentions are the closest to be realized and thus the most vulnerable to the change in external conditions caused by the outbreak of covid19 as we are interested in working arrangements we further select those who were employed both before the pandemic and at the interview furthermore we excluded those respondents who were pregnant or whose partner was pregnant at the interview we did not exclude couples who have a newborn child born between february 2020 and june 2021 instead we control for these situations with the use of the age of the youngest child we checked however that our results are robust on the inclusion of these individuals in our sample lastly we selected only those who already have at least one child and who provide complete information on our variables of interest so that the final samples amount to 814 mothers and 877 fathers method our response variable is built based on two questions on fertility intentions from which one relates to the prepandemic times did you intend to have a child within the next 3 years before the outbreak of the pandemic and one concerns the current situation do you intend to have a child within the next 3 years the answer ranges from 1definitely not to 10definitely yes then we measure the change in fertility intentions comparing current intentions with prepandemic intentions these changes range from 9 for the highest decrease in fertility intentions to 9 for the highest increase as such all the negative values stand for the decrease in childbearing intentions 0 stands for intentions hold the same and all the positive values represent the increase in fertility intentions our key explanatory variable related to hbw is the change in access and frequency of use of hbw that took place between february 2020 and june 2021 the information on whether the respondent has only gained access to hbw during the pandemic we derive from two questions 1 did you have an opportunity to work from home before the outbreak of the covid19 pandemic and 2 do you currently have an opportunity to work from home the information on actual use of hbw before the pandemic and at the moment of the interview we acquire by using two other questions 1 how often did you work from home before the outbreak of the covid19 pandemic and 2 how often do you currently work from home based on these questions we identify people who a had no access to hbw prior the pandemic and still have not got it by the time of the interview b those who had no access to hbw prior the pandemic but got it during the pandemic c those who had access to hbw already but havent changed the intensity of its use during the pandemic and d those who had access to hbw before the pandemic but only during the pandemic took advantage of it or intensified its use as the last category was smaller in size it was collapsed with the third category for further analysis respondents who have lost access to hbw during the pandemic were excluded from further analysis as they were too few to construct a separate category using a multinomial logit model we regress the change in fertility intentions against our main explanatory variable ie change in the access and use of hbw we conducted all computations using the r programming language and utilized version 113 of the ggeffects package to determine predicted probabilities of reduced and elevated fertility intentions as formulated in our hypotheses 24 we expect that the relationship between the change in fi and hbw accessuse may be moderated by certain conditions these include worsening of the financial situation during the pandemic the division of childcare in the family before the pandemic and holding a nonmanagerialnonprofessional occupation we test the hypotheses related to these three covariates by interacting them with our main explanatory variable we run our models separately for mothers and fathers we measure the division of childcare duties between partners by an index built based on questions who in your household did the following childcare tasks before covid19 these tasks include physical care playingreading helping with schoolwork transport and accompaniment to activities and general oversight and supervision we then sum up the number of tasks which women do always or usually as such the childcare index takes values between 0 and 5 second the worsening of the financial situation is identified based on a choice of a statement comparing the current situation with the month before covid19 the financial situation of my family somewhat deteriorated deteriorated a lot finally occupation is identified using answers to a question what is your occupation and coded using isco08 to address our fourth hypothesis we build a dummy variable where 1 indicates nonmanagerial or nonprofessional positions we account for many other changes in ones life related to both professional and family spheres that may influence childbearing intentions and the hbw status and thus confound the relationship between these two variables we consider the change in partnership status and worsening partnership quality we also account for the duration of the use of hbw during the pandemic by the partner of the respondent further we control for covid19 health risk for a respondent and other household members finally we control for housing conditions that are particularly important during the pandemic socioeconomic status and age we additionally control for the number of children and the age of children results descriptives among the 1700 respondents selected for our analysis of fertility intentions in poland 42 of women and 33 of men had access to hbw in june 2021 this represents an increase of 15 percentage points among women and 12 percentage points among men compared to the prepandemic period of those who had access to work from home during the pandemic 27 reported that their partners also had access to hbw more than 12 of women and 9 of men reported a decline in their fertility intentions as compared to the prepandemic times for another 9 of women and 11 of men fertility intentions increased in the analyzed period the majority of those with increased fertility plans are at young reproductive age the decrease is pronounced among those women and men who gained access to hbw during the pandemic 19 of those women and 11 of men decreased their childbearing plans nevertheless a substantial share of respondents who have gained access to hbw or had access to hbw already before the pandemic also increased their fertility intentions regression we estimated multinomial logit regressions with the dependent variable assuming three categories increase in decrease in or unchanged fertility intentions we run our models by sex accounting for the moderators and the control covariates next we allow for interactions between our moderators and our main explanatory covariate measured by change in access to and use of hbw while interpreting our findings we refer to predicted probabilities rather than to odds ratios as they are recommended as the most accurate and straightforward inference in multinomial regressions estimated marginal means are interpreted as the predicted probability that the response takes a certain value depending on the value of the selected explanatory covariate and averaged over all the remaining covariates we evaluate whether the difference between two predicted probabilities is significant by comparing 83 confidence intervals we do it following austin and hux who showed that two means differ from each other with the pvalue at around 005 if 83 ci do not overlap the estimates of our models can be found in the appendix table 5 main effects based on the estimates of basic models for mothers and fathers we draw predicted probabilities of a change in fertility intentions by change in access and use of hbw and present them with 83 confidence intervals in fig 1 we find partial support for our first hypothesis stating that the overall relationship between hbw and fertility intentions is negative but only for women namely gaining access to hbw during the pandemic seems to be related to a decline in further childbearing plans this finding is manifested in a higher predicted probability of decreased fi in comparison to those mothers who did not have access to hbw before the pandemic and did not gain it we do not find any statistically significant results for fathers worsened financial situation interactions with hbw bring some evidence that stays in line with our second hypothesis which expects that among parents whose financial situation has deteriorated during covid19 pandemic hbw may bring important financial gains to cancel out or even outweigh the negative effects of hbw on fertility intentions among mothers whose financial situation worsened but who newly gained access to hbw the probability of increasing fi is higher than among those with worsened financial situation whose workplace arrangement has not changed furthermore the newly gained access to hbw accompanied by worsened financial conditions of mothers and fathers is linked with a lower probability of decreasing fi than among onsite workers exactly the opposite is observed among mothers whose financial situation remained the same or improved childcare burden before the pandemic we have formulated two competing hypotheses concerning the moderating role of the division of childcare tasks between partners prior to the pandemic for fertility intentions of mothers hypothesis h3a states that the negative impact of hbw on fertility intentions during the pandemic vanishes among women living in egalitarian unions ie who shared childcare more equally with their partners before the pandemic competing hypothesis h3b posits that the negative impact of hbw on fertility intentions during the pandemic among women living in egalitarian unions would actually be stronger than among other women our findings support the competing hypothesis h3b we show that for mothers in egalitarian relationships there is a negative link between hbw and change in fertility intentions and it actually vanishes out for women who did most of or all of the childcare already before the pandemic to be specific those who shared childcare duties with their partners and had access to hbw already before the pandemic or who intensified its use are less likely to increase their childbearing plans than mothers with similar division of childcare having no access to hbw moreover mothers in egalitarian unions who either gained access to hbw or had this access already intensify its use are more likely to decrease their fertility plans than their egalitarian counterparts with no access to hbw occupational position lastly we expected that women holding nonprofessionalnonmanagerial positions who work from home are more likely to increase fertility intentions as in this case they may be more willing to temporarily opt out from working actively our results do not support this hypothesis namely we do not observe mothers holding nonprofessional occupations who gained access to hbw to have higher predicted probabilities of increased fi or lower predicted probabilities of decreased fi than women who neither had access nor gained access to hbw during the pandemic furthermore we do not find statistically significant differences between predicted probabilities of decreased fi among naa and aa groups we however find that women holding nonprofessional occupations with continued access to hbw or intensified use of hbw are actually less likely to increase their fi compared to their counterparts with similar occupational positions but working from the office discussion and conclusion in this study we explored diverse aspects of working from home during the covid19 pandemic and their impact on fertility intentions among parents as there may be both positive as well as negative mechanisms linking home based work and fertility intentions the overall effect depends on the circumstances in our study we argued that the covid19 pandemicrelated lockdowns school and childcare closures source own calculations based on polish familydemic dataset followed by widespread moves toward remote learning even for the youngest children as well as frequent individual and familial quarantaines created a situation in which the negative effects of hbw on the workfamily reconciliation could haveon averagedominated the positive ones parents were faced with the need to simultaneously combine paid work and childcare orand homeschooling at their homes this resulted in an immense increase in unpaid tasks work fragmentation multitasking and mentalload limited possibilities of outsourcing not only childcare but also housework created additional burden on families women were the ones to bear the most of it but men have also increased their engagement in unpaid work during the pandemic these experiences have been shared by large parts of the population across all countries our findings are partly in line with this general expectation namely we found that mothers who gained access to hbw during the pandemic experienced a decline in their fertility intentions our study thus shows that the pandemic context has accentuated the role of negative aspects of hbw for combining work and care for mothers this might explain why our findings are in contrast to the findings of sinyavskaya and billingsley the only previous published study on the topicthat found a positive relationship between access to hbw and fi in the prepandemic period in russia we have also explored particular situations in which we expected the negative relationship between hbw and fi to be leveled out or even outweighed by other mechanisms first we argued that hbw might have been perceived as a particularly convenient solution during the pandemic in cases when the family has suffered financially during this period it has been shown that money savings have been one of the important advantages of working from home for people during the pandemic and that financial savings from hbw were indeed substantial therefore we expected that among individuals whose financial situation deteriorated during covid19 pandemic hbw might have brought enough positive gains that canceled out or even outweighed the negative effects of hbw on fertility intentions during the pandemic in our study we found support for this expectation as the effect was significant among both mothers and fathers second we considered two competing hypotheses on the role of prepandemic division of unpaid labor in couples our findings support the expectation that the negative effect of hbw on fertility intentions would be stronger among women who shared childcare responsibilities with their partners before the pandemic specifically we found that hbw had a negative effect on fertility intentions of mothers who shared childcare duties with their partners before the pandemic but not among those who already did most or all of the childcare duties before the pandemic a possible explanation for this finding is that women who live in egalitarian or nearly egalitarian relationships may be used to the situation in which they share childcare duties equally with their partners or at least receive substantial support from them they may even have more demanding jobs than other women which simply do not allow them to spend much time or energy on childcare andor housework and the social distancing policies made it difficult for them to outsource the additional domestic and childrelated duties it is also likely that in a nonegalitarian context such as the polish one men have not shared the increase in childcare and housework which emerged during the pandemic equally with their female partners even if before the pandemic they participated in housework and childcare in fact numerous studies have shown that the additional housework and childcare burden which emerged during the pandemic was primarily carried out by women regardless of whether they previously lived in egalitarian relationships or not and regardless whether their male partners worked from home as well mothers from more traditional families in contrast to those from more egalitarian ones might have been more used to the situation in which they have to carry out most of the childcare and housework and could more easily accept an increase in familyrelated responsibilities without questioning it for them the possibility to work from home could emerge as a convenient solution for combining paid work and care finally we also explored the situation of cumulation of negative effects of hbw on fi we expected that for mothers holding jobs characterized by low autonomy which are not suited to be executed from home working from home while at the same time taking care of a childchildren might have resulted in significant drop in their work satisfaction andas a consequenceled to increased fertility intentions the latter may serve as a way to temporarily opt out from working actively and to take advantage of generous maternity and parental leave entitlements in poland along with employment protection our findings do not confirm these expectations we suppose that this is because employment and fertility plans of polish women are also shaped by longterm careerand earningsrelated considerations namely women holding lower occupational positions may be afraid toeven temporarilyopt out from working actively regardless if they find their jobs unsatisfactory or not as their earnings may be an important source of income for their families in the longterm this finding may be particularly valid in the polish context it is because it is characterized by relatively low income levels and substantial contributions of womens incomes to the household budgets but this finding may be increasingly relevant for other developed countries as well with the changing role of women in the society and increasing importance of womens income in the family all in all our study demonstrates that hbw rather discouraged family expansion during the pandemic in the polish context except for some specific social groups ie women who were largely responsible for housework and childcare in addition to working for pay as well as households who had difficulties with making ends meet these findings pertain to a very specific context in which couples were unexpectedly faced with additional childcare obligations and were deprived of the possibilities to outsource some of the unpaid work nonetheless they may also have important implications for the role of hbw on fertility in the aftermath of covid19 when hbw will likely be far more widespread than before the pandemic based on our findings it can be concluded that having the possibility to work from home may encourage fertility of couples in worse financial situations for which this work arrangement implies important savings on workrelated expenses it may also facilitate family formation among couples with a more traditional division of labor in which she works for pay but is at the same time mostly responsible for the housework and childcare and is only a secondary income provider for such women hbw may be an attractive possibility of combining paid work and care as they cannot count on the support from their partners this implication may be particularly true in the country context like the polish one where division of unpaid labor between partners is still heavily asymmetric and where male partners are very rarely responsible for larger share of housework or childcare and hardly ever take advantage of parental leaves different implications may be derived for women who are highly attached to the labor market for these women hbw may not constitute an attractive option for combining paid work and care at least as long as it is utilized mainly by women and not by men and continues to exert negative consequences on career outcomes of homebased workers as well as increases their responsibility for childcare and housework as it used to happen before the pandemic more research is needed however in order to establish how hbw affects fertility in different social contexts and what the mechanisms behind these effects are so far the topic has received little attention in demographic research this study has its limitations of which the most important are the potential selection effects to employment and to hbw as well as some weaknesses of our measures of hbw as for the first some women and men may be more likely to be employed than others and some may be more eligible to hbw these choices may relate to parenthood status and their subsequent fertility plans further the pandemic hit some job sectors more than the others and working from home was also a solution for a limited number of workers in order to reduce the selection bias we control for ses which was shown to be an important determinant of ones ability to hbw during the pandemic second our main explanatory covariates which defines whether the respondent received access to hbw during the pandemic captures only two points in time february 2020 and june 2021 we thus are not able to take into account potential changes in workplace arrangements that happened in between eg we do not capture persons who gained access to hbw in mid2020 but lost it half a year later despite the limitations our study provides an important contribution to literature on the complex interplay between work and family shedding light on these relationships in the unprecedented times of the covid19 pandemic it is the very first comprehensive study on the link between hbw and childbearing intentions which not only provides novel empirical findings but also outlines a theoretical framework on how hbw may affect fertility intentions and behavior in the context of increased social uncertainty levels it also helps to better understand the role of specific conditions for the direction of the link between hbw and fertility decisions as such the study has a potential to stimulate future research which will likely become widely discussed among demographers due to the growing body of literature pointing out numerous consequences of the pandemic on family development including the role of uncertainty job andincome loss termination of infertility treatment and access to external childcare with this study we add another strand to this research data availability the dataset we are using is not yet publicly available it comes from a cawi survey carried out on a representative sample from the polish population within the frames of the project funded by the national science center in poland after the end of the project the dataset is planned to be made available for other uses by showing the importance of hbw for the change in fertility intentions during the pandemic appendix see tables 4 and5 authors and affiliations anna kurowska 13 • anna matysiak 3 • beata osiewalska 23 anna kurowska

the covid19 pandemic and related massive spread of home based work led to substantial changes in the conditions for combining work and childbearing on the one hand working from home helped parents to accommodate increased childcare needs during the pandemic on the other hand it led to acute experiences of blurred boundaries between work and family life during childcare and school closures therefore the direction of the impact of working from home on fertility intentions during the pandemic is not unequivocal in this paper we investigate how working from home was related to change in fertility intentions of mothers and fathers during the pandemic and discuss the complex mechanisms behind these relationships with the use of unique familydemic survey data from a representative sample of parents in poland we estimate multinomial logit regressions by gender and consider a set of potential moderators including financial wellbeing gender relations and occupational characteristics we find evidence for an overall negative relationship between home based work and fertility intentions for mothers but we also uncover some positive moderating effects in particular we shed light on the unobvious moderating role of gendered division of unpaid labor from before the pandemic

19892_0

establish a causal effect of community characteristics on individual health with observational data would be to mimic an experimental design by sampling homogeneous persons residing in heterogeneous communities observing communities of catholic order members to approximate experimental conditions in the current study we approximate the experimental conditions in the spirit of oakes by testing whether community social characteristics explain variations in health among female and male catholic order members living together in religious communities relative to the general population catholic order members are a homogenous population with regards to a number of individuallevel characteristics relevant for health such as occupation income religiousity marital status and living arrangements furthermore the physical and socioeconomic characteristics of their communities are relatively homogenous for instance with regards to material living standards and access to medical services nonetheless the social characteristics of their religious communities can differ significantly thus order members represent a population of relatively homogenous individuals residing in communities with homogenous physical and socioeconomic characteristics but with heterogeneous social characteristics furthermore with few exceptions catholic order members live in the same community for most of their lives the rare moves between communities are usually imposed by the superiors and are only to a minor extent initiated by the sisters and brothers themselves consequently any observed relationship between the social characteristics of the community and individual health is unlikely to be due to selective mobility whereby a persons health influences where they choose to live and whether they move to a different community in sum catholic order members represent a population in which it is possible to isolateat least approximatelyhow community social characteristics are related to individual health independent of several individualand communitylevel confounders and selection effects that have complicated the interpretation of results from previous observational studies the similarity between sisters and brothers with regards to individualand communitycharacteristics and the stability of organization and rules of order life across the life course also make the subpopulation of catholic order members particularly interesting for investigating potential age and gender differences community conflict community connectedness and health importantly social relationships provide a mix of both positive and negative experiences which each have independent relationships with health in the current article we therefore specifically investigate whether the level of conflict as well as the level of connectedness of community members are related to individuals health we use the term conflict to refer to discord controversy andor quarrel between people community conflict refers to the degree to which there is conflict among members of the community perceived connectedness is the counterpole to loneliness and refers to the extent to which a person feels socially and emotionally connected with others community connectedness refers to the degree to which members of the community feel connected why should community connectedness and community conflict be related to individual health community connectedness is thought to be related to individual health through several mechanisms for instance healthrelated information is thought to diffuse more quickly in wellconnected communities more connected communities may also be better at reinforcing positive health behaviors among its members through mechanisms of social control more connected groups are thought to have higher levels of cohesive efficacy and may thus be better able to respond when a community member needs additional support due to for example illness injury or other healthrelated deficits more connected communities may be better able to lobby authorities for healthpromoting public goods finally individuals embedded in more connected communities may also benefit from a higher sense of selfesteem and sense of belonging with positive effects on health to date there has been little work on the potential mediating mechanisms between community conflict and health based on previous research on neighborhoods families and married couples we suggest that living in communities characterized by higher levels of conflict may be associated with a lower sense of attachment to the community resulting in negative emotions and subsequent negative effects on health being exposed to conflict in the community may also affect health through repeated activation of the psychological and physiological stress response studies on the effects of marital conflict and the emotional quality of parental relationships on offsprings psychosocial functioning physiological stress response and health behaviors demonstrate that being exposed to conflict can have detrimental effects on the stress response and health even if a person is not directly involved in the conflict him or herself communities characterized by high levels of conflict may also offer fewer resources for recovery from stress current study in the current study we add to the literature by examining the relationships of community conflict and community connectedness with individual health using evidence from a unique sample of religious communities in addition to main effects we also investigate whether the relationships between health and community social characteristics vary by age and or by gender we use the group actorpartner interdependence model and multilevel regression analysis to appropriately separate contextual effects from composition effects and to account for interdependencies in the data method data source a sample of older catholic order members in germany and austria were recruited to take part in a health survey data was collected in summer and fall 2012 the sample was recruited by contacting the leadership of various semicontemplative and active orders of the 28 orders contacted 20 agreed to participate in the study all members aged 50 years or older of the consenting orders received a paperandpencil questionnaire and a return envelope by mail further details about sample recruitment are available elsewhere a total of 1158 participants completed the questionnaire participants were classified as belonging to the same community if they shared a common postal address communities were singlesex environments we excluded participants who lived alone and participants for whom we had no data from any other community members this procedure resulted in a final sample of n 1041 participants living in k 156 communities just over half of the participants were women participants were on average m 7325 years old and 43 had a university degree the average response rate at the community level was high community size ranged from 2 to 77 median community size was 14 measures health participants indicated their overall health based on the question how would you rate your health in general using a scale ranging from 1 to 5 perceived connectedness perceived connectedness was measured with the 11 items from the loneliness scale from de jonggierveld and kamphuls and a scale ranging from 1 to 4 the scale items assess both the emotional and social dimensions of connectedness example items include i often feel rejected and there are many people i can trust completely scale reliability was high scores across the items were averaged higher scores indicate higher perceived connectedness conflict participants used a scale ranging from 1 to 5 to respond to the facevalid item i often get into arguments with my sistersbrothers control variables individuals indicated the day month and year of their birth from which we calculated their age participant gender was based on respondents community membership we statistically controlled for education and community size as potential confounders analytic strategy missing data the majority of the participants had complete data missing data on the perceived connectedness items ranged from 77 to 142 missing data on the conflict item was 102 missing data across all other variables was low to preserve power we used the multiple imputation procedure from spss 22 to produce 10 data sets with missing values imputed analyses were conducted on the 10 imputed data sets unless otherwise noted we report and interpret the pooled statistics which account for the uncertainty of the estimates due to missing data statistical analysis we first used spss 22 to analyze the descriptive statistics and the bivariate correlations between all study variables next we analyzed the multivariate relationships between health on the one hand and the individualand communitylevel social characteristics on the other hand we followed the guidelines of the gapim to account for the interdependencies among community members and to determine the unique effects of individual and community social characteristics the gapim examines the relationship between each participants own involvement in conflict and perceived connectedness with hisher own health as well as the relationship between conflict and perceived connectedness of the other community members and the actors health we therefore calculated the mean conflict of the other community members and the mean perceived connectedness of the other community members for each individual note that in the gapim the actors response is excluded from the calculation of the community means in order to be able to check whether age andor gender moderated the relationship between actor health and actor and community social characteristics we calculated four gender interactions and four age interactions genderage by actor conflict actor perceived connectedness community conflict and community connectedness we then used hlm 70 software to conduct a linear multilevel regression analysis with actor health as the dependent variable individuals were nested within communities in the multilevel model we started the multilevel analysis with an empty model in a second step we added just the control variables next we ran a main effects model finally we added the gender and age interactions to the model in accordance with the gapim the community effects were used as predictors on the individual level in each of the models actor conflict actor perceived connectedness community conflict and community connectedness were grand mean centered age was centered on 50 the age of eligibility of the study all other variables were uncentered in a final step we used the online tool from preacher and colleagues to probe the significant interaction terms the online tool allows users to calculate the simple intercepts and simple slopes at specific values of a moderator to test whether the simple intercepts and simple slopes differ significantly from zero using ttests as well as to identify the region of significance that is the range of values of one predictor for which the simple slope of another predictor is statistically significant different from zero specifically we used the tool to calculate and test the significance of the simple intercept and slope terms for men and for women separately and for participants aged 50 65 and 80 years results table 1 displays the descriptive statistics and bivariate correlations the highest correlation was between gender and high education reflecting the different educational levels of female and male order members all other bivariate correlations were moderate or low in magnitude suggesting no major problem with multicollinearity among the independent variables the results of the empty model indicated that a small but significant proportion of the variance in actor health was associated with community membership actor health did not statistically differ between communities after we statistically controlled for age gender education and community size the change in variance between the empty model and the model with the control variables indicated that the control variables explained 76 of the individuallevel variance in selfrated health table 2 displays the results of the main effects and main effects with interactions models in the main effects model younger age high education higher actor perceived connectedness and lower community conflict were each significantly related to better actor health the significant interaction terms in the model with the main effects and the gender and age interactions indicated that the relationships between actor health and both actor perceived connectedness and community connectedness depended on the actors gender and that the relationship between actor health and community conflict depended on the actors age the change in variance between the model with just the control variables and the model with the main effects and the gender and age interactions indicated that the actor and community social characteristics explained 49 of the individuallevel variance in selfrated health further graphical and statistical analysis revealed the specific nature of the gender and age interactions as displayed in figure 1 the relationship between actor perceived discussion previous research on the potential link between social characteristics of communities and individual health has been criticized based on a number of problems including potential confounders potential selection effects and the conflation of contextual and compositional effects to reduce these problems in the current study we approximated experimental conditions by analyzing data from catholic order members living together in religious communities we found evidence that community conflict and community connectedness were both related to individual health the probability that the current results are biased due to confounders is low because of the relatively homogenous individual characteristics of order members and the relatively homogenous physical and socioeconomic characteristics of their communities our results are unique in that the relationships between the community characteristics and individual health cannot be attributed to common method bias and are unlikely to arise from selection effects by approximating experimental conditions the current study reduces the uncertainty in drawing causal inferences about the relationships between community social characteristics and health thus the results of this study offer further evidence that social characteristics of the community may indeed be causally related to individual health in the current study we found that individuals living in communities characterized by higher levels of conflict reported worse health independent of their own involvement in conflict to date studies of community conflict and health have been rare it is therefore difficult to interpret our finding that individuals health is related with community conflict in the context of the existing literature based on previous research on neighborhoods families and married couples we have suggested that living in communities characterized by higher levels of conflict may be associated with a lower sense of attachment to the community lower psychological wellbeing and higher physiological stress and lower likelihood that a person will benefit from interactions with community members in a way that may help them to recover from other sources of stress we found evidence that the relationship between actor health and community conflict was stronger among older participants evidence from other studies has likewise revealed age differences in how people react to and are affected by social conflict interestingly unlike in previous studies we did not find evidence that individuals involved in higher levels of conflict themselves had worse health this may be because being involved in conflict necessitates a certain level of vitality hence the crosssectional relationship between conflict and health may differ from the prospective relationship between conflict and health observed in other studies given that both health and social functioning tend to change with age the relationships between actor health and actor and community conflict are likely to be very complex especially among older adults we therefore encourage future research regarding age as a potential moderator of the relationships between health and the social characteristics of an individual and his or her community in line with many previous studies we found that people who felt more connected with other people also reported better health we also found evidence that women living in more connected communities reported particularly good health the genderdependent relationship between community connectedness and individual health observed in the current study is also partially in line with previous research which has found associations between community social characteristics similar to connectedness and indicators of health at least among certain subgroups studies of married couples have likewise suggested that people have better health when their close social network members are embedded in closer and more supportive social networks independent of the characteristics of their own social network our finding that women seem to profit more than men from community connectedness is consistent with the results from eriksson ng weinehall and emmelin who also found that women but not men in communities with higher levels of community connectedness indicated better selfrated health womens health is often thought to be more closely associated with the quality of their interpersonal relationships in part due to womens stronger orientation toward social relationships there is some evidence that men and women are differentially affected by the positive and negative aspects of their marital life as well as the social characteristics of their communities in the current study we found a more complex relationship between gender and social charactersitics on the one hand we found that the relationship between personal feelings of connectedness and health was in fact stronger among men at the same time however our results also suggest that women seem to profit more than men from higher levels of community connectedness thus the current results therefore do not support the suggestion that women are universally more affected by social characteristics than men rather the current results suggest that men may be more sensitive to the characteristics of their own social relationships than women while women may be more sensitive to the characteristics of the relationships among the people in their environment supplementary analyses indicated that neither ceiling or floor effects can explain the gender differences since there were no meaningful gender differences with regards to the range mean or standard deviation of actor perceived connectedness community connectedness or health there is some evidence that womens health is more strongly related to emotional aspects of perceived connectedness while mens health is more related to the social aspects of perceived connectedness because our measure included both emotional and social aspects of perceived connectednessloneliness it is also unlikely that a genderbias in our operationalization of perceived connectedness explains the observed gender differences potentially the gender differences observed in the current study might be due to how the men and women in our sample have been socialized traditionally women have been socialized to become caregivers which may have made them more attune to the social characteristics of their communities although sisters do not act as caregivers for their biological families their occupations are nevertheless much more related to caregiving than monks occupations the gendered opportunities of the brothers and sisters are also reflected in the high negative correlation between gender and high education consistent with the fact that women in germany and austria born before the 1960s did not have as much access to higher education as men while the lives of nuns and monks are still clearly influenced by traditional gender roles one unique aspect of order life is that in contrast to the general population a genderbased division of care work does not take place in communities of monks and nuns this is because nuns and monks live in singlesex communities and because nuns and monks have the same living arrangements monks may therefore do relatively more care work than men in the general population and nuns potentially less care work than women in the general population the different allocation of care work between male and female order members relative to men and women in the general population may explain why the relationship between perceived connectedness and health was in fact stronger among the men in our sample in contrast to previous research the current study has a number of strengths including a high response rate on the individualand communitylevels and the use of appropriate analysis to separate individual effects from contextual effects nevertheless the current results should be interpreted in light of a number of limitations we only had data from community members who were 50 years or older thus the community social characteristics do not take into account the conflict and connectedness of younger community members because of the dramatic decrease in entries since the 1960s there are in fact very few order members under 50 years old we therefore do not believe that the absence of data from younger order members represents a meaningful limitation there is also some ambiguity regarding the direction of the relationships since our analyses are based on crosssectional data longitudinal studies would be needed to confirm the directional relationship between community social characteristics and individual health studies which measure changes in the community social characteristics and changes in individual health over time would be especially helpful further more detailed analyses with alternative measures of health and studies that include measures of potential mediating mechanisms are needed to confirm our results this would also help to determine whether the relationships we found between community social characteristics and individual health are rooted in specific dimensions of health we have argued that our analysis of order members has distinct advantages for approximately isolating the relationship between community social characteristics and health due to the control of several potential individualand communitylevel confounders and the low mobility of our participants when interpreting the results it is important to note that the religious communities in the current study were relatively proximal relative to the types of communities in some other studies of the relationship between community characteristics and health we argue that smaller more proximal living environments are more relevant for individual health especially when social interactions are thought to be the underlying mediating mechanisms linking community social characteristics to individual health it is also unclear whether results based on communities of order members are generalizable to other types of communities and social groups found in the general population for instance the religiosity of our participants may limit the applicability of our results to the general population since religion can have profound effects on interpersonal interactions and the management of interpersonal conflict furthermore there is evidence that catholics are more collectivistic than protestants that is relative to protestants catholics tend to define themselves more in terms of their interpersonal relationships and their communities perceived and community connectedness along with perceived and community conflict may be more strongly related to health of the highly religious catholics in the current sample relative to members of more individualistic populations and less strongly related to health relative to members of more collectivistic populations finally the rules of order life determine many health behaviors the relationship between individual and community social characteristics and health may therefore be stronger within the general population because of the additional possibility for individual and community social characteristics to affect health via behavioral pathways importantly we argue that our results are relevant for the general population because communities of order members bear meaningful similarities to family networks specifically family networks in the general population are similar to the communities of order members analyzed in the current study with regards to the inclusion of nonkin members size stability and the ambivalent nature of relationships for instance evidence from a representative study of the noninstitutionalized dutch adult population suggests that older people often consider nonkin to be family members people name on average about seven people in their family network and the size of the family network is stable across the life course finally in the general population older adults negative social exchanges like their positive exchanges tend to occur in their family relationships and friendships due to the similarities between the characteristics of the religious communities in the current study and family networks in the general population we believe that future research which seeks to replicate the current results using data from family networks would be especially fruitful

objectives previous studies have found that individuals health is associated with the social characteristics of their communities however interpreting the causality of the relationships is difficult due to a number of potential confounders on both the individualand communitylevels as well as potential selection effects in the current article we analyze data on health and community characteristics from catholic order members aged 50 living together in religious communities we argue that the potential for confounders and selection effects is reduced in our sample method we use multilevel group actorpartner interdependence models and crosssectional questionnaire data n 1041 k 156 communities to test whether individuals selfrated health was associated with the level of social conflict and connectedness of their community separate from their own involvement in conflict and feelings of connectedness results we find that living in communities with higher levels of conflict is associated with worse health especially at older ages we also find that a the relationship between health and own feelings of connectedness is stronger for men and b women report better health than men in more connected communities discussion our results offer further evidence that at least some social characteristics of the community have a causal impact on health

19893_0

introduction adolescence is among the age group which highly experiences several factors in their daytoday activities 1 adolescent age group is also a time that individuals will experience physical changes and take different responsibilities which may give rise to get mental disorders as it is a new environment for them youths constitute almost onethird of the worlds population and among them onethird live in the developing world where they form up to half of the population 2 child or adolescent abuse is an issue concerning millions of youths and their families worldwide maltreatment of youths can be defined as an act of omission or commission by others who are caregivers that may have danger possibility of danger or threats of danger to adolescents 3 parental neglect involves an act of omission and it is defined as a failure by a caregiver to address the adolescents basic physical emotional medicaldental or educational needs 45 the burden of psychiatric disorders on youths is enormous and covers a great number of people in all types of societies the majority of psychiatric disorders begin at an early age even though they are supposed to be experienced in older individuals later in life depression is the most common and severe psychiatric disorder that leads to magnifying problems in an adolescents capacity to take care of his or her everyday responsibilities and functionalities depressive disorders in adolescents result in a horrible consequences even to other healthy components it may lead to educational impairment comorbid psychoactive substance abuse behavioral difficulties and risky reproductive and sexual practices 6 a mental health service for adolescents mental health problems is not adequate yet even in the developed world agerelated stigma is among the major contributory factors for unmet mental health needs in youths 7 currently depression is recognized as the first psychiatric disorder of youths which is related to its common presentation episodic nature and its ability to cause significant complications and impairment according to the 2009 discussion paper released by the world health organization among 66 million individuals experiencing depression 85 live in the developing world 8 some statistics indicate that depression is as frequent as 20 common in adolescents 9 and 434 of high school students in tehran to be depressed 10 a study which was conducted between china and america using the chinese version of the beck depression inventory reported that 15 of participants had depression among 503 subjects 11 another study in new york revealed the magnitude of depression in high school students to be 34 12 another survey using a summarized selfadministered becks questionnaire reported severe depression in 18 of 8206 adolescents 13 a schoolbased crosssectional survey was conducted in south india to estimate the prevalence of depression among schoolgoing adolescents in this a total of 2432 schoolgoing adolescents were included in the study and 25 of them have been found to have depression 14 though depression is one of the major diseases that cause failure to socialize among youths it is often neglected and has not been given adequate attention it needs the scarcity services to emotional and other mental problems of children and adolescents make this study necessary for strong emphasis to be given for the support of mental health in ethiopia for the sake of mental and behavioral welfare of growing children and adolescents 15 materials and methods 21 study design period and setting we conducted a facilitybased crosssectional study from january 1 to 302019 the study targeted adolescents at aksum town high schools aksum is located in the tigray region which is 1024 km far from addis ababa there are three high schools in aksum town currently named aksum secondary school atsekaleb secondary school and kedamay minilik secondary school and there are a total of 2579 grade nine and 2241 grade ten students in the three high schools sample size calculation and sampling procedure we calculated the sample size using a single population proportion formula and we took the following assumptions 95 confidence interval and 4 marginal error the proportion of depression is 393 from the previous study 16 with a nonresponse rate of 10 the final sample size was taken to be 630 all governmental high schools found at aksum town were included in our study students were accessed from each high school proportionally to its total number of students sampling frames were prepared in alphabetical basis for each level of grades then a random sampling technique was applied to select proportionally allocated number of participants from each level of grades finally 285 females and 339 males were selected 23 data collection instrument and techniques data was collected by facetoface interview initially screening tools and other developed structured questionnaire in english language were translated to amharic and tigrigna and back to english by independent person to check for consistency and understandability of the tool data was collected by six bachelor degree holder health professionals the data collection process was supervised by the principal investigators training was given for data collectors for two days by the principal investigator regarding the process and techniques of data collection phq9 was used to assess depression which is a multipurpose instrument for screening diagnosing monitoring and measuring the severity of depression phq 9 score of greater than or equal to 10 has sensitivity and a specificity of 88 and cronbachs alpha reliability of 077 for major depression adverse childhood experience questionnaire which is a 10item screening tool was used to access parental neglect aceq includes questions that assess emotional abuse and neglect physical abuse and neglect educational and medical neglect and sexual abuse 17 aceq was checked for reliability test and it has been found to have cronbachs alpha of 083 to assess parental neglect for this study the oslo 3 social support scale was applied to know the level of social support towards adolescents the scale divides the level of social support into three as poor social support moderate social support and strong social support 18 for this study its cronbachs alpha has been found to be 084 depression this refers to those whose score is greater than 5 from the phq9 scale 19 parental neglect this refers to aceq which is a selfreport instrument covering 10 items to rate the severity of emotional abuse and neglect physical abuse and neglect and sexual abuse 17 social support according to the oslo3 social support scale a score of 38 is taken as poor support 911 as moderate support and 12 and 14 as strong support 18 25 data analysis and interpretation after the questionnaire was checked for cleanliness data was entered using epidata 31 and exported to ibm spss version 22 statistical software for analysis sociodemographic characteristics of respondents were analyzed by descriptive statistics and presented in percentage mean and standard deviations bivariate analysis was used to see the association between outcome and 2 depression research and treatment independent variables multivariate logistic regression was done for those variables whose p value is less than 02 the significance of variables was considered at a p value 005 and 95 ci of their respective adjusted odds ratios results and discussion 31 sociodemographic characteristics a total of 624 participants with a response rate of 9905 were included in the study among this 339 were females the age of the majority of students were known to be 15 years followed by 16 years of age and more than half were grade 9 students more than threefourths of participants were orthodox christian religion followers 32 social supportrelated variables among participants the level of social support was measured based on the result of this study majority of students have been found to have poor social support followed by moderate social support and only 151 students were under good social support 3 adverse childhood experience questionnaire which assesses physical neglect educational neglect emotional neglect and medical neglect was used to assess the main independent variable physical neglect refers to parents negligence to provide adequately nutritious meals consistently or it might mean that parents have abandoned their child educational neglect is a failure to provide a child with adequate education in the form of enrolling them in school or providing adequate homeschooling emotional neglect is consistently ignoring rejecting verbally abusing teasing withholding love isolating or terrorizing a child medical neglect is in turn the failure to provide appropriate health care for a child 20 the adverse childhood experience questionnaire was checked for colinearity between each item using the pearson correlation coefficient at the p value of 005 as a result there was no colinearity found between each item of the screening tool a reliability test was conducted among the 10 items and it has been found to have high reliability after it is checked for colinearity it was entered into logistic regression analysis and it is found to have a p value of 025 on bivariate analysis crude odds ratio p value 0000 in addition to parental neglect bivariate analysis was done for other explanatory variables for depression and the result revealed that explanatory variables sex family size fathers education mothers education social support and current use of alcohol were found to have a p value 02 these factors were entered into multivariate logistic regression for further analysis to control confounding effects as a result being female poor social support mothers educational status and parental neglect are found to be statistically significant for depression at a p value 005 the odds of developing depression among those who had parental neglect were 261 times higher as compared to those who have no parental neglect discussion on the prevalence of depression and parental neglect the study revealed that the prevalence of depression was 362 this result was in line with studies conducted in addis ababa among adolescents in governmental high schools 16 and northern iran 34 among high school and preuniversity adolescents using becks questionnaire 21 however the current finding for the study on depression was higher than that for the studies conducted among adolescents at korea 22 saudi arabia 23 egypt 24 malaysia 25 and trinidad 26 the reason for the above difference might be due to difference in adolescent age which was only 1319 in trinidad 26 study populations who were only boys in korea 22 the type of study conducted which was a large survey in ethiopia 27 the screening tool which was bdi ii in a study conducted in saudi arabia 23 and the childrens depression inventory in a study in malaysia 25 and the sample size which was 1373 in egypt 24 on the other hand the finding of this study on the prevalence of depression was lower than that of a study conducted in can tho city vietnam 28 and hong kong china 29 this difference might be attributed to the time point of the study conducted which was a longterm study in hong kong 29 difference in study subjects in which only those adolescents who are abused physically and emotionally were studied and difference in sample size in which a large sample size was used in vietnam ie 1159 students 28 the above difference might also be due to differences in screening tools used to determine depression in which the center for epidemiology studies depression scale was used in a study conducted in can tho city vietnam 28 regarding the severity of depression the prevalence of mild depression was in line with a study conducted in egypt which was 215 however the result of this study for moderate and severe depression is higher than that of a study conducted in egypt which was 71 and 0 respectively 24 and in iran 57 and 03 respectively 21 depression research and treatment the result of this study on mild depression is also found to be lower than that of a study conducted in iran among high school and preuniversity adolescents which was 28 21 a possible reason for the difference might be difference in screening tools used to determine depression such as cesd which was applied in iran 21 and sample size which was 1373 in egypt 24 furthermore the result of this study revealed the prevalence of parental neglect among adolescents to be 535 this result has been found consistent with the study conducted in addis ababa preparatory school which was 531 16 on the other hand the result of this study regarding the prevalence of parental neglect is lower than that of a general population survey study done at quezon city in metro manila which was 75 30 838 in a study conducted in iran 31 and 707 in south africa 32 this might be due to the difference in the study populations who were adults and sample size which was 1068 in a study done at quezon city in metro manila and 700 children in a study in iran this difference can also be due to the reason that they use different screening tools to assess parental neglect however the result of this study was higher than that of a study conducted at 26 the possible reason for such difference might be sample size difference which was 8667 in atlanta and study participants who were children in a study conducted in atlanta 33 38 discussion on the association between depression and parental neglect parental neglect which is the main independent variable is found to be statistically associated with depression at a p value 005 analysis of the students parental neglect with other explanatory variables was tried 5 depression research and treatment to control for confounding variables after multivariate analysis the strength of association between depression and parental neglect does not show a significant difference ie cor 275 and aor 261 students who were experiencing parental neglect were 261 times more likely to develop depression than those who did not experience parental neglect this study is in line with a study conducted in addis ababa 16 this may be because among the most common outcomes of neglect is the failure to succeed breakdown to succeed is a term that is normally applied to explain kids with a strange prototype of weight gain or weight loss or experiencing inadequate growth patterns per a kids age and developmental phase this situation can occur when a child does not get sufficient diet or necessary medical consideration essential for appropriate bodily development 6 depression research and treatment 34 which may later hinder adolescents overall physical health including mental health and lead them to depression in more tremendous cases breakdown to succeed can also influence children over their entire existence course by really destructing their cognitive progress and their immune system due to inadequate calorie intake or lack of therapeutic consideration making the child lose developmental milestones to a great extent and a great extent prone to poor health even after adulthood and give way to depression 34 it might also be because a preponderance of neglected kids displays attachment disorder manifestations and finally forms timid connections even to their close families this disturbed attachment to their primary caregiver alters their upcoming interaction with peers by making them emotional and physically isolated from others and this in turn reduces the possibility of forming true relations moreover as a result of their precedent abuse neglected children experience that forming close relationships with others loses their control in life and exposes them by raising their susceptibility 35 neglectful parents and caregivers give poor interaction and positivity for their belongings which is linked to increased levels of shame called shameproneness 36 shameproneness may increase neglected adolescents risk for depressive symptoms since they try to suppress such an aversive feeling shame suppression in turn may lead to sadness social isolation and withdrawal and lastly depression 3738 the development of the brain may continue beyond adolescence age group therefore neglectful experiences may impose a lasting effect on the continuing need for optimal conditions for development of some structures concerned with attention and emotional regulation which contributes to the heightened occurrence of depression in victims 39 the increased occurrence of depression in those who are experiencing parental neglect might also be due to the reason that neglected children show trouble in regulating their feeling and appreciating others emotional expression and trouble in differentiating emotions which amplify their susceptibility for developing depression youths with a history of neglect during their early ages may also have stressful reminders which contributes to their current depressive state by suppressing and leads to deregulation of their emotion 40 the higher prevalence of depression may also be a result of the injured hippocampus as there are elevated levels of stress hormones such as cortisol due to increased stress levels in youths who had experienced neglect this increased release of stress hormone is assumed to have an injury on the hippocampus cortical area implicated in diverse brain function and this in turn gives rise to developing depression in youths 41 conclusions and recommendations in the current study the prevalence of depression is found to be high when compared to other populations a significant and strong association is also determined between parental neglect and depression during the data collection period patients with a severe depression category were linked to a hospital and 24 of them got psychiatric evaluation for diagnosis and treatment accordingly the result of this study has been submitted to stallholders for special consideration to depression and parental maltreatment towards adolescents it is good if school teachers give emphasis to those students who seem psychologically unwell it is better if school teachers exercise recommending such students to school psychologists it is good to conduct a prospective cohort study to investigate the temporal relationship between factors and depression it is good if aksum university comprehensive hospital starts a campaign which will teach about the effect of parental neglect on the adolescents mental health then it is good to start clinic service for students who are psychologically unwell including consultation service data availability all the data included in the manuscript can be accessed from the corresponding author mengesha srahbzu upon request through email address of depression research and treatment governmental high school head office for their cooperation during the data collection period finally we would like to extend our thanks to the study participants ethical approval ethical clearance was obtained from the ethical review board of the institute of health aksum university consent written consent was asked from each selected student after being informed about the nature purposes benefits and adverse effects of the study and invited to participate written assent was also obtained from those who are under 18 years old from their parentsguardiansteachers confidentiality was ensured participants were strictly informed as they have the right to refuse or discontinue participation at any time conflicts of interest the authors declare that there is no conflict of interest regarding the publication of this paper authors contributions all authors contributed to the study conception and design material preparation and data collection and analysis were performed by enguday tirfeneh gebeyehu and mengesha srahbzu biresaw the first draft of the manuscript was written by mengesha srahbzu biresaw and all authors commented on the previous version of the manuscript all authors read and approved the final manuscript

background depression is one of the most serious and prevalent mental illnesses that can result in serious disability and ending life by committing suicide and homicide the risks of having depression are substantially higher in persons who have parental neglect when compared to the general population objective to detect prevalence of depression and its association with parental neglect among adolescents in governmental high schools at aksum town tigray ethiopia 2019 method a facilitybased crosssectional study was conducted at aksum town high schools a simple random sampling technique was applied data was collected with facetoface interview data was analyzed using ibm statistical package for social science version 22 bivariate and multivariate logistic regressions were done adjusted odds ratio at a p value 005 with 95 confidence interval was taken to declare statistical significance of variables result a total of 624 students were asked to participate with a response rate of 9905 prevalence of depression was found to be 362 depression among adolescents was found to have significant and strong association with parental neglect aor 261 95 ci 183 372 conclusion and recommendation in the current study the prevalence of depression is found to be high when compared to other populations significant and strong association is also determined between parental neglect and depression it is good if teachers give emphasis for those students who seem psychologically unwell it is good if aksum university comprehensive hospital starts a campaign which will teach about the effect of parental neglect on the adolescents mental health

19894_0

digital technology has become critical for making social connections and providing social support during covid19 however social isolation challenges disproportionately affected older adults living alone in lowincome communities due to a lack of internet access digital technology ownership and limited capital we conducted a mixedmethods study to examine the role of digital technology in this population to keep socially connected during the national lockdown of the participants 36 reported social isolation and 36 reported loneliness both quantitative and qualitative data illustrate differential experiences of technology use for remaining socially connected the qualitative data from focus group interviews show that participants were forced to adapt to the isolated situation quickly by learning about new ways of connecting with others through technology this enabled a longoverdue adoption of digital technologies among individuals who had experienced digital exclusion before the pandemic despite the high interest in digital technologyenabled social connections concerns about its surveilling nature the possibility of overdependence on technology and negative technology experiences due to unreliable functions or lack of tech support made them hesitant to adopt new technology future research should highlight the need to include older adults in all stages of technological solution development that recognize the sociocultural context of use with a focus on growthoriented opportunities for older people digital technologies have the potential to help older adults in various aspects of their lives but older adults need to adopt and keep using the new technologies to reap the benefits previous research on digital divide mainly focuses on adoption and acceptance of new technologies and little is known about what might influence actual use and disuse after this initial stage the current study modeled changes in constructs related to computer use after initial computer adoption and examined whether these changes predict continued use we used data from the computer arm of a 12month field trial examining the potential benefits of computer use in older adults individual differences identified in the technology acceptance literature were measured before during and after the intervention univariate and bivariate latent change score models examined changes in each predictor and their potential causal relationship with use results demonstrated large interindividual differences in the change patterns of individual difference factors examined change in perceived usefulness perceived ease of use and computer interest computer selfefficacy and computer anxiety were correlated with but not predictive of change in use our findings demonstrate the limitation of popular constructs in technology acceptance literature in predicting continued use after initial adoption and point out important gaps in knowledge to be targeted in future investigations

existing and emerging technologies hold great promise with respect to improving the lives of older adults in particular by supporting and enhancing their independence productivity health safety social connectivity and quality of life unfortunately although differences in technology use and adoption between younger and older adults have declined over the past decades barriers still exist that fully prevent the promise of technology from being realized to achieve these aims this presentation will provide an overview of the current state of the intersection of aging and technology nationally and internationally with special attention to factors such as diversity disability and geographic region next i will discuss approaches available to reduce the digital divide these include changing the person eg changing attitudes and proficiency and changing the technology human factors engineering i will then discuss how a usercentered design process is crucial for the success of technologybased interventions without placing the user at the center of the design process many novel technology solutions will likely fail to reach their potential finally i will conclude with a discussion of if and when the agerelated digital divide might close entirely by projecting changes in demographics technology proficiency technology proliferation and technology change into the future

19895_0

introduction the role of diversity and cultural competence in the practice of orthopaedic surgery will continue to grow as the ethnic composition of our patients continues to change minorities accounted for nearly onethird of the population in the 2000 us census with projections for minorities to compose more than half of the us population by 2070 24 as the role of diversity is amplified in society it will be increasingly important for orthopaedic surgeons to be adept at interacting with patients from all backgrounds efforts to improve the diversity of the workforce of orthopaedic surgeons have shown promise in the past 1522 but much progress must be made before the demographic makeup of our workforce comes close to reflecting our surrounding society utilization of culturally competent care is critical to gaining the trust of any patient and the physician must practice effective communication skills to connect with and engage patients of all backgrounds most simply explained cultural competence has been described as the ability of health care providers to interact with patients who are different than themselves 18 diversifying the workforce of orthopaedic surgeons is an important first step toward improving patient communication and addressing disparities in musculoskeletal health efforts are being made to increase the number of minority and female applicants to orthopaedic residencies however with fewer underrepresentative minorities in college and medical school efforts to dramatically increase diversity in the short term are not realistic therefore improved training of the current and future generations of orthopaedic surgeons in culturally competent care is critical for presentday efforts to reduce healthcare disparities and improve the care of patients while efforts from the american academy of orthopaedic surgeons have provided greater visibility for diversity and culturally competent care these concepts have not been universally embraced as witnessed in current disparities in the representation of female and ethnic minorities in residency programs and academic faculty 7 attitudes toward diversity exist on a continuum from discouragement to effective management 14 and the leadership of orthopaedic surgery departments plays a critical role in establishing a culture that understands the value of diversity and crosscultural communication both in daytoday interactions and furtherreaching administrative actions 1415 attending surgeons must be aware their interactions with patients colleagues and ancillary staff are constantly being observed by students and trainees and the importance of these observations cannot be underestimated to reach the goal of a workforce of orthopaedic surgeons who are adept at interacting with patients of all backgrounds greater emphasis will need to be placed upon improving patient communication skills cultural competence and diversity where are we now before the introduction of communication skills training orthopaedic surgeons were regarded by both patients and their colleagues as poor communicators 23 crosscultural communication creates a barrier to relationship building between patients and orthopaedic surgeons 11 which strains the already diminished trust between minority patients and healthcare providers 6 as the nations minority population continues to grow it will be increasingly important for the orthopaedic surgery workforce to diversify its demographics and improve its ability to effectively communicate with patients of all backgrounds workforce demographics the workforce of orthopaedic surgeons in the united states does not reflect the community it serves nearly 90 of the aaos membership is caucasian and only 43 of the aaos membership is female 2 the current group of orthopaedic surgery residents is nearly threefourths caucasian and nearly ninetenths male while physicians are certainly capable of providing highquality care to patients of all backgrounds racial concordance between patient and physician plays a role in patient satisfaction and utilization of healthcare resources among minority patients 19 after a period of stagnancy 421 the aaos diversity advisory board now reports a 181 increase in the number of female orthopaedic surgery residents but an unchanged number of african american and hispanic orthopaedic surgery residents while larger initiatives are in place to increase the number of minority entrants to medical school 20 and individual efforts to increase recruitment of minorities to orthopaedic surgery have been encouraged 8 there is no nationally coordinated effort to recruit minority and female medical students to the specialty of orthopaedic surgery crosscultural communication effective crosscultural communication becomes even more important when culturally concordant relationships between patient and physician cannot occur the association of american medical colleges has succeeded in incorporating culturally competent care into the formal undergraduate medical education curriculum based on the recommendations of the liaison committee on medical education 12 additionally the accreditation council for graduate medical education has included cultural competency in its guidelines for the core competency of professionalism 1 however many surgical residency programs lack a formal curriculum to teach cultural competency to their residents 25 the reasons for this may be numerous including lack of time and lack of role models 25 there are a number of required competencies that must be taught to orthopaedic surgery trainees in an increasingly constrained work hour schedule and cultural competency may not be viewed as a priority in surgical training 5 additionally orthopaedic faculty themselves may not have received the appropriate training in cultural competence and patient communication needed to formally teach these skills to residents 26 while virtually all residents understand the value of addressing cultural issues when caring for patients 83 of surgical residents report they receive little or no evaluation in crosscultural care during their residencies 25 because training in crosscultural communication is often not included in formal curricula the communication methods exhibited by attending surgeons during their interactions with patients colleagues and ancillary staff become more valuable as they are observed by trainees on a regular basis these interactions provide opportunities for attending surgeons to teach by example during their exchanges with individuals who are from backgrounds different from their own current efforts to address the importance of crosscultural communication include the aaos communication skills mentor program in which trained mentors conduct workshops for residents fellows and aaos members on basic patient communication skills these valuable skills provide a basis for more advanced communication such as interactions with patients with limited english proficiency and poor health literacy there is currently no advanced communication skills course through the aaos but the aaos has created a selfdirected culturally competent care guidebook with an online learning module and accompanying test these programs represent important initial efforts to provide orthopaedic surgeons both in training and in practice with opportunities to improve basic and advanced patient communication skills where do we need to go recruitment of female and minority applicants to careers in orthopaedic surgery is an important step toward reducing increasing diversity and cultural competence of all trainees and decreasing musculoskeletal healthcare disparities 21 we need to increase the gender and ethnic diversity of orthopaedic surgeons in training programs both as trainees and faculty 7 to adapt to the everchanging composition of our patient population workforce diversity and crosscultural communication need to be valued by all orthopaedic surgeons and should be championed by the leaders of academic departments 1415 strategies to improve trainee and faculty diversity should be implemented as well as a structured curriculum to teach trainees and faculty about the importance of basic and advanced patient communication skills with emphasis on culturally competent communication 26 how do we get there diversification of the orthopaedic profession requires a multifaceted approach active recruitment of women and underrepresented minorities into orthopaedic surgery is a strategy with a fast return on investment recruitment involves not only piquing the interest of women and minorities for a career in orthopaedic surgery but also increasing the number of training programs where women and minorities will feel comfortable and not out of place it is relatively easier to recruit women as they compose more than 50 of medical students but the recruitment of minority students is more difficult because they are often underrepresented in both college and medical school therefore to successfully increase diversity among underrepresented minorities programs need to work on increasing the pipeline with mentoring and educational programs from as early as middle or elementary school 20 this will subsequently increase the number of minority students who enroll in college and medical school efforts to increase the pipeline begin with mentoring programs for children as early as preschool some programs have focused on middle school as a time where children are sufficiently mature but also sufficiently malleable as an ideal time period to instill the confidence humility and values required for success the sullivan alliance to transform americas healthcare professions established by former us secretary of health and human services the honorable louis sullivan md is dedicated to stimulating diversity initiatives across medical professions and to disseminating best practices that have been successful in enhancing diversity 9 enlightened orthopaedic leaders committed to increasing diversity should look for opportunities to learn from or collaborate with programs such as the sullivan alliance in an effort to increase the number of applicants to healthcare professions and to promote orthopaedic surgery as a career choice for all aspiring physicians efforts to improve workforce diversity among orthopaedic surgeons can begin at various stages in a future physicians career path individual initiatives as seemingly small as allowing high school students to shadow an orthopaedic surgeon can have a lasting effect in shaping a young adults career ambitions additionally more formalized programs that provide young students with exposure to the technical appeal of orthopaedic surgery such as operating room experiences and bioskills laboratories can be coordinated on a local level support for these types of programs such as small project grants or logistical support can be provided by academic departments or orthopaedic societies or organizations for example medical student attendees at the student national medical associations 2008 annual medical education conference participated in a bioskills workshop organized by the aaos and funded by the new york university hospital for joint diseases 17 this recruitment event targeted at the predominantly minority student constituency of the snma raised awareness about the field of orthopaedic surgery among medical students and yielded 27 aaos and ruth jackson orthopaedic society mentorship applications from the 70 attendees who visited the aaos booth the aaos has also sponsored similar events at subsequent snma meetings and at the 2010 latino medical student association national conference 16 the final opportunity to recruit interested students to the field of orthopaedic surgery is during medical school leaders at academic training programs such as chairpersons and residency program directors should focus efforts on recruiting and encouraging medical students of both genders and all cultural backgrounds many students do not receive guidance from an orthopaedic surgeon during their career planning and may subsequently be discouraged from applying to such a competitive specialty as a result female african american and hispaniclatino medical student applicants to orthopaedic surgery residencies are substantially lower than those to general surgery and other surgical and nonsurgical training programs 7 initiatives to recruit and encourage all medical students but especially females and underrepresented minorities to orthopaedic surgery should be implemented by departmental leadership at each medical school one potential way to advance the mentorship of physiciansintraining at all stages would be to organize a group of female and minority orthopaedic surgeon role models through the aaos rjos j robert gladden orthopaedic society and american association of latino orthopaedic surgeons this group could help establish formal programs to engage and recruit students of all backgrounds and could potentially serve as a networking tool for interested trainees the leadership of each academic department must capitalize on early opportunities to emphasize the importance of diversity and cultural competency to young trainees the faculty and especially the residency director and chairperson must model behavior to residents and fellows that demonstrates an appreciation for the importance of diversity and cultural competency attending surgeons must realize their interactions with patients colleagues and ancillary staff are constantly observed by trainees who are often impressionable about ways in which to interact with these same groups additionally department leaders should document the type and amount of training that both faculty and residents receive in both basic and advanced patient communication skills furthermore female african american and hispaniclatino orthopaedic surgeons are substantially underrepresented on academic faculty in comparison to their representation in residency training 7 leaders of academic departments should be cognizant of this when recruiting orthopaedic surgeons to join their faculty and in managing department personnel with a goal of cultivating an appreciation for diversity among personnel of all backgrounds 14 efforts should be made to incorporate patient communication and cultural competency into the curriculum of each training program aspects of cultural competency can be improved in surgical residents even after a brief educational intervention 10 program directors should take advantage of currently available resources such as the aaos communication skills mentor program and culturally competent care guidebook while also including material that is particularly relevant to their surrounding patient population an additional step to formalize the role of cultural competency and patient communication in residency training curricula would be to include these topics on intraining and board certification examinations the involvement and support of the acgmes orthopaedic surgery residency review committee and the american board of orthopaedic surgery would be helpful toward incorporating cultural competency and patient communication into residency program assessment and board certification examination finally resources should be dedicated toward evaluating the effectiveness of culturally competent care initiatives on improving outcomes and reducing healthcare disparities 3 establishing an evidence base for these interventions is critical to advancing their implementation within the field of orthopaedic surgery and throughout medicine increased funding is necessary for research evaluating the importance of diversity and cultural competence in addressing musculoskeletal healthcare disparities prospective clinical studies are needed to establish the link between diversity and cultural competence in medicine as has been demonstrated in other disciplines 313 moreover prospective evaluation needs to be conducted to determine whether improvements in cultural competence and patient communication lead to enhancements in patient trust medical literacy patient voluntary and involuntary compliance physician recommendations and patient outcomes 313 in short do diversity and improved cultural competence lead to fewer health disparities and improved care for our patients persuasive research linking diversity cultural competence patient communication patient compliance health literacy and reduced healthcare disparities should increase appreciation and acceptance of the importance of having a diverse and culturally competent workforce the patient population we serve as orthopaedic surgeons is becoming increasingly more diverse we must make efforts to increase the gender and ethnic diversity of the orthopaedic surgery workforce and must also work toward improving our ability to communicate with patients of all backgrounds the former can be achieved through programs that recruit females and underrepresented ethnicities

background the patient population served by orthopaedic surgeons is becoming increasingly more diverse but this is not yet reflected in our workforce as the cultural diversity of our patient population grows we must be adept at communicating with patients of all backgrounds where are we now efforts to improve the diversity of our workforce have been successful in increasing the number of female residents but there has been no improvement in the number of african american and hispanic residents there is currently no centralized effort to recruit minority and female students to the specialty of orthopaedic surgery the american academy of orthopaedic surgeons has been leading workshops to train residents and practicing surgeons in communication skills and cultural competency where do we need to go we must train the current generation of orthopaedic surgeons to become adept at interacting with patients of all backgrounds while initiatives for crosscultural communication in orthopaedic surgery have been established they have not yet been universally incorporated into residency training and continuing medical education programs how do we get there we must continue to recruit the brightest students of all backgrounds with a concerted effort to provide equal opportunities for early guidance to all trainees opportunities to improve diversity among orthopaedic surgeons exist at many stages in a future physicians career path including shadowing in high school and college and continuing with mentorship in medical school additional resources should be dedicated to teaching residents about the immediate relevancy of cultural competency and faculty should model these proficiencies during their patient interactions dr dy has no conflicts of interest related to this study dr nelson serves on the aaos diversity advisory board and is president of the j robert gladden orthopaedic society both of which are organizations that advocate diversity cultural competence and elimination of musculoskeletal healthcare disparities dr nelson has no financial conflicts of interest related to this study

19896_0

introduction worldwide the illicit opioid market is expanding with increasing availability of heroin and opioid analgesic medications many people who use illicit opioids rely on injection as route of drug administration and opioids are among the most frequently injected illicit drugs worldwide it is estimated that over 80 of the 156 million people who inject drugs inject opioids injection drug use is a key driver of bloodborne disease globally 178 of pwid are living with hiv 1 excluding subsaharan africa nearly 30 of hiv infections are due to unsafe drug injection 2 additionally an estimated 52 of pwid worldwide are hcv antibodypositive about 28 of whom are younger than 25 years old 1 the world health organization recommends four interventions that if delivered at scale can contain and reduce hiv prevalence among pwid needle and syringe programs opioid substitution therapy and other evidencebased drug treatment hiv testing and counselling and antiretroviral therapy to leverage the benefits of treatment as prevention 3 despite these who recommendations and an increase in the number of countries where injection drug use is taking place 1 the predictable hiv and hcv epidemics associated with drug injection are often met with equally predictable policy debates regarding the merits of introducing harm reduction interventions of proven efficacy such as syringe exchange in many nations these preventive strategies are not in place or are implemented at insufficient scale to effectively prevent or halt hiv epidemics in local populations of pwid 4 these policy debates often result in impeding or delaying prevention efforts that could be most effective if implemented in the early stages of hivhcv epidemics when background prevalence among pwid is relatively low 5 6 this seemingly contradictory pattern the spread of hivhcv among pwid along with slow public health policy responses was true in past decades and remains true in many countries and geographical regions today despite robust evidence of harm reduction programs efficacy and costeffectiveness in curbing the spread of bloodborne viral diseases 7 in the us for example numerous states are facing an increase in the number of people who inject opioids 89 despite mounting evidence of increasing incidence of acute hcv attributed to injection drug use 1011 in many hardhit regions of the us there is little implementation of harm reduction services that could prevent the spread of hcv and potentially hiv 12 given this unfortunate mismatch between known epidemiological risk and public health response it is worth asking if other healthprotective measures could be taken while the struggles to implement comprehensive prevention strategies continue in this paper we present data suggesting that drug users themselves can be a key resource in spreading knowledge of safer drug use and injection practices and safetyenhancing social norms that prioritize the prevention of hiv hcv and overdose the social networks of pwid have long been studied to better understand disease transmission dynamics and social influences on risky and safe injection practices 13 14 15 16 17 18 this research has found that pwid can be effective change agents and opinion leaders disseminating hivrelated knowledge and promoting safer sexual and injection practices among their peers 1920 informed by these findings we suggest that in the face of policy indifference drug users themselves function as the primary agents of prevention on the ground we discuss how communities can help address their hivhcv epidemics in pwid populations by encouraging and facilitating the healthrelated preventive actions that drug users may already be engaging in to support their fellow users supporting encouraging and facilitating drug users as a community prevention resource could have a rapid effect on slowing the spread of hiv and hcv among pwid especially in the early stages of epidemics we present data from three cities in three different countries nyc st petersburg and pereira in order to highlight several characteristics that make pwid especially wellsuited to be key players in supporting the health of the drugusing community in three distinct drug policy and druguse contexts because drug use is often initiated and sustained in a social context with peers drug users particularly those who are young have varying numbers of social network ties with others in the drugusing community as the members of these social networks interact they share norms about safe drug use and often engage in drug use together drug users network connections can therefore serve as a pathway for the transmission of hivhcv infection if these connections involve unprotected sex andor unsafe drug injection practices however these same networks can also function to enhance safety for example a drug user may teach a fellow user safe injection techniques or suggest an alternative route of administration to an individual who is considering injecting drugs for the first time in the next sections we briefly outline salient macrocontextual factors that influence hiv and hcv transmission dynamics among local pwid populations in the us russia and colombia in comparing patterns of prevention efforts and social network linkages among drug users in these three countries we aim to illustrate the role of pwid as active agents for hiv hcv and overdose prevention and the potential of their efforts to help protect drug users from healthrelated harms even when governmentled prevention efforts are insufficient the opioid epidemic in the us starting in the early 1990s the us experienced a sharp increase in prescribing rates of opioid analgesic medications rooted in changing attitudes towards pain treatment within medicine that was abetted by pharmaceutical companies aggressive promotion of new extendedrelease opioid formulations marketed as aroundtheclock treatments for chronic pain these changes led to a dramatic and widespread increase in the availability of prescription opioids throughout the country which in turn led to widespread diversion and misuse of pos particularly among youth 21 and concomitant increases in overdose mortality that continue today 2223 many young people who initiated opioid use with the misuse of pos have subsequently transitioned to the use of heroin 2425 and to injection as a route of opioid administration 2627 leading to an emerging us epidemic of hcv among young pwid especially in nonurban areas 28 more recently a new trend has emerged with the rise in consumption of and mortality due to illicitly manufactured fentanyl and fentanyl analogs drugs which are many orders of magnitude more potent than other opioids in prior research our team has found that drug users commonly engage in healthrelated actions aimed at supporting their fellow drug users and embedding safety in their networks we refer to these actions as intraventions 29 a better understanding of the network characteristics and intravention activities of young opioid users may suggest how their indigenous harm reduction efforts can be supported and strengthened to maximize their effectiveness in preventing hivhcv and overdose to this end we present structured assessment data from a nyc study of young adult opioid users recruited using respondentdriven sampling we examine three aspects of young opioid users network connections to other opioid users 1 the age composition of participants opioid user networks 2 associations between the age of participants network members and participants likelihood of being hcvpositive and 3 the prevalence of intravention activities engaged in by participants with members of their opioid user networks the hiv epidemic in russia the russian federation has the largest hiv epidemic in eastern europe and central asia in russia the number of people newly diagnosed with hiv has risen by 149 since 2006 54 of those newly diagnosed with hiv were infected via unsafe injection drug use 30 funding for nsps in russia is low resulting in extremely low coverage ost remains illegal and its use is punishable by prison 31 pwid are heavily stigmatized and criminalized in russia with extrajudicial policing practices leading to fear terror 32 and sexual violence 33 within this structural context characterized by a lack of services for and severe hostility to pwid our exploratory mixedmethods study of 1826 yearold drug users in st petersburg examined actions that young pwid engage in to prevent hiv transmission and overdose these actions are especially relevant given that russian prevention policies fall far short of addressing the overwhelming needs and have failed to curb the countrys expanding injectiondriven hiv epidemic 34 heroin production driving drug injection in colombia while in the us a major structural factor changing drug use dynamics among youth over the past 20 years has been pharmaceutical opioids leading to increases in nonmedical use of pos and heroin in colombia the factor of change has been heroin production in colombia starting in the early 1990s illicit drug production diversified to include heroin as well as cocaine 35 heroin production led to the development of a local market for heroin and the uptake of heroin use among young people 3637 the growth in the countrys production and distribution of heroin has corresponded with an increase in its local consumption including the use of heroin by injection there is evidence that heroin uptake is increasing among young people in colombia and is more prevalent than previously assumed 38 39 40 since the mid1990s colombia has also had an increase in the number of pwid who now face a rising prevalence of hiv 36 37 38 39 colombia ranks third in hiv prevalence among pwid in latin america 41 and since 2011 has also experienced an increase in the number of reported hiv infections among pwid 36 we present results of a pilot conducted in pereira colombia to study injection and sexual risk behaviors among pwid and their sexual injection and highrisk friendship networks pereira is one of the colombian cities with the highest prevalence of heroin consumption 42 located in the main coffeeproducing region of the country by 2008 pereira had become the trafficking epicentre for heroin produced in colombia leading to an oversupply of heroin in local drug markets in response to an increasing prevalence of viral infections among pwid a pilot syringe exchange and naloxone distribution program was opened in pereira 43 results of our pilot study show how in some contexts pwid are connected via social network ties to members of other groups at high risk for hiv infection specifically men who have sex with men transgender individuals and sex workers therefore supporting pwid in their prevention efforts could have effects that ramify beyond communities of drug users potentially benefiting other vulnerable groups methods new york city in nyc young adult opioid users were recruited in 20142016 via respondentdriven sampling a form of chainreferral sampling designed to engage hardtoreach populations twenty eligible index participants were directly recruited by research staff interviewed and invited to refer up to three opioidusing peers to the study this process was repeated with the seeds recruits and for successive sampling waves eligible participants were englishspeaking nyc residents ages 1829 who had used pos nonmedically andor heroin in the past 30 days structured interviews assessed participants sociodemographic and opioid user network characteristics drug use behaviors and intravention activities hcv and hiv status was established via rapid antibody testing network questions focused on the number of nyc residents participants knew personally who use opioids nonmedically and the number of such people they saw in the past 30 days based on formative qualitative research we developed a 26item instrument to measure participants lifetime intravention activities in the following domains a drug use management b supporting injectionrelated risk reduction and c overdose prevention and response an additional domain inquired about healthnegative activities ie actions that are intended to help other opioid users cope with the exigencies of opioid dependence but which may inadvertently foster risky behaviors all intravention items addressed either opioid userelated health advice given by participants to fellow opioid users or actions aimed at supporting fellow opioid users to analyze the age composition of participants opioid user networks participants were categorized into 3 age groups and network members into 4 groups and proportions of total network members within participant age group and injection status were calculated logistic regression was used to estimate odds ratios and 95 confidence intervals for the associations of knowing at least one network member older than 29 and having seen at least one network member older than 29 in the past 30 days with testing hcv antibodypositive these models were run for the subsample of participants who reported ever injecting drugs and were stratified by participant age group bivariate descriptives were used to characterize prevalence of engagement in intravention activities and number of people participants engaged with for each intravention activity chisquare and ttests were used to compare differences between injectors and noninjectors st petersburg the st petersburg pilot study of young adult hard drug users aimed to better understand emerging drug use patterns and young drug users social networks the study conducted in 2016 and 2017 employed a mixedmethod research design with semistructured qualitative interviews followed by structured assessments to be eligible for phase 1 participants had to be 1826 years of age report any drug use in the past 30 days be a current resident of st petersburg and speak russian participants were recruited from a local drug treatment program and a local narcotics anonymous group semistructured interviews assessed drug use practices and patterns social network characteristics attitudes towards heroin users sexual practices and overdose history interviews were conducted in a private setting lasted about 90 minutes and were digitally audiorecorded thematic analysis of the qualitative data was conducted using the program open code 36 in phase 2 modified respondentdriven sampling techniques were used to recruit young hard drug users eligible participants were russianspeakers aged 1826 who reported using any illicit drug besides cannabiscannabinoids in the past 30 days and were willing to perform hiv and hcv selftests in the presence of an interviewer screening procedures included age verification via photo id and a visual check for injection marks for those reporting recent injection structured assessments were based on phase 1 findings and covered the same topical domains as the qualitative interviews assessments lasted between 90 to 120 minutes and were followed by oraquick rapid hiv and hcv oral fluid antibody tests pereira a pilot study conducted in pereira colombia in 2017 sought to describe network connections among different hiv risk groups to better understand the spread of hiv to and from pwid and other risk groups using modified respondentdriven sampling recruitment procedures 5 hivpositive pwid were recruited by research staff to serve as initial seeds with the remainder of the sample recruited by targeted chainreferral each seed was asked to recruit up to 9 peers up to 3 in each of the following 3 networks a people with whom the participant had injected drugs in the past 30 days b sex partners in the past 6 months and c friends in key groups at risk for hiv in colombia seeds and referrals were interviewed about their injection and sexual risk behaviors and provided blood samples for hiv and hcv rna testing also as part of the interview participants were asked to name and describe characteristics of up to 9 people from their injection sexual and highrisk friendship networks results new york city nyc participants had a mean age of 245 years sixtysix percent were male 72 identified as white 27 as latino and 10 as multiracial fiftyfive percent reported growing up in a household with an annual income of 51000 or higher fiftyseven percent had been homeless at some point in their lives and 66 reported ever injecting drugs the 539 participants reported knowing a total of 26507 nyc residents who used opioids although the majority of participants network members were a similar age as themselves network connections across age groups were also present of all the opioid users younger participants reported knowing 14 were older than 29 and 18 were younger than 18 for slightly older participants 27 of their opioidusing acquaintances were older than 29 participants who injected drugs had a higher proportion of network members older than 29 than noninjectors ranging from 17 for younger participants to 32 for the oldest group considering injectors of all age subgroups together knowing any opioid user older than 29 had a moderately strong association with testing hcvpositive a similarly strong association was found between having seen any opioid user older than 29 in the past 30 days and hcvpositive status when stratified by participant age group although not significant participants ages 1821 had 3 ½ times the odds of testing hcvpositive if they knew any opioid user older than 29 large proportions of participants reported engaging in intravention activities in all four domains and the total number of peers intravened upon by all participants combined ranged in the thousands for most activities for 22 of 26 intraventions significantly higher proportions of lifetime injectors than noninjectors ever engaged in these activities and for 21 of the 26 intraventions they engaged in them with greater numbers of people for example in the drug use management domain injectors were significantly more likely than noninjectors to urge peers to enter drug treatment encourage peers to sniff opioids instead of inject and help peers cope with withdrawal symptoms the two activities in the drug use management domain in which all participants regardless of drug injection experience were equally likely to intravene were helping peers reduce drug intake and recommending that their peers not use heroin not surprisingly the domain of supporting injectionrelated risk reduction presented the largest differences between injectors and noninjectors both in terms of the proportion who reported ever engaging in the activities and the mean number of people intravened upon for example 846 of injectors ever gave sterile syringes to fellow users with a mean of 119 people injectors were also significantly more likely to intravene and to intravene with a larger number of people for 3 of the 4 overdose prevention and response activities this same pattern of responses was observed for the 5 healthnegative intraventions with injectors significantly more likely to report engaging in these activities and doing so with more members of their opioid user networks st petersburg the 39 participants who completed the structured assessment had a mean age of 224 years 57 were male 73 were full or parttime employed and 15 had ever been homeless the majority of participants reported that they never socialized with older drug users and 36 reported rarely doing so participants in qualitative interviews reported proactively engaging with fellow drug users in order to prevent injection risk and overdose these findings are reflected in the results of the structured assessment table 4 based on the 24 respondents who reported recent injection indicates that a majority of pwid engaged in most healthand safetyrelated intraventions in the past 6 months more specifically considerable proportions of young pwid engaged in the following activities with high frequency discussing the need to inject safely providing sterile syringes to their injection network carrying enough syringes to provide to anyone who needs one and discussing protection from police or other people not involved with drugs pereira among the 5 seeds and 45 network members recruited the mean age was 29 years 70 were 1829 and 30 were older than 29 fortyeight percent were male 42 were female and 10 were transgender just over half of the sample were pwid and all but 7 of pwid reported sharing syringes in the past 6 months including 71 who shared with 12 people and 22 who shared with 3 or more potentially highrisk sexual behaviors were prevalent in the pwid subgroup with regard to the past 6 months 39 of pwid reported engaging in sex work 18 in group sex and 36 had samesex partners accordingly hcv and hiv prevalence was high among pwid while pwid and noninjectors had the same hiv prevalence noninjectors had lower hcv prevalence among all 50 participants hiv prevalence was highest among those in the highrisk friendship subgroup close to the mean among those with whom participants reported injecting and lowest among those with whom participants reported having sex despite the high hiv prevalence in the overall sample only 40 of hivpositive participants had seen a doctor in the past 12 months pwid reported injecting drugs with a total of 155 individuals in the past 6 months the majority of those with whom pwid in both the younger and older age categories reported injecting were 1829 years old participants named a total of 82 people with whom they injected in past 30 days 112 people with whom they had sex in past 6 months and 117 highrisk friends with whom they interacted also in the past 6 months a large number of sexual injection and social network connections overlap across hiv risk groups discussion networks of people who use drugs large interconnected and supportive results of recent research conducted by members of our team in nyc usa st petersburg russia and pereira colombia indicate that people who use drugs can be active players in promoting risk reduction and that their large social networks provide them with ample opportunities to help fellow drug users with drugrelated supportive activities we report widespread efforts on the part of members of drugusing communities to support other pwud in various healthrelated domains including drug use management injectionrelated risk reduction and overdose prevention and response present findings also show that pwid are more likely than noninjecting drug users to report engaging in healthrelated actions to support their fellow drug users and to do so with larger numbers of people a possible explanation for these findings is that pwid may know more people who engage in serious drug use and are therefore in greater need of support pwids greater involvement in intravention activities might also be due to their greater situational opportunity that is for some activities pwids intravention potential is enhanced because they are likely to be present when and where risky injection situations take place for example 54 of pwid in our st petersburg study reported supplying sterile syringes to those with whom they inject because drug injection is often a group activity pwid are likely to witness potentially risky injection events in which they could effectively intervene additionally data from pereira indicate that pwid not only are well connected with fellow drug users but also interact socially sexually and within injection contexts with members of other stigmatized groups at high risk for hiv including sex workers transgender people and men who have sex with men such interconnections between pwid and members of other risk groups place pwid in a key position to potentially spread hiv prevention knowledge and resources to other vulnerable groups beyond drugusing populations supporting pwud particularly pwid as key players in the fight against hiv hcv and overdose this paper demonstrates that drug users themselves and particularly pwid are often proactive players vested in contributing to the wellbeing of their fellow pwud this finding is especially important when we consider how rare it is to think of pwud as allies in the fight against hivaids and how often pwud are instead the targets of punitive measures such as arrest and incarceration which heighten their risk of viral infection and other healthrelated harms data from st petersburg suggest that young drug users engage in extensive intravention efforts even in settings characterized by minimal harm reduction services and open hostility toward drug users although frequently neglected drug users could become a critical resource for hivhcv prevention if supported especially in localities where emerging epidemics are taking hold yet harm reduction services are in short supply in short we suggest that in the face of policy indifference pwud themselves can become primary prevention agents on the ground and indeed in many ways are already doing so professional prevention efforts may benefit by supporting and building on the selfinitiated healthprotective actions that local communities of drug users are already engaged in facilitating encouraging and expanding these indigenous harm reduction efforts could have rapid effects on slowing the spread of hivhcv among pwid especially in the early stages of new epidemics formal harm reduction services such as nsps could support existing intravention activities by providing or facilitating pwuds access to the resources needed to enact safer practices efforts to expand upon pwuds intravention efforts would need to be tailored to existing structural limitations in a given location for example nsps in colombia and russia are very limited in number and scope while most pharmacies can sell sterile syringes overthecounter a simple public health intervention could support pwids efforts to promote safe injection practices by subsidizing the cost of syringes with coupons to be redeemed at designated druguserfriendly local pharmacies other intraventionenhancing modalities could involve the distribution of the overdosereversal medication naloxone to pwud the promotion of intravention activities needs to be adapted for specific locations and druguse contextsresearch can help identify areas of high need for example promoting the use of nsps could be a futile exercise if such services are unavailable or inaccessible or if the cost of transportation to them is too high local context should also inform which prevention measures may be feasible in a given area for example in canada harm reduction services discourage the cleaning of syringes with bleach in favor of advising pwid to use a new sterile syringe for every single injection such a recommendation in a setting with a severe syringe scarcity could be unattainable and even counterproductive where syringes are scarce it may more feasible to support pwid by disseminating instructions and supplies for effectively cleaning syringes with bleach 44 especially if the current practice is cleaning syringes with water only intravention activities are conducted and sustained through ongoing actions by and for drugusing communities promoting these healthfocused collective actions has the potential to achieve broader impact than individualfocused interventions because intraventions are enacted in a community by members of that community they are likely to reach larger numbers of drug users than traditional individuallevel interventions like drug use itself intraventions operate at all hours of the day and night they are therefore likely to be available in the precise location and moment of need promoting these internallydriven cultures of support may help foster the development of healthprotective group norms thus laying a foundation for selfsustaining behavior change rather than requiring constant external interventions delivered by trained personnel or professionals it could also be useful to engage drug users civic potential by using online and offline strategies to promote hivand drug userelated activism and encouraging the formation of grassroots drug users organizations we do not mean to suggest that supporting drug users intravention efforts should be a substitute for policy work to allow for the implementation of formal harm reduction services for pwud rather we believe that supporting drug users preexisting intravention activities could help overcome existing shortcomings of a given communitys hivhcv policy response while the struggle to implement comprehensive harm reduction services continues we believe this supportive work should be tailored for specific druguse contexts in collaboration with members of local drugusing communities contextually specific harm reduction strategies would insure that at least basic safety measures are in place should efforts to implement formal and professionalized harm reduction services fail pwids risky healthrelated activities while this paper highlights drug users proactive engagement in actions designed to protect their own and other drug users health drug usersinjectors can also promote risky behaviors within their drugusing networks and serve as sources of viral infection most hiv epidemiological research focuses on pwids network connections and interactions as a potential source of viral transmission risk in this paper we identified five healthnegative intraventions a encouraging the use of benzodiazepines to cope with opioid withdrawal b injecting others with drugs c providing another injector with a syringe containing leftover drug solution recommending d heroin use and e drug injection as means to reduce the cost of opioid use similar to healthpositive intraventions we found that drug injectors were more likely than noninjectors to engage in these actions and to do so with larger numbers of pwud we believe these negative healthrelated actions are best understood in a context of situated rationality 45 as such the risks associated with these actions might be counterweighed by other rationalities of more immediate priority such as supporting fellow injectors in avoiding drug withdrawal therefore negative intravention actions can be understood as pragmatic responses by members of a stigmatized community to structural constraints as such there are two possible ways to address negative health related interactions in the pwud community onethe idealwould be to eliminate the structural constraint that drives the need for a negative healthfocused action another option could be to redirect the health negative action in a more healthpromoting direction while enabling drug users to continue supporting their fellow users for example pwud could be encouraged to provide referrals to ost programs instead of injecting a fellow user for the first time such redirection of course requires the availability of viable healthpromoting alternatives such as ost prevention efforts should count on pwud to become key contributors to prevention efforts while taking into consideration the risk environments they face limitations this study is limited by the disparate data available from each of the three cities the data from nyc are the most extensive while the data are much more limited for the other two locations the small sample sizes in the pereira and st petersburg pilot studies limit the conclusions we can draw about drug users in these locations because most of the data presented in this paper derives from studies of young adult drug users it is unclear to what extent our findings are specific to young drug users or more broadly applicable to drug users in general future research is needed to assess the generalizability of the findings to drug users of different age groups in view of these limitations the findings should be interpreted with caution young pwud associate with similarage peers but also interact with older pwud data presented in this paper suggest that young pwud tend to associate mostly with other drug users close to their own age group however despite this general tendency a smaller yet not insubstantial proportion interacts with older pwud for young pwid in nyc knowing older drug users was associated with increased likelihood of exposure to hcv therefore the observed tendency of young pwid to interact with drug users of a similar age as themselves could serve as a partial barrier to the spread of hivhcv from groups of older pwid to groups of younger pwid prevention efforts focusing on recentlyinitiated pwid even in settings such as nyc or st petersburg where the overall prevalence of hivhcv in pwid is high could help prevent viral transmission among young pwid while their subgroup hivhcv prevalence is still relatively low and they are less likely to interact with older pwid given the evidence of pwids willingness to enact healthpositive preventive actions older pwid could be recruited to assist these efforts for example older pwid could be encouraged not to initiate young drug users into injection to promote safe injection practices within their injection networks and given the greater likelihood of serodiscordant hivhcv status to be especially cautious when injecting with younger pwid raising awareness among all pwid of the heightened vulnerability of young recent pwid could help foster intravention efforts within pwid networks by preventing transition to drug injection among youth and intensifying safe injection practices when younger and more experienced injectors use drugs together

the social networks of people who inject drugs pwid have long been studied to understand disease transmission dynamics and social influences on risky practices we illustrate how pwid can be active agents promoting hiv hcv and overdose preventionwe assessed drug users connections and interactions with others at risk for hivhcv in three cities new york city nyc usa n539 pereira colombia n50 and st petersburg russia n49 in nyc we measured young opioid users healthrelated actions to support fellow users intraventions and the age composition of opioid user networks and examined associations between knowing older pwid and being hcvpositive in pereira we measured characteristics of pwids injection sexual and highrisk friendship networks in st petersburg we examined young pwids actions to help others prevent hiv and overdose results in all three cities the majority of participants network members were of a similar age as themselves yet connections across age groups were also present in nyc knowing any opioid user s older than 29 was associated with testing hcvpositive in nyc and st petersburg a large proportion of pwid engaged in intravention activities to support safer injection and overdose prevention in pereira pwid injected had sex and interacted with other key groups at risk

19897_0

introduction socioeconomic status is a complex multifactorial variable which has been shown to influence many aspects of human health 1 2 3 for example studies have demonstrated relationships between ses and increased risk for coronary heart disease 4 5 6 diabetes mellitus 7 8 9 obstructive sleep apnea syndrome 10 cardiovascular mortality 11 12 13 and cancer 1114 venous thromboembolism manifested as deep vein thrombosis or pulmonary embolism is a common major cause of mortality and morbidity although there are several studies suggesting that inflammation may trigger coagulation both in the arterial and venous circulation 15 16 arterial atherothrombotic disease and vte are not only separate diseases but also have partly different causes 17 18 furthermore the differences in the pathogenesis of this two different diseases are far from fully understood it is therefore of great interest to know whether variables reflecting the ses of an individual are related to the risk for vte in the same way as has been shown for different manifestations of arterial vascular disease 4 5 6 11 12 in 1981 a study by samkoff et al demonstrated an increased rate of pe in subjects with less than 8 years of education compared to in subjects with longer education 19 another study by rosengren et al 20 it showed that ses variables such as persistent stress and low occupational class were independently related to future pe while no such significant relationship could be demonstrated between dvt and ses 20 it is also important to note that this study 20 which to the best of our knowledge is the only that has evaluated possible associations of this kind was performed in male subjects only while information on possible associations between ses and vte are scarce several concomitant diseases such as for example malignancy 21 inflammatory bowel disease 22 fractures and surgical procedures 23 and infection 24 have all been reported to confer an increased risk for vte the aim of the present study was to assess whether both variables reflecting ses and diagnoses of concomitant diseases prospectively influence the risk for vte during followup in individuals of both genders derived from a total population population and methods description of the database and definition of the population the present study is included within the research project longitudinal multilevel analysis in skåne conducted at the unit for social epidemiology at the lund university the project has been approved by the data safety committees at statistics sweden the swedish centre for epidemiology and by the regional ethical review board in lund the personal identification number assigned to each person in sweden was used by the swedish authorities to link information on socioeconomic demographic and health care variables from different registers once the record linkage was done the original personal identification number was encrypted to strenght the anonymity of the individuals 1 assessment of on socioeconomical and demographical variables statistics sweden provided information on socioeconomical and demographical variables for the year 1990 according to the swedish census and the population register we categorized age into five groups and used the youngest age groups as references in the comparisons we considered annual equalized family disposable income in 1990 divided into three categories using the tertiles of distribution the highest tertile was used as reference in the analysis we categorized formal educational achievement into less than 9 years 10 12 years and 13 years or more and used this last category as reference in the comparisons since a 16 of the women and 11 of the men lack information on educational achievemet we create a category of missing values marital status was dichotomised into marriedcohabiting and living alone marriedcohabiting was used as reference in the analysis country of origin was categorized into two groups using information from the population register we calculated the number of years every individual had been registered as resident in sweden an categorized this variable into 04 59 1014 and 15 years or more we applied this last category as reference in the comparisons statistical analyses we followed all individuals from january 1 st 1990 until december 31 st 2003 until the first hospitalization with a dvt diagnosis or until death we did not include any other criteria for lost of follow up since the national in hospital and mortality registries cover the whole country of sweden and therefore we were able to identify those events occurring outside the county of skåne we assumed that migration from the country did not have any mayor effect on our estimations we performed a sex stratified cox regression and obtained hazard ratios and 95 confidence intervals we developed two different models in model a we included only demografical and socioeconomical variables in the expanded model b we added previous diseases and risk factors for vte results table 1 shows number and percentages of women and men who were diagnosed with or died from vte during prospective followup 19912003 table 2 show hazard ratios with confidence intervals for vte diagnosis or death separately for women and men respectively in both genders age above 40 years at baseline increased the risk of a vte diagnosis whereas age 39 years was associated with a lower vte risk subjects in the lowest and middle tertile concerning household income had an increased risk for vte compared to subjects in the highest tertile single subjects had an increased risk for vterisk than married and cohabitating individuals compared to those with the longest duration of education an increased risk for vte both in those with less than 9 years of education 146 discussion vte is associated with several anatomical biochemical and acquired risk factors high age is an important risk factor in many different populations 25 26 27 including our own 28 this was confirmed in the present study as higher age at baseline in both genders was associated with increased vterisk during followup many other factors were also important for vte incidence in this study however during a followup of 13 years fewer vtecases occurred among married subjects of both genders as well as in subjects with higher income similar relationships have been demonstrated for diseases such as chd 4 12 13 29 and osas 10 in the malmö population subjects with low income also run increased risk for prehospital death after acute myocardial infarction 12 similar relationships have also been shown between these socioeconomic factors and mortality in lung cancer and copd in the united states 14 furthermore both men and women with fewer years of formal education also showed an increased vteincidence during followup corroborating findings from studies examining effects on education and income on incidences of type 2 diabetes and lung cancer and on copd mortality 714 a relationship between ses and pe has previously been demonstrated in swedish men 20 among whom a high ses was protective against pe we now extend this finding by confirming that ses is of relevance also among female subjects and for both dvt and pe there might be different explanations for effects of ses on vte incidence a higher level of education for example may affect an individual in many positive ways the subject might be more receptive to information in health matters since this type of messages are often written in educated language making it possible for such individuals to more easily adapt to healthy behaviours furthermore previous studies have shown that better education is also associated with both higher compliance 30 and commitment to medical treatment 31 having been born outside sweden on the other hand was shown to be associated with a lower risk for vte during followup for both men and women as data were age adjusted this could not only be a result of younger age among immigrants furthermore as the risk for vte in immigrants increased with longer inhabitance in sweden the results cannot be entirely explained by genetic factors either our results thus clarify that both environmental and genetic factors interact in vte pathogenesis a high prevalence of different genetic risk factors for vte has been described in the skåne population 32 and the fact that we do not have data on hereditary thrombophilia in our cohort is of course a study limitation in order to be able to present reliable data on the importance of hereditary thrombophilia for vte diagnosis and death we would have had to examine not only cases however but also controls without vte occurrence or vte death during followup evaluation of a cohort of over 700000 subjects in this respect would have presented obvious practical difficulties the key strength of our study is the large sample size explained by the fact that we have included the whole population above 25 years of age in the county of skåne in 1990 our cohort is larger than previous materials as it includes over 700000 subjects another difference between the present study and the study by rosengren et al 20 is that we studied both men and women and measured ses by income marital status education country of birth and years in sweden in the study by rosengren et al ses was measured by occupational class and factors reflecting stress as in the study by rosengren et al 20 we found that several important concomitant diseases such as for example malignancies inflammatory bowel disease and cvd at baseline was associated with an increased risk for vte in both genders these diseases might of course also be more common among patients with low ses the well known relationship of vte development with common risk factors at baseline such as fractures trauma or surgery was also confirmed during followup in both genders even if the confidence interval for fracture or trauma only narrowly overlapped 10 among females it is important to note that our data on ses concomitant diseases and risk factors associated with vtedevelopment during followup are derived from the period 19871990 and apply to the risk of vte development and death during 19912003 we cannot be sure that having the same background factors in 2012 has the same implication upon vte risk during the upcoming 13years we are currently following up more contemporary patient materials in order to evaluate whether our conclusions about the importance of ses risk factors and concomitant diseases for vtedevelopment are relevant also for the future since there are no previous prospective studies examining the role of ses in both genders in vtedevelopment comparisons of our results in relation to other studies are difficult however samkoff et al 19 reported a higher perate in subjects with less than 8 years education compared to those with higher education our study has limitations the database includes data on the entire population in the county of skåne and we could not objectively verify diagnosis in all cases furthermore only inhospital diagnoses were registred as data on hereditary thrombophilia body mass index history of smoking and alcohol abuse are not registred by the authorities and therefore not available it was not feasible to identify possible contribution of these variables to vterisk conclusions our study demonstrated that higher age and socioeconomic status as measured by lower income single marital status and lower level of education were independently related to an increased risk of vte during prospective followup foreign ancestry on the other hand was related to a lower vte risk aknowledgements this study is supported by the swedish research council research grants legend to figures crude and adjusted cumulative survival time free of venous thromboembolism during the 13 years followup period

socioeconomic factors and concomitant diseases are related to the risk for venous thromboembolism during long time followup

19898_0

introduction in 2019 more than onethird of the european population aged 16 years and older reported having a chronic disease 1 a condition lasting for at least 1 year and requiring ongoing medical attention andor limits daily activities is considered a chronic disease 2 persons with chronic diseases have a higher risk of becoming unemployed compared with persons without chronic diseases 3 4 and the proportion of the ageing working population with a chronic disease is increasing 5 alongside precarious work such as nonstandard employment contracts also increased in the past decades 6 in the netherlands the number of persons with a temporary contract or contract with varying hours per week increased from approximately 15 million in 2010 to almost 26 million in 2021 7 if persons with chronic diseases are more likely to get precarious work this may further increase health inequalities several studies have investigated the impact of chronic diseases on obtaining paid employment 8 9 10 11 12 they showed that in general unemployed persons with chronic diseases were less likely to become employed some of these studies used selfreported data to determine chronic diseases and employment status 8 9 while other studies used pharmacy data what is already known on this topic ⇒ a few studies showed that persons with chronic diseases are less likely to enter paid employment compared with persons without chronic diseases ⇒ research points to the negative impact of precarious employment such as temporary employment contracts on health outcomes however less is known about the selection of persons with health conditions into precarious employment and whether this is moderated by educational attainment what this study adds ⇒ by using objective pharmacy data linked with registrybased data on monthly employment status this study showed that dutch unemployed persons with chronic diseases entered paid employment less often and spent more months in nonemployment compared with persons without chronic diseases during a 10year followup which was most pronounced with increasing educational attainment ⇒ conditional on entering paid employment workers with cardiovascular diseases inflammatory conditions and diabetes needed more time to obtain a permanent contract compared with workers without these diseases but educational inequalities were not found how this study might affect research practice or policy ⇒ the findings emphasise that policies need to focus on the prevention of chronic diseases and the promotion of stable paid employment among persons with chronic diseases original research on prescribed medication to determine unemployed persons health conditions 10 11 12 selfreported measurements of chronic diseases are more prone to reporting bias or justification bias which occurs when unemployed persons overreport health problems to justify that they do not have paid employment 13 these sources of bias can be minimised by using pharmacy data to more objectively identify chronic diseases 14 from the studies on the associations between chronic diseases and entering paid employment it remains unclear whether persons with chronic diseases are selected for precarious work although there is no single agreed definition of precarious employment yet existing frameworks indicate the following characteristics employment insecurity low financial compensation and lack of rights and protection 15 16 nonstandard employment contracts such as temporary contracts are used as a measure of precarious work 17 18 while studies primarily have focused on the impact of precarious work on health 19 studies on the selection of persons with health conditions for precarious employment are scarce persons with disabilities were found to have temporary employment contracts more often compared with persons without disabilities 20 likewise wagenaar et al 21 found that having musculoskeletal symptoms was associated with a lower likelihood to obtain permanent employment among dutch workers with temporary work although this association was not statistically significant after adjustment for demographic characteristics the impact of having a chronic disease on entering paid work and obtaining a permanent position might differ depending on educational attainment previous research demonstrated that differences in paid work between persons with and without chronic diseases were most pronounced for persons with lower educational attainment 22 it could be hypothesised that persons with lower educational attainment with a chronic disease are less likely to obtain a permanent contract the current registrybased study with a 10year followup aimed to investigate among workingage unemployed persons in the netherlands the impact of having a chronic disease on entering paid employment and subsequently on obtaining a permanent contract and the extent to which these associations differ by educational attainment methods study design and population in this dutch longitudinal study registrybased databases provided by statistics netherlands on monthly income components contract type purchased medication demographics and educational attainment were linked at the individual level by means of pseudonymised numbers for each respondent 23 the linkage level was high because the information from tax registries based on national citizen service numbers was used however variables for educational attainment and household characteristics had missing values to prevent individuals from being excluded due to missing values these categorical variables had an extra category missing informed consent from respondents was not required for this study because according to dutch legislation research institutes are permitted to use pseudonymised registrybased data in this study 667 002 dutch residents were selected who consecutively received unemployment benefits or social security benefits in october november and december 2010 and were aged between 18 and 64 years old at baseline the impact of having a chronic disease on obtaining paid employment and on obtaining a permanent position was investigated over a 10year followup period between january 2011 and december 2020 employment status and contract type employment status was defined by monthly income components from statistics netherlands persons who received unemployment benefits or social security benefits were considered as being unemployed persons receiving income from paid employment or selfemployment were defined as being in paid employment the transition from unemployment to paid work was measured as the first month at which persons were in paid employment for at least three consecutive months registrybased data on contract type was used to distinguish between persons with a temporary employment contract and those with a permanent contract in the netherlands a temporary contract may typically vary between 2 months and 48 months depending on national legislation and collective labour agreements the transition to a permanent contract was operationalised as the first time persons had a permanent employment contract for at least three consecutive months since the first month they were in paid work chronic diseases the presence of chronic diseases was measured with data from 2009 and 2010 on purchased medication from pharmacies and reimbursed by insurance companies the who anatomical therapeutic chemical classification of medication was used to categorise persons with and without chronic diseases 24 in total 21 chronic diseases could be identified based on medication 12 14 the following six chronic diseases were investigated in this study cardiovascular diseases inflammatory conditions diabetes respiratory illness common mental disorders and psychotic disorders 12 these six chronic diseases concern diseases with the highest prevalence among unemployed persons persons were considered as having a specific chronic disease when they purchased medication for one of these chronic diseases in both 2009 and 2010 covariates sociodemographic data from statistics netherlands on age gender household composition and migration background from 2010 were used age was categorised into the following categories 1829 years old 3044 years old 4554 years old and 5564 years old with regard to household composition persons with and without a partner or children in the household were identified to prevent the exclusion of persons with missing values for household composition an additional category missing was added to the variables having children and living with a partner migration background was divided into native dutch turkish moroccan surinamese and antillean and other educational attainment from 2016 was used since this was the first year statistics netherlands followed the international standard classification of education from 2013 25 education was categorised into low intermediate and high to prevent the exclusion of persons with missing values for education a fourth category was added to the education variable indicating missing information based on monthly income components from january 2009 up until september 2010 the number of months in paid employment prior to baseline was categorised original research into 0 months 112 months and 1321 months persons not in paid employment prior to baseline were unemployed disabled economically inactive early retired or had missing information on employment status statistical analysis descriptive statistics were used to investigate the baseline characteristics restricted mean survival time analyses were performed to investigate the impact of each of the six chronic diseases on entering paid employment among all persons who were unemployed at baseline and obtaining a permanent contract among persons who entered paid employment during the 10year followup period rmst was used instead of traditional cox proportional hazard models because it does not require the proportional hazard assumption to be met and it allows the outcomes to be expressed as the absolute difference in the average number of months to paid work or obtaining a permanent contract between persons with and without a chronic disease 26 for each specific disease a comparison is made to persons without that specific disease both persons with the specific disease as well as persons without the specific disease may have one of the other diseases persons were censored when they reached the statutory retirement age of 65 years information on employment status was missing for at least 3 consecutive months persons with a chronic disease at baseline stopped using medication for the chronic disease of interest persons without a chronic disease at baseline started using medication for the chronic disease of interest or at the end of the followup period in the analyses of the impact of having a chronic disease on obtaining a permanent contract persons were additionally censored when they exited paid employment first descriptive analyses and rmst analyses were performed for each chronic disease in general and stratified by educational attainment to determine the proportions of persons who entered paid employment or obtained a permanent contract and the average number of months until the transition of interest the time difference in months until the specific event occurred between persons with and without a chronic disease was adjusted for the following covariates age gender living with a partner having children migration background educational attainment number of months in paid employment before baseline and the presence of an additional chronic disease at baseline we additionally determined whether the adjusted time differences in months until the events of interest between persons with and without chronic diseases differed by educational attainment therefore the interaction terms intermediateeducation chronicdisease highereducation chronicdisease and missingeducation chronicdisease were added to the rmst model with these interaction terms it was tested whether the influence of a chronic disease on entering paid employment and on obtaining a permanent contract among intermediate respectively higher educated persons differed from lower educated persons statistically significant interaction effects are indicated by † in the tables all analyses were performed with rstudio v141103 the rmst2 function of the survrm2 package was used for the rmst analyses results characteristics of the study population onethird of the unemployed persons entered paid employment during followup in total 431 had low educational attainment 252 had intermediate 108 had high educational attainment and 209 did not have information on educational attainment persons with a chronic disease most often had inflammatory conditions common mental disorders or cardiovascular diseases and 254 had two or more chronic diseases almost 70 of the unemployed persons did not have any paid employment in the 2 years before baseline during the followup period 336 entered paid employment impact of having a chronic disease on entering paid employment table 2 shows that the proportions of unemployed persons who obtained paid employment were lower for persons with chronic diseases compared with those without chronic diseases persons with cardiovascular diseases inflammatory conditions diabetes respiratory illness common mental disorders and psychotic disorders all spent more months impact of having a chronic disease on obtaining a permanent contract the differences in the proportions of persons with or without a chronic disease who obtained a permanent contract were smaller compared with the differences in the proportions of persons with or without a chronic disease who gained paid employment in the unadjusted analyses the time until obtaining a permanent contract was shorter for persons with cardiovascular diseases diabetes respiratory illness common mental disorders and psychotic disorders compared with those without these chronic diseases ranging from 55 27 original research discussion this study showed that unemployed persons with chronic diseases entered paid employment less often and spent more months in nonemployment during followup than persons without chronic diseases for most chronic diseases differences in time until entering paid employment between persons with and without chronic diseases were larger with increasing educational attainment most pronounced for persons with a high educational attainment and psychotic disorders for most categories of chronic diseases these profound differences between persons with and without chronic diseases in entering paid employment were substantially less for gaining a permanent contract conditional on having entered paid employment the time until obtaining a permanent contract was longer for persons with cardiovascular diseases inflammatory conditions and diabetes for persons with psychotic disorders the time until obtaining a permanent contract was shorter the majority of unemployed persons at baseline did not enter paid employment during the 10year followup in line with this finding yildiz et al 12 found that only 32 of the unemployed persons entered paid employment during 3 years of followup a possible explanation is the prolonged nonemployment history of the included persons the majority of unemployed persons did not have any paid employment in the 2 years prior to baseline which might have decreased their likelihood to reenter the labour market likewise schuring et al showed that for dutch persons who left paid employment the likelihood to reenter paid employment was lower with increasing nonemployment duration 27 the selection of longterm nonemployed persons in the current study might be the result of also defining persons with social security benefits as unemployed in addition to those with unemployment benefits in the netherlands most workers who become unemployed will first receive an unemployment benefit and after an extended period will be transferred to the much lower social security benefit this study pointed out that persons with chronic diseases obtained paid employment less often and spent more months in nonemployment before entering paid employment these findings corroborate results from previous studies on the lower likelihood to enter paid employment for persons with chronic diseases 8 9 10 11 12 while the difference in prevalence of persons who entered paid employment was largest for persons with psychotic disorders compared with persons without psychotic disorders differences in time spent in nonemployment were most pronounced for persons with cardiovascular diseases in comparison with persons without cardiovascular diseases the difficulties persons with chronic diseases experience in entering paid employment could partly be explained by their functional limitations or lower psychological resources 28 other explanations may be selfstigmatisation and stigmatised attitudes and original research discrimination from employers in case employees disclose about their conditions which was shown for persons with disabilities in a recent systematic review 29 in general persons with higher education entered paid employment more often and spent less time in nonemployment than persons with low education however differences in time before entering paid employment between persons with and without chronic diseases were more pronounced among persons with higher educational attainment since persons with higher education experienced fewer difficulties in entering paid employment compared with persons with low education having a chronic disease may be a stronger limiting factor for participation in paid employment than those with higher education having a chronic disease might have played a smaller role for persons with low education because besides reasons related to health their participation in paid employment could be hampered by various other individuallevel factors 30 31 economic and technological developments other new insights were that compared with the healthbased selection into paid employment and educational differences in these associations obtaining a permanent contract was affected less by having chronic diseases and educational inequalities were less present employers might be more reluctant to offer persons with chronic diseases a permanent contract because they are less inclined to implement continued workplace adaptations 32 and because in the netherlands they are obliged to pay wages for up to 2 years in case employees with chronic diseases report sick a surprising observation was that persons with psychotic disorders had a shorter time until obtaining a permanent contract compared with those without psychotic disorders unemployed persons with psychotic disorders entered paid employment least often which may have introduced the strongest healthbased selection into paid employment since this group likely consists of persons with high motivation to work and persons who receive support in obtaining and retaining employment for instance by means of individual placement and support programmes 33 this might explain the shorter time until obtaining a permanent contract a major strength of the current study is the use of registrybased information over a 10year followup period the information from tax registers on monthly employment status of all dutch citizens made it possible to include a large study population and to avoid the risk of selective nonresponse in cohort studies this increased the generalisability to the dutch population and provided sufficient statistical power to evaluate the associations across educational attainment in addition precise statements could be made about the longterm impact of having a chronic disease on entering paid employment and obtaining a permanent contract another important strength is that the use of rmst analyses compared with cox proportional hazard models allowed for a more intuitive interpretation of the impact of chronic disease on paid employment in terms of the difference in the average number of months until the event of interest 26 several limitations also have to be addressed by using data on prescribed medication purchased at pharmacies and reimbursed by insurance companies persons with chronic diseases who are not treated with medication were not defined as having a chronic disease in this study 12 this could have underestimated the proportion of the study population having a chronic disease especially for common mental disorders in addition since only yearly information was available on medication censoring based on a change in medication for a particular chronic disease during followup resulted in some imprecision when determining the rmst in months a limitation of rmst analysis is that the estimates are dependent on the length of the examined followup period and the proportion of outcome events 34 we observed that the majority of unemployed persons did not enter paid employment and were censored at the end of the followup period hence the estimated rmst must be interpreted within the period of 10 years in mind and shorter followup periods would have resulted in lower rmst values last 20 of the included persons missed information on educational attainment to prevent the exclusion of these persons a separate category was added indicating this missing information for future research it would be relevant to get insight into genderspecific associations as well as into the influence of comorbidity on entering paid employment and on obtaining a permanent contract this would be relevant as the patterns of participation in paid employment differ between men and women with women being more often nonemployed and more often working part time 35 36 however similar patterns have been observed for men and women concerning differences in participation in paid employment between persons with and without a chronic illness 22 in conclusion this study showed that having a chronic disease was a barrier to entering paid employment especially for persons with higher education and a chronic disease and to a lesser extent also for obtaining a permanent contract these results underline the need to prevent chronic diseases and to promote stable employment among persons with chronic diseases competing interests none declared provenance and peer review not commissioned externally peer reviewed data availability statement no data are available 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 this study aimed to investigate among unemployed persons 1 the impact of having a chronic disease on entering paid employment and obtaining a permanent contract and 2 whether these associations differed by educational attainment methods register data from statistics netherlands on employment status contract type medication and sociodemographic characteristics were linked dutch unemployed persons between 18 and 64 years n667 002 were followed up for 10 years 20112020 restricted mean survival time analyses rmsts were used to investigate differences in average months until entering paid employment and until obtaining a permanent contract between persons with and without cardiovascular diseases inflammatory conditions diabetes respiratory illness common mental disorders and psychotic disorders interaction terms were included for education results onethird of the unemployed persons at baseline entered paid employment during followup persons with chronic diseases spent more months in nonemployment compared with persons without chronic diseases difference ranging from 250 months 95 ci 197 to 303 months to 1037 months 95 ci 998 to 1077 months especially for persons with higher education conditional on entering paid employment the time until a permanent contract was longer for persons with cardiovascular diseases 442 months 95 ci 185 to 699 months inflammatory conditions 480 months 95 ci 202 to 759 months and diabetes 832 months 95 ci 426 to 1237 months than for persons without these diseases these latter differences were similar across educational attainment conclusions having a chronic disease is a barrier to entering permanent paid employment the findings underline the need to prevent chronic diseases and promote an inclusive workforce

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introduction people are increasingly recognizing that reconnecting to nature positively contributes to individual and social health and wellbeing 1 particularly with regard to psychological and physiological benefits 2 for example being connected with nature helps people exercise better promote the physical health increase the local knowledge have a heightened sense of place and cultivate an intuitive respect for ecological conservation contact with nature may also prevent mental illness 3 in this sense reconnecting to nature benefits to society and peoples social value the social value can be realized as the benefits created for society and accruing to society as a whole 4 it can be described as the perceived nonmarket values public ascribes and assessable for various groups 5 in general humannature connections over the longterm affect social value although socioecological systems are complex reconnecting people with nature can help move society towards sustainability 6 moreover natural settings such as landscapes provide opportunities for interpersonal interaction and strengthening connections within communities although structural changes are constantly producing public natural landscapes residents seldom have opportunity to voice their reflections on connections with natureeven if they are commonly saturated by natural settings in their daily lives the concept of humannature connections stems from multiple viewpoints 7 the most common theory involves the concept of ecosystem services derived from the millennium ecosystem assessment 8 it emphasizes the benefits of nature to people and quantifies various values of ecosystem services however ives et al 6 argued that the notion of ecosystem services is insufficient and urged a broader approach to humannature connections with a discourse tending to environmental and sustainability challenges across different sociocultural contexts ives et al 9 divided the construct of connections to nature or nature connections into five types material experiential cognitive emotional and philosophical experiential connection is substantially direct interaction with nature environment cognitive connection is knowledge or awareness of the environment and values towards nature and emotional connection is a feeling of attachment to nature 6 it is basically an individual analytical scale furthermore understanding connections with nature across various spatial scales of a landscape has become crucial because such an understanding is useful to land and resource managers 10 peoples perceptions of both nature and policy interventions must not underestimate connections with nature moreover most landscapes near a metropolis are determined by human activities which are vital to biodiversity conservation and rational land use planning 11 however examining how structural changes produced by education or planning policy may be necessary to reveal how human intervention has affected connections to nature united nations sustainable development goal 15 of life on land 12 addresses the commitment to leave no one behind in a coordinated manner un deputy secretarygeneral amina mohammed stated that everyone is a development actor and that socializing goals are crucial 13 echoing arguments that equitable access and equal participation are fundamental principles of the sdg era identifying the nature connections of residents is related to landscape socialization from an archaeological perspective landscape socialization means the social relationships of people are constructed with their landscape indicating the relationship between people and their landscape 14 it is the direct social interaction between people and topography where meaning is imbued into the physical features of the terrain by human viewers and inhabitants 14 the establishment of landscape socialization originates in primary and secondary socialization 15 16 17 primary socialization refers to the acquisition of the basic abilities of landscape cognition and appreciation through family and school education whereas secondary socialization denotes the ability to evaluate landscapes residents with a strong sense of community create strong neighborhood bonds thwaites 18 stated that residents with a strong bond to their neighborhood are prone to identify discuss or criticize the landscapes they encounter for example the close relationship between farmers and the land has a decisive effect on farmers grounded perception of landscapes when multifunctional agricultural strategies are implemented thus examining how educational attainment sense of community and grounded occupation vary with respect to landscape socialization is worthwhile the connection of people with nature underpins landscape socialization and is associated with residents perceptions of landscapes which are connected with spatial representations of structural change through for example policy interventions in land use planning no matter whether policy interventions are conservationor recreationoriented their influence is becoming increasingly crucial to providing nature connections in urbanized society this study aimed mainly to understand peoples connections with nature through landscape socialization under different land use policies examining landscape socialization this study aimed to clarify whether educational attainment sense of community and grounded occupation affect residents connection to nature under conservationand recreationoriented policy interventions taking these variables that possibly influence landscape socialization into account this study hypothesized that a resident with high educational attainment a strong sense of community and who is not a farmer can better identify conservationand recreationoriented social values within the scope of policy interventions compared with a resident with lower educational attainment a weak sense of community and who is a farmer to elucidate landscape socialization 14 this study explored how policy interventions on a landscape influence residents social value towards that landscape methodology conceptual framework this study assumes that landscape socialization is measured by a collection of various quantifications of social value that are given by residents for specific landscapes the collection is regarded as representing the comprehensive social value of the landscapes as a whole furthermore this study analyzed examples involving conservationand recreationoriented policy interventions and their corresponding social values the analytical concept is presented in figure 1 methodology conceptual framework this study assumes that landscape socialization is measured by a collection of various quantifications of social value that are given by residents for specific landscapes the collection is regarded as representing the comprehensive social value of the landscapes as a whole furthermore this study analyzed examples involving conservationand recreationoriented policy interventions and their corresponding social values the analytical concept is presented in figure 1 study area the north coast of taiwan encompassing five administrative districts was selected as the study site landscape policies have been implemented and these overlap two locations namely yangmingshan national park and the north coast and guanyingshan national scenic area a survey of residents was conducted across the study site followed by a comparison of differences to assess the stated hypotheses the north coast has a land area of 3005 km 2 the designated area had an overlap of approximately 646 km 2 with ynp and a 615 km 2 overlap with the ncgnsa the research location and spatial distribution are depicted in figure 2 study area the north coast of taiwan encompassing five administrative districts was selected as the study site landscape policies have been implemented and these overlap two locations namely yangmingshan national park and the north coast and guanyingshan national scenic area a survey of residents was conducted across the study site followed by a comparison of differences to assess the stated hypotheses the north coast has a land area of 3005 km 2 the designated area had an overlap of approximately 646 km 2 with ynp and a 615 km 2 overlap with the ncgnsa the research location and spatial distribution are depicted in figure 2 int j environ res public health 2020 17 x 3 of 18 methodology conceptual framework this study assumes that landscape socialization is measured by a collection of various quantifications of social value that are given by residents for specific landscapes the collection is regarded as representing the comprehensive social value of the landscapes as a whole furthermore this study analyzed examples involving conservationand recreationoriented policy interventions and their corresponding social values the analytical concept is presented in figure 1 study area the north coast of taiwan encompassing five administrative districts was selected as the study site landscape policies have been implemented and these overlap two locations namely yangmingshan national park and the north coast and guanyingshan national scenic area a survey of residents was conducted across the study site followed by a comparison of differences to assess the stated hypotheses the north coast has a land area of 3005 km 2 the designated area had an overlap of approximately 646 km 2 with ynp and a 615 km 2 overlap with the ncgnsa the research location and spatial distribution are depicted in figure 2 ynp is one of nine national parks in taiwan these parks are areas where important natural or historical sites are located the national park law was implemented by the ministry of the interior with the objective of achieving sustainable conservation of unique landscapes and ecosystems and the maintenance of biodiversity and cultural diversity the land planning and operation of parks are organized exclusively by management offices in the construction and planning agency administered by the ministry of the interior special attention is given to conservation no one is permitted to arbitrarily destroy landscapes damage cultural resources hunt animals or pollute the water or air the national park law is strictly enforced by official organizations with environmental protection as the central tenet to ensure that ecosystems are fully protected ynp was established in 1985 due to its unique volcanic geology and biological features and conservation has long been promoted there 19 after years of conservation advocacy landscape policies are likely to have intervened in the conservationoriented landscape socialization of nearby residents the ncgnsa is one of 13 national scenic areas in taiwan article 10 of the act for the development of tourism specifies that the objective of these areas is to organize tourism resources within the designated management area to promote them at local and national levels governed by the tourism bureau of the ministry of transportation and communications national scenic area administration offices are responsible for the management of the scenic areas land in these areas is not necessarily designated for particular uses but the objective for the areas is to maintain and encourage local tourism accordingly landscape policies are aimed at promoting the tourism industry on the basis of adequate use of nationallevel tourism resources within regulatory frameworks founded in 2002 the ncgnsa is rich in tourism resources featuring the worldrenowned baisha bay qianshui bay and yehliu geopark topographical landscape recreational resources are combined with shore and mountain features diverse natural landscapes and humanrelated characteristics 20 longterm tourism development has likely enabled surrounding residents to become competent at identifying the recreationoriented social values of the landscape accordingly this study used ynp for the representation of conservationoriented social values in landscape socialization and ncgnsa was used as for the representation of recreationoriented social values in landscape socialization measures using a questionnaire designed to measure sense of community and the social values for ecosystem services application as analytical tools this study assessed how residents with varying levels of educational attainment sense of community and grounded occupation identify conservationand recreationoriented social values of landscape assets background measurement to reveal the spatial distribution of the residents perceived social values of landscape assets in the north coast area this study designed a questionnaire to determine residents educational attainment sense of community grounded occupation and the social values they attach to the north coast area demographic information collected was related to age occupation and educational attainment age was divided into seven ranges grounded occupation was divided into 10 options educational attainment was divided into six options the design of sense of community indices was based on the sense of community index 2 proposed by chavis et al 21 and a 4point likert scale was employed for evaluation the 24 questionnaire items for sense of community are listed as table 1 the responses to these items were expected to distinguish residents with a strong sense of community from those with a weak sense of community social values measurement residents of local communities can assess the social values that reveal their nature connections through landscape socialization in addition because residents understand the social values of landscapes they should have opportunity to participate in the comanagement of landscapes consequently this study presumed that variability in resident characteristics leads to differences in identifying the social values of landscapesa proxy for landscape socialization in the study area spatial ranges designated by the social values of policies as perceived by residents were used to collect and compare residents identifications allowing an understanding of the value area and spatial distribution related to the social values of landscapes for the questionnaire items for social values the north coast area of taiwan was selected as the site for identifying positions for spatial analysis brown 10 argued that because of the ambiguity of the spatial attributes of landscape value the social values of landscapes classified in a specific typology comprises constructs that residents can easily associate with landscape attributes when an operational definition is provided thus to help respondents clearly understand the meanings of the elements in the typology respondents evaluated seven elements of social valuenamely aesthetics recreation education history and culture spirituality conservation and human survivalwhich had operational definitions this approach is corresponding to scholars 22 similar work a monetary value of nt 100 was allocated across these elements which reflected how important each element was to the respondent the questionnaire was written in mandarin and the results were subsequently translated into english as written in appendix a this study evaluated the overall weight of the social value elements and subsequently used recreation and conservation as examples to compare the influences of the policy interventions on social values for each value the two most representative spatial points were identified and their names and positions were noted and marked basic information such as administrative divisions road names and contour lines was integrated into the map so that respondents could locate reference points in the identification process only the north coast area was used because landscape policy boundaries or areas overlapping with ynp and ncgnsa were neither marked nor mentioned the identification process was a blind test although numerous quantitative tools have been developed for spatial analysis quantifying these social values for indepth analysis required further development 23 this study utilized social values for ecosystem services an opensource toolbar developed by the united states geological survey in combination with arcgis 104 for quantitative data analysis of landscape social values practical cases studies of the social values based on the solves model are prevalent 2425 in addition solves 30 be used to easily obtain and process nonmarket social values the use of solves entailed two basic analytic steps first the points identified by the respondents were randomized using an analogous method the potential point distributions of each social value were then inferred using the quadratic kernel function without considering environmental variables this provided the intermediate value index for which a high value indicated a high probability of social value being distributed in a region second by applying maximum entropy modelling the maximum intermediate value index was used as an input after the distribution of environmental variables was considered raster data ranging from 0 to 1 were generated the closer a value is to 1 the more likely a social value exists under the environmental variable 24 after these two steps were combined the solves programme outputted a social value index within a value range between 1 and 10 through a standardization process the obtained value was the maximum score of the social value for values ranging from 1 to 10 a higher score signifies that a particular social value is more likely to be distributed at a certain location 26 the study used the geospatial database of the north coast area and arcgis for solves to analyze the database after the geospatial data and raster data of various environmental variables were combined the points identified by the respondents were ordered to create the coordinate data of a digitized space based on their questionnaire responses the characteristics of the residents were analysed educational attainment sense of community and grounded occupation scores of the respondents were substituted into the human activity subcategory index of dissimilarity to analyze respondent variety in terms of two landscape policies this study overlaid maps of conservationand recreationoriented social values onto the spatial ranges of ynp and ncgnsa the proportion of landscape area and the distribution of two social values in the policyregulated spatial range of two spaces were presented on maps using arcgis furthermore landscape socialization groups were categorized according to demographic variables namely educational attainment sense of community and grounded occupation through this grouping method differences in the spatial distributions of conservationand recreationoriented social values were determined to compare variation among residents with different characteristics the area of the social value of subcategories was calculated using the index of dissimilarity 27 the formula for the index of dissimilarity is as follows ∆ 12 n i1 ai at bi bt × 100 where ∆ denotes the index of dissimilarity ai is the area of the ith social value score obtained from the residents of group as characteristics at is the total area of the social value score of group a bi is the area of the ith social value score obtained from the residents of group bs characteristics and bt is the total area of the social value scores of group b survey implementation two areas where natural landscapes have been involved in longterm land use planning were chosen because their landscape boundaries and the scope of policies for the conservation of national parks and the recreationrelated development of national scenic areas are clear a blind test identifying social values was conducted to examine variables which may indicate the variability of residents ability to engage in landscape socialization the designated north coast area contains five administrative districts namely the districts of tamsui sanzhi shimen jinshan and wanli the area has a total of 89 villages among which 11 have completed communitybased incubation courses in the rural regeneration project administered by the soil and water conservation bureau under the council of agriculture executive yuan after completion of the fourstage incubation courses these villages could conduct planning and propose projects on their own these community development associations are located in jhongshan jhongliao and shuhsing in tamsui district sanho kungjung letien and ankang in sanzhi district sungshan in shimen district liusan in jinshan district and chungfu and huangtan in wanli district the association members are highly familiar with their residential areas they participate in bottomup community affairs understand the implications of instilling a sense of community and are familiar with landscape orientation and location residents wording and relevant contact and policy information 28 all of which enabled them to accurately convey the concept of the survey therefore members of the 11 community development associations in the aforementioned five districts were recruited as interviewers workshops for association members were held at community centers or district offices beginning in july 2017 to give instructions on questionnaire completion and sampling as well as other training after practicebased skills were developed and handson training courses were delivered 25 people became qualified interviewers who could assist in the investigation of the social values of the policyregulated landscapes of the north coast area the formal investigation was conducted in may 2018 when 550 questionnaires were distributed the interviewers and respondents were given convenience store gift cards as an incentive to increase the response rate nonprobability rolling sampling was employed 29 in the hope of deeply engaging with communities and obtaining the opinions of less reachable residents by leveraging local interpersonal relationships between interviewers and residents results all 550 questionnaires were returned among these 550 questionnaires 328 were valid and thus retained the data from valid responses were input into excel to conveniently calculate the score and rationally present the ranges for one of the variables namely sense of community the original range was changed from 14 to 03 with a maximum total score of 72 the variable sense of community was analyzed using spss 180 software descriptive statistics revealed no significant variations between the median and mean scores this measure was very reliable the cronbachs alpha value was 0956 which is consistent with the results of chavis et al 21 thus the mean value was set as the threshold to differentiate between residents with weak versus strong senses of community residents who selected agriculture or forestry or animal husbandry as their occupation were defined as farmers and those who selected another occupation were defined as nonfarmers although the data slightly skewed toward nonfarmers the variable had a demographically similar sample population in the same study area the study revealed that respondents with high or low educational attainment a strong or weak sense of community and a grounded or nongrounded occupation achieved different landscape socialization points the identification of landscape assets with conservationoriented social values for the entire area was determined using descriptive statistics of the respondents 180 and 148 had high and low educational attainment respectively and the respective numbers of identified socialization points were 247 and 203 in all 151 and 177 had a sense of community above and below the mean value respectively and the respective numbers of identified points were 252 and 198 farmers numbered 66 and nonfarmers 262 and the respective numbers of identified points were 100 and 350 regarding the perceived recreationoriented social values of landscapes in the area the numbers of residents in each category were the same as those for conservationoriented social values the numbers of points identified by residents with high and low educational attainment were 280 and 232 respectively the numbers of points identified by those with a strong and those with a weak sense of community were 269 and 243 respectively farmers and nonfarmers identified 112 and 400 points respectively overall the distribution of respondents and identified points was considered appropriate as figures 3 and4 reveal the values of the area under the curve for all samples and for each category of residents were both higher than 07 in the training and testing modes of solves the values of the auc suggested that the models could explain the distribution of identified points and could also be used to predict social values for areas where no primary survey data were available but which had similar environmental conditions in terms of conservationoriented social values only 47 of the 450 identified points fell within ynp regarding recreationoriented social values 274 of the 512 identified points fell within the ncgnsa the maximum score of conservationoriented social values for all samples was eight the scores for high and low educational attainment were nine and eight respectively the scores for strong and weak sense of community were seven and nine respectively and the scores for farmers and nonfarmers were nine and seven respectively the maximum score of recreationoriented social values for all samples and each subcategory was 10 regarding the identification of conservationoriented social values that between high and low educational attainment was 152 that between strong and weak sense of community was 144 and that between farmers and nonfarmers was 60 regarding the identification of recreationoriented social values the index of dissimilarity between high and low levels of educational attainment was 411 that between strong and weak sense of community was 156 and that between farmers and nonfarmers was 644 regarding conservationoriented social values residents with high educational attainment identified a greater spatial distribution area and had a higher maximum social value score compared with residents with low educational attainment the index of dissimilarity between the two groups was 152 in terms of specific spatial distribution most points identified by residents with high educational attainment were on terrace fields of sungshan in shimen district or in the bayan settlement in jinshan district whereas those identified by residents with low educational attainment were on the west side of datun mountain and the northeastern side of the bayan settlement residents with a weak sense of community identified a greater spatial distribution area and had a higher maximum social value score compared with residents with a strong sense of community the index of dissimilarity between the two groups was 144 regarding the specific spatial distribution of the identified points the groups exhibited a pattern similar to that of educational attainment groups farmers and nonfarmers had a similar proportion of landscape socialization distribution but farmers had a higher social value score than did regarding conservationoriented social values residents with high educational attainment identified a greater spatial distribution area and had a higher maximum social value score compared with residents with low educational attainment the index of dissimilarity between the two groups was 152 in terms of specific spatial distribution most points identified by residents with high educational attainment were on terrace fields of sungshan in shimen district or in the bayan settlement in jinshan district whereas those identified by residents with low educational attainment were on the west side of datun mountain and the northeastern side of the bayan settlement residents with a weak sense of community identified a greater spatial distribution area and had a higher maximum social value score compared with residents with a strong sense of community the index of dissimilarity between the two groups was 144 regarding the specific spatial distribution of the identified points the groups exhibited a pattern similar to that of educational attainment groups farmers and nonfarmers had a similar proportion of landscape socialization distribution but farmers had a higher social value score than did nonfarmers the index of dissimilarity between the two groups was 60 regarding the specific spatial distribution of the identified points most points identified by farmers were on the west side of datun mountain and the northeastern side of the bayan settlement whereas those identified by nonfarmers were on the terrace fields of the sungshan community in shimen district or in the bayan settlement in jinshan district regarding recreationoriented social values respondents in the high educational attainment group stated that the entire spatial range of the ncgnsa had recreation value the spatial distribution identified by the low educational attainment group reached 923 the index of dissimilarity between the two groups was 411 regarding specific spatial distribution in addition to renowned tourist sites such as qianshui bay linshanbi fugui cape the jinshan seaside area and yehliu residents with high educational attainment identified jinshan district sanzhi district and other locations in the scenic area and rated them with high scores with respect to proportion of landscape socialization residents with low educational attainment gave only 13 points to areas other than wellknown tourist sites groups of residents with strong or weak senses of community identified 97 of the area proportion of spatial distribution with a 156 index of dissimilarity between the two groups compared with the group with a weak sense of community that with a strong sense of community identified more areas of spatial distribution and social value in jinshan district and sanzhi district regarding grounded occupation the proportion of areas with spatial distribution identified by nonfarmers was greater than that of farmers with a 644 index of dissimilarity between the two groups compared with farmers nonfarmers were also more capable of identifying areas with a recreationoriented social value at renowned north coast tourist attractions such as qianshui bay linshanbi fugui cape the jinshan seaside area and yehliu the results revealed that compared with residents with low educational attainment those with high educational attainment had higher maximum social value scores and the points identified as having social values were distributed more widely similar to the current situation compared with residents with a weak sense of community those with a strong sense identified a smaller spatial distribution area and maximum social value score for conservationoriented policy intervention but the result for recreationoriented policy intervention was exactly the opposite compared with nonfarmers farmers had a higher maximum social value score and the identified points of social values were distributed more widely and precisely in terms of conservationoriented policy intervention but the result for recreationoriented policy intervention was exactly the opposite consequently residents with high educational attainment had a greater understanding of both the national park and the national scenic area residents sense of community did not significantly affect their ability to identify social values and farmers identified the national park better than nonfarmers did by contrast nonfarmers identified the national scenic area more than farmers did notably regarding the effects of the variables on conservationoriented social values the intergroup differences for educational attainment and sense of community exerted greater effects than did grounded occupation this implies that residents with high educational attainment often absorb familiarize themselves with and gain knowledge of landscape policies moreover they may frequently participate in community activities which increases their ability to absorb information such as that regarding ecological habitats or tourism attractions consequently these people have a higher level of landscape socialization and are familiar with the conservation values advocated by national park landscape policies conversely those with low educational attainment and a weak sense of community rarely participate in community activities therefore they have a vague understanding or lack of understanding of conservationoriented landscapes resulting in a discrepancy between the understanding of those with high and low education attainment resident education and training and community activities are excellent starting points to increase the perceived value of conservation in landscape policies policies and activities related to community construction and rural regeneration such as policies and experiential activities promoting national park and landscape conservation can increase residents landscape socialization regarding the effects of the variables on recreationoriented social value grounded occupation exhibited the highest dissimilarity value followed by educational attainment and sense of community this indicates that nonfarmers have a greater understanding of recreationoriented social values compared with residents with low educational attainment highly educated residents have more experience and knowledge pertaining to tourism and leisure with a greater understanding of conservation values and actual landscapes residents with high educational attainment may appropriately comprehend the recreationoriented landscapes of scenic areas and thus have superior landscape socialization residents with low educational attainment might not be able to clearly identify the tourism attractions of scenic areas and rarelyor not at allbelieve that their livelihood or daily activities are related to the scenic areas therefore residents with low educational attainment tend to have landscape socialization inferior to those with high educational attainment this study has the following limitations first because this study adopted only quantitative investigation and spatial analytical methods specific cases could not be described comprehensively in addition this study analyzed only conservationand recreationoriented policy interventions and the corresponding social value elements therefore landscape socialization as captured in overall social value or other types of social value could not be analyzed in this study discussion a reasonable conclusion from the results is that landscape socialization was indeed an effect of longterm policy intervention which has accomplished structural changes that have led to perceived social values therefore these effects were reflected in the demographic variables of educational attainment sense of community and grounded occupation internalization of connections to nature the results support kühnes 15 16 17 classification concept of primary and secondary socialization the first uses educational attainment as a factor in analysis regardless of the social value identification of conservation or recreation orientation residents with higher educational attainment are superior at identifying social values an inference is that the landscape is more socialized the finding confirms that educational attainment is a crucial factor in landscape socialization the acknowledgement of landscapes is a subjective process in which opinions vary according to an individuals life experiences where they grew up and their personality traits 30 31 32 these perspectives highlight the value of the educational attainment of residents as it may affect landscape socialization and be related to landscape identification therefore this study clarifies that formal education involving for example the natural sciences experiential activities and environmental education is a key variable in landscape socialization the study adopted a questionnaire combined with a spatial analysis tool namely gis it assumed that sets of individual cognitions of landscapes can be aggregated to determine the effect of social scale the results can also be explained as experiential connections which have both spatial and social implications although not everyone is equipped with such competencies social learning through community activities may enhance such capabilities in individuals studies 3334 have revealed that group perspectives such as collective experience actions or attitudes towards the environment affect landscape cognition these perspectives highlight the learning value provided by diverse social groups a cognitive connection to nature is measured by an individual analytical scale and reflects knowledge of nature 635 in reality residents strengthen their experiential connections through landscape socialization because they live in local communities and usually have direct experience and interaction with natural landscapes this also indicates a limitation of this study it was too brief to include an empirical method for obtaining direct evidence that the results were actually generated from interactions between residents and natural landscapes nevertheless the results are consistent with those of ives et al 6 who suggested that different types of nature connection do not operate in isolation strongly interlinked especially via emotional and experiential connectedness 36 therefore landscape socialization may result from the interdependency of experiential and cognitive types of nature connections in the real world as for secondary socialization the results indicate a subtle contrast in the sense of community variable between recreationoriented and conservationoriented landscape socialization respondents with a strong sense of community have superior landscape socialization in an area covered by a recreationoriented policy intervention whereas those with a weak sense of community have superior landscape socialization in a conservationoriented area in general residents who live in a community for a long time have a strong feeling of attachment to or empathy towards nature sense of community and place attachment are also correlated 37 thus a possible explanation for this phenomenon may be that most respondents lived in communities outside the ynp area residents with a strong sense of community have greater group cohesion spend more time engaged in community affairs and express concern regarding landscape changes within the community but exhibit less recognition of and concern regarding landscapes outside the communal area to restate the concept of nature connection type of ives et al 6 emotional connection refers to positive feelings towards nature recreationoriented scenic destinations can bring tourism income convenient transportation and possibly economic development they offer employment and daily life in a tourism atmosphere and thus residents here can connect with nature with positive emotions this study posited that residents regardless of their sense of community may regard recreationoriented landscapes as part of community life because they are accustomed to their areas of residence 38 although residents sense of community did not significantly affect perceptions of recreationoriented landscape socialization a closer inspection revealed that residents with a strong sense of community pay more attention to tourism development opportunities indicating that they have greater comprehension of recreationoriented landscape socialization residents who scarcely engage in community affairs namely those with a weak sense of community are less concerned about opportunities for tourism development thus the landscaperelated comprehension of residents with a weak sense of community was slightly inferior to that of residents with a strong sense of community this result was consistent with the findings of stewart 39 this insight illustrates the relationship between sense of community and landscape socialization residents with a high sense of community seem to be easily affected by regional policy interventions meaning that they have a more acute emotional affinity with nature 40 and a stronger place attachment to natural areas 41 compared with those near the national park people with a strong sense of community have more opportunities to access sightseeing in the national scenic area and hence have superior landscape socialization therefore landscape socialization has the effect of inducing an inner trend from having a cognitive to emotional connection with nature conversely respondents with a strong sense of community exhibit weak landscaperelated comprehension of policy intervention visàvis the national park which is for most outside their community hence they have weaker landscape socialization presumably few respondents live in the national park residents of outside communities also have fewer place attachments and emotional connections to natural environments in the park this implies that sense of community seems to be limited to the neighborhood scale communityoriented people tend to identify with their own inner familiar landscapes when social values are located outside the community at the regional scale they exhibit less care and inferior landscape socialization therefore sense of community may be a meaningful secondary socialization variable which may be used to identify emotional connections between community and region or in alternate phrasing between insiders and outsiders regarding the concept of humannature relationships to strengthen the function of landscape socialization internalizing connections to nature is necessary this means focusing on improving awareness and direct interactions from the community to the regional scale this difference of landscape socialization implies that multilevel governance could potentially be applied to landscapes to appropriately connect communities to regions as well as reorganize the politicalspatial dimension of environmental governance thereby achieving effective landscape governance 42 however the concept of landscape socialization does not reflect material and philosophical types religious and spiritual values may be necessary to explain types of philosophical connection future research may determine whether landscape socialization can scale up inner leverage points landscape socialization incorporating daily life in policy interventions the landscape socialization described herein involves social value in the context of desired and actual relationships this implies relational values between people and nature an interdisciplinary perspective on the benefits and the perceived nonmarket quantity of social value 45 can yield a variety of value concepts chan et al 43 described relational values as those that refers to diverse roots of relevantly new expression relational values also appropriately prioritize existing ways of knowing landscapes relational values describing the relationships between people and natural places 43 function at either the individual or the collective level this studys results are certain consistent with those of klain et al 44 who when comparing relational values between farmers and tourists reported that farmers shared higher relational values díaz et al 45 emphasized that nonmaterial contributions which are subjective underpin quality of life at the individual and collective levels people are increasingly realizing that interactions with nature benefit psychological social and physical health and wellbeing shared interactions and experiences with natural environments provide opportunities for social interaction and strengthen networks between social groups and communities outdoor recreation is also increasingly essential to enhancing accessibility to or contact with nature while daily natural connection is decreasing in an urbanized society the functions of natural areas have changed from enabling survival to enriching public recreation experiences where nature is valued differently by residents sense of community in this study derives from respondents feelings about the community collective and thus it can illustrate the relational values of landscapes through the human collective the study determined that sense of community reflects more attention to landscape socialization in smallscale daily life in addition based on langleys 14 anthropological construct this study addressed whether landscape socialization can be a tool for understanding the humannature relationship on the basis of the frequency of residents interactions with the landscape maintaining contact with nature and the behavioral space of daily life in the community is essential and landscape socialization has potential roles in maintaining harmonious relationships and reconnecting people with nature díaz et al 45 contended that culture plays defining roles in all links between people and nature and the inclusiveness of local communities is essential furthermore mainstream policies are primarily derived from the natural sciences with less emphasis on social values than on biophysics and policy formulation does not benefit from insights and tools developed in the social sciences and humanities 4546 changes to landscapes after policy formulation and residents understanding and cognition of landscapes and their social values are of importance because both are directly conducive to promoting resident participation in landscape comanagement thus the results indicate that sense of community can affect landscape socialization under various policy interventions and policy intervention should highlight inclusion and participation and incorporate local knowledge and the cultural context of communities during the policy intervention process in addition the results indicate that farmers exhibit superior landscape socialization under conservationoriented policy intervention but under recreationoriented policy intervention they exhibit inferior landscape socialization farmers pay more attention to the productiveness of land than do nonfarmers moreover they do not readily change agricultural land to other land uses and regard landscape processes as a part of their work processes land is the basis of agricultural production farmers cannot grow crops without land and their livelihood is based on agricultural landscapes because they are in close contact with the land on a daily basis farmers pay particular attention to conservationoriented landscapes farming is a grounded occupation with respect to occupational differences between farmers and nonfarmers in taiwan the daily lives and production of farmers are embedded in the natural environment whereas nonfarmers focus on pursuing leisure opportunities outside of work and thus develop greater concern for recreationoriented landscapes this restates chan et als 43 claim regarding relational values between people and nature in which peoples personal identities are rooted in the longterm care of nature rural farmers take interactions between farming and farmland for granted regarding cultural identity some farmers and communities believe their good and wellbeing are derived from shennong and the earth god as well as their relationship with nature or others farmers participation in conservation activities or in planning and implementing national parks should be enabled this study posits that the characteristics of residents are related to their landscape socialization regarding recreationoriented policy intervention the index of dissimilarity between farmers and nonfarmers was 644 indicating that farmers have inferior landscape socialization a possible explanation is that farmers regard recreationoriented landscapes as less crucial because their life livelihood and land use are less related to such values nonfarmers are generally more sensitive to tourism development opportunities although they live within the spatial range of such landscapes they may commute to work in cities to release stress from work on weekends nonfarmers often engage in leisure activities which enable them to gain a recreationoriented comprehension of landscapes this result also echoes stottens 47 argument that farmers develop their landscape perceptions from their daily lives a cultural agricultural activity is an ongoing process through which farmers undergo landscape socialization stotten 48 stated that participation and increased awareness among farmers can enhance their analytical and critical abilities hence communities mindful of conservation efforts pay particular attention to the actions of farmers and the preservation of agricultural history in an area whereas farmers calmly face the use of regional landscapes for tourism and related economic benefits conclusions this study mainly sought to determine whether landscape socialization is related to longterm processes of policy intervention functions to connect people with nature the process of landscape socialization can strengthen humannature connections combining experiential cognitive and emotional aspects a longterm structural change such as through a policy intervention affecting residents landscape socialization may induce a deeper reconnect people with nature the discussed communityregion spectrum may be able to scale up at deep leverage points through landscape socialization landscapes affect perceptions after interaction landscapes can also be identified through experiential cognitive and emotional types of nature connections which then lead to landscape socialization educational attainment sense of community and grounded occupation are key variables in landscape socialization and landscape socialization can help strengthen humannature connections in addition improving education strengthening sense of community and encouraging young people to work in agriculture may be effective but shortterm training or fostering work may not be considering the humannature relationship the concept of landscape socialization helps explain the role from external to internal connections on the system leverage the spatial identification of social values revealed variation in landscape socialization and demonstrated that sense of community and having a grounded occupation are prominent variables landscape socialization is closely related to connections with landscapes and involves experiential cognitive and emotional dynamics this result emphasizes that landscape socialization can help transpose more abstract humannature relationships analysis of the three variables suggests that shifting leverage points through the connection of accumulated experiences and then strengthening cognitive and emotional connections to move towards sustainability transformation may be possible

understanding the landscape socialization underpinning the humannature relationship is essential because it can contribute to assisting us to reconnect with nature reconnecting to nature is increasingly recognized as positively contributing to health and wellbeing this study aimed to understand peoples connections with nature through landscape socialization under different land use policies the study assumed that social values as perceived by residents facilitates their landscape socialization using a questionnaire measuring sense of community and the social values for ecosystem services application as analytical tools the study assessed how residents with varying educational attainment sense of community and grounded occupation differ in identifying with conservationand recreationoriented policy interventions the results demonstrated the role of landscape socialization in how people connect with nature and the landscape socialization as a result of longterm policy interventions may exert substantial effects on residents social values across various spatial scales the results deepen the general understanding of system leverage points for creating inner connections to nature which can aid sustainability transformation