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19900_0

i am thankful to quillien for his response to my paper as it allows clarifying my position firstly i would like to underline that the purpose of my paper was to flesh out the statistical assumptions underpinning crosscultural correlations however what i highlighted is but a sideissue when working with macrolevel crosscultural data i would like to bring the discussion back to earth and clarify why i believe in contrast to quillien that finite populations might be problematic in this context i put forward that the sampling units for macrolevel crosscultural correlations are finite in contrast quillien argues that this does not have to be the case i believe for the examples i cited the statistical data are clearly scores derived countries states etc and are therefore by their definition finite data at countrystateregion level are very much unlike a population of people or an experiment where we can gather new independent observations quillien presents no argument that these observed entities such as statescountriesetc are in fact infinite but rather argues that the scores these researchers use represent something else let us return to a specific example we both discussed us state scores i put forward that if we sampled all possible units here all us state scores then there is no probability for the statistical population of us states the sample matches the population we wish to make statistical inferences about if the observations we sample are from a finite population this needs to be corrected for once we have sampled the last us state the population pool is empty we sampled and measured everything not explicitly defining the population does not alter this nor does assuming that these state scores are part of a larger potentially infinite whole many authors such as quillien might want to make statistical or logical inferences beyond these scores for example to other macrolevel units or the human mind but what we have in terms of data are us state scores plain and simple these are by their very nature finite quilliens argument thus seems to crucially rest on the claim that the observed unit of analysis is not a us state score but rather something else what this different unit of analysis would be is typically not clearly defined neither by quillien nor by the authors cited in pollet for now like quillien let us assume the unit of analysis is some human social unit relevant to some evolutionary process such a stance ie the data representing something else than a us state score is in my view deeply problematic firstly if one assumes the scores are something else then one needs to explicitly define the unit of analysis a priori otherwise it seems reasonable that the unit of analysis is indeed a us state score let us tentatively define this alternative unit of analysis as a social unit in which humans live relevant to an evolutionary process why would a us state then be representative of the pool of such social units in which humans lived perhaps these data can indeed tell us something about us states but it is unclear whether any documented statistical relationship would hold for other units fitting the broader definition it is unclear whether any statistical inference can be done beyond us states as that is all we have there is no logical reason to assume that any statistical relationship found for us states should hold for other human social units such as for example world regions canadian provinces polynesian chiefdoms 19th century german states hunter gatherer populations let alone that these different human social units can be meaningfully lumped together and assumed to be governed by the same evolutionary process as quillien seems to imply in addition suppose that we do follow quilliens logic and pretend the pool is larger and even infinite then a different problem still arises we have clearly drawn a biased sample traditional statistical inference based on rejecting a null hypothesis in the population cannot be applied in the first place as there was no random sampling for example canadian provinces are underrepresented absent even in our sample while they are in our statistical population perhaps i am thus opposed to logical induction and view moving from us states to other not clearly defined units as problematic and quillien does not i will leave the reader to decide but it seems a much safer bet to stick to inferences about us states and not even rely on these data to make any inference on for example canadian provinces ideally researchers would then define and measure those rather than assuming that one process must govern all these units finally if we take these state level data to be representative of processes at an individual level as several authors including quillien seem to suggest then the ecological fallacy looms inferences from one level of statistical analysis need not correspond to a different level of analysis these arguments have been made at length elsewhere and will not be reiterated here in summary in my view the statistical inferences we can make based on units such as us state scores can be about nothing else but us states as this is the only unit being sampled one might want to strengthen the statistical and logical inference based on those data but this is likely invalid either due to sampling bias andor the ecological fallacy i therefore maintain that the pvalues commonly used for statistical inference are inappropriate for macrolevel crosscultural correlations when the sample matches the population closely conflict of interest statement the author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest

population finiteness is not a concern for null hypothesis significance testing when studying human behavior a reply to pollet 2013 by quillien t 2015 front neurosci 981

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introduction social competence refers to the efficacy with which one can use social interactions to achieve personal goals through their capacity to initiate and maintain positive social relationships 1 it is a multidimensional construct based on a variety of social skills that must be used adaptively according to specific situations 2 in order to pursue successful social interactions 3 previous research has indicated that young children who are able to interact successfully with their peers and use social signals effectively are less likely to develop behavioral and emotional problems over the primary school years and beyond 24 on the contrary children who lack such skills more frequently experience peer rejection 5 social anxiety bullying 6 and aggression 7 developmentally the transition to primary school represents a particularly challenging period for children with regard to the refinement of social competence as they enter a new environment where they need to learn how to build significant relationships with peers and teachers deal with frustrations and conflict and engage in group activities requiring adherence to rules and social norms 8 this process can be more difficult for children from immigrant families who often lack the second language and preliteracy skills necessary to adjust to school demands and have had few opportunities to interact with their ethnic majority peers due to cultural and socioeconomic barriers 9 indeed there is evidence that children with a migration background tend to exhibit less social competence and more behavioral problems than their nonimmigrant peers 10 possible explanations for these phenomena include cultural differences in parental socialization practices concerning the management of social relationships challenges related to the family migration process and poor social capital 11 yet little is known about the correlates of peer social competence among ethnicminoritized and majoritized children entering primary school especially in relation to sociocognitive and emotional skills that undergo substantial changes at this age this knowledge is paramount with respect to providing information to prevention andor intervention programs aiming to reduce the risk of disparities between children with and without a migration background in terms of psychological and school adjustment 12 the current study sought to address this gap by comparing levels of teacherrated social competence in relation to peers between children from immigrant families and their nonimmigrant counterparts in italy and examining the associations of a key component of executive functions ie inhibitory control and two domains of social cognition namely theory of mind and facial emotion recognition with peer social competence among first graders with and without a migration background inhibitory control social cognition and peer social competence executive functions play a key role in the development of childrens social competence 13 they comprise a series of interconnected and interdependent processes that are responsible for intentional behaviors whose aim is to achieve goals in an articulated and flexible way 14 functioning as an integrated supervisory and control system 15 among ef processes inhibitory control is the most widely studied with regard to links with social competence especially in early childhood 16 the ability to manage behaviors and emotions according to societal expectations plays an important role in school adjustment and achievement because it serves as a key internal resource for young children faced with the social challenges presented by a classroom in the first grade as the learning environment becomes increasingly structured children who are unable to pay attention to or control their own behavior may develop relationship difficulties with peers and teachers 17 while those who present good control skills tend to present a good degree of social competence 18 however research examining the associations between inhibitory control and social competence has yielded conflicting results some studies have shown that preschoolaged children with inhibitory control deficits have low levels of social competence or related difficulties 1920 that can persist over time 21 whereas others failed to replicate these findings 2223 it has been suggested that the associations between inhibitory control and social competence become more pronounced as children reach kindergarten and early elementary school ages due to the increased ability to inhibit a strong dominant response in favor of a subdominant one to reach current and future goals 24 however more studies are needed to shed light on this issue especially among ethnically diverse firstgrade students social cognition can be defined as the mental operations that underlie the interpretation and response to social stimuli including mental state attribution the recognition of affect attributional style and social perception 25 among social cognition processes theory of mind that is the ability to understand ones own and others mental states and to predict the feelings and behaviors of others 26 plays a pivotal role in the presentation of positive social skills 27 by the age of 5 children have a basic understanding of beliefs and desires but investigations conducted in the past decade indicate that this ability develops well into middle childhood and early adolescence 28 in particular scholars suggest that individual differences in tom explain variability in social competence with respect to peers in addition to other cognitive factors such as language and ef 29 in support of this view previous studies have indicated that successful performance on tom tasks positively correlates with childrens ability to coordinate peer social interactions and with teachers ratings of social behavior 30 31 32 however other studies did not find any significant difference in the ability to pass tom tasks between children with positive peer evaluations and rejected children 33 lending support to the view that individual differences in tom trump differences in general cognitive processes and therefore do not result in any significant associations after controlling for language and efs 34 another possible explanation of this inconsistency is related to the source of information used to assess childrens social competence as there is evidence that different raters may provide different evaluations 35 an additional relevant domain of social cognition is childrens ability to recognize facial emotional expressions which play a role in social competence 36 fer include the ability to recognize and label ones own and others emotions tie them to situations understand their causes identify familial and cultural display rules and recognize disparities between outward displays and felt emotions 3738 the ability to recognize nonverbal emotional cues is positively associated with better peer relationships and higher levels of social competence while inferior emotional recognition skills are associated with social difficulties and withdrawal 39 indeed being able to recognize emotions through facial expressions is necessary for the development of more advanced emotional comprehension skills as this ability may provide information that can help to help a child to establish early social networks and peer relations 40 although little research has examined fer among immigrantorigin children there is evidence that the fersocial competence link is observable in both individualistic and collectivistic societies despite differences in emotion socialization 41 in summary the empirical evidence disseminated thus far suggests that inhibitory control and social cognition processes are important correlates of social competence yet few studies have simultaneously examined their contribution to peer social competence among firstgrade children razza and blair 42 investigated the relationships between efs tom and teacherrated social competence in a longitudinal study involving fiveto sixyearold children from lowincome families assessed in preschool and kindergarten the results showed that tom was an independent predictor of social competence even after accounting for ef and was identified as a possible mechanism through which early efs may affect later social competence the role of migration background in social competence childrens social competence is influenced by cultural values and beliefs which guide parents childrearing practices and socialization goals 43 children with a migration background might be challenged in their social competence development as they navigate between microsystems which are often characterized by different cultural norms values and behaviors during social interactions 44 to date conflicting data on social competence among children with a migrationethnic minority background have been reported the bulk of the corresponding studies found lower levels of peer social competence among these children especially when originating from asian cultures 45 which is a pattern that can partly be ascribed to different cultural expectations concerning the development and manifestation of sociability 46 children with a migration background tend to fall further behind their peers in terms of measures of social competence 4547 although this could be related to teacher bias in assessing childrens social competence that is precipitated by the adoption of solely the perspective of the educational setting on the other hand mounting evidence is indicating the potential beneficial effects of having an immigrant background on peer social competence because children from immigrant families are exposed to different experiences and sets of values and learn diverse and complementary social skills 1248 children with a migration background may rely on a wide variety of predictions that allow them to interpret others emotions and intentions and express emotions in different languages and contexts 49 the possibility of relying on better efs may boost their capacity to balance and integrate different perspectives and select appropriate behaviors according to a given context resulting in appropriate social behaviors 5152 thus it is possible that exposure to culturally diverse environments may be an asset in relation to childrens social competence with respect to peers but more research is needed to uncover the mechanisms involved in these associations the current study although the extant research has provided important contributions to our understanding of the factors underlying childrens social competence 5354 little is known about the influence of inhibitory control tom and fer on first graders social competence with respect to peers especially among children with a migration background this is surprising given that peer social competence in the transition to primary school is particularly important for children who might face additional challenges compared to their nonimmigrant peers in terms of school adjustment peer socialization and exposure to different cultural norms and expectations hence this study addressed two main research questions rq1 do children with and without a migration background differ in terms of their levels of social competence with respect to peers as assessed by their teachers previous research has yielded contradictory findings with some studies reporting less peer social competence among immigrantorigin children compared to their ethnic majority counterparts particularly when rated by their teachers 4755 while others found similar or greater competence in this developmental domain due to increased cognitive resources among immigrantorigin youth hence no a priori hypothesis has been formulated in this regard rq2 are childrens inhibitory control tom and fer linked to teacherrated peer social competence and if so do these associations vary as a function of childrens migration background based on the literature reviewed above we expected inhibitory control tom and fer to be positively related to first graders social competence in relation to peers especially in light of existing evidence suggesting that these associations are consolidated during primary school years 56 with regard to moderation to the best of our knowledge no study has considered this issue in the context of peer social competence among first graders however it is reasonable to expect that the associations of inhibitory control tom and fer with social competence in relation to peers would be stronger for children with a migration background given that these children are exposed to multiple languages and environments that may facilitate perspective adoption social problem solving and the inhibition of automatic responses in order to adapt their behaviors to social expectations 52 in our analyses we also controlled for gender receptive vocabulary and parental education as these variables have been shown to be associated with childrens peer social competence 57 specifically peer social competence is typically higher among girls compared to boys 58 and receptive vocabulary is positively related to measures of peer acceptance and sociometric status 59 additionally children from lowerses families tend to exhibit less social competence although such findings are not clearcut 60 materials and methods procedure trained psychology graduate students tested each child individually in a quiet room during the school day tasks were administered in a fixed order which is preferred for the investigation of individual differences each child was tested over three sessions scheduled on consecutive days each lasting approximately 30 min at the end of which time the experimenters thanked the child for participation and rewarded him or her with free playtime the study was approved by the ethics committee of the university of removed for review and performed in accordance with the principles expressed in the declaration of helsinki only children with signed parental consent participated in the study materials 231 outcome variable peer social competence a subscale from the selfperception profile for childrenteacher report was used by teachers to rate childrens social competence at school the sppctr is a multidimensional measure designed to evaluate childrens global selfworth and selfperceptions of adequacy across different areas of the self it contains six subscales tapping five specific domains in addition to global selfworth each subscale contains 6 items totaling 36 items for each of the five specific domains the teacher rated the childs actual behavior with respect to each area for the purpose of this study we used the social competence subscale in which teachers indicated their perceptions of the degree to which the child has friends feels popular and feels that most kids like them items were scored as either 1 2 3 or 4 where a score of 1 reflects the lowest perceptions of competence and 4 reflects the highest perceptions of competence the reliability reported in the manual which was evaluated by calculating cronbachs alpha is 078 whereas the internal consistency for this study sample was α 092 independent variables inhibitory control the dayandnight test was used to assess childrens ability to suppress a dominant response related to perceptual stimuli while selecting and executing a competing conflicting response this test contains two decks of cards the first of which contains 8 cards depicting a chessboard and 8 cards depicting an x while the second of which contains 8 cards depicting a sun and 8 cards depicting a moon under the baseline condition the tester trains the child to say day when there is an x card and night when there is a chessboard card under the inhibition condition the child must say the word day when viewing a card depicting a nighttime sky and night when shehe is shown a picture of daytime sky each child completes 16 trials for each condition that are scored from 0 or 1 two different scores are calculated in both conditions accuracy and speed total accuracy is obtained by subtracting accuracy in the baseline condition from performance in the incongruent condition whereas speed is determined by subtracting the time spent in the two conditions we used the difference score as an indicator of inhibitory control the reliability of this task for this study sample which was evaluated using calculating cronbachs alpha for individual trials was 085 theory of mind tom was investigated using a subtest from the nepsyii battery 64 the subtest comprises a verbal and a contextual task in the verbal task questions are based on verbal scenarios with or without pictorial support the subtest measures childrens understanding of beliefs intentions others thoughts ideas and comprehension of figurative language the contextual task measures a childs ability to relate an emotion to a given social context in this subtest the child first sees pictures with a target girl in different social contexts whose face is hidden and has to select among four photographs depicting the girl expressing different emotions the one showing the emotion she is feeling in that context the child needs to infer the girls emotion based on the social context and not her face reliability reported in the manual which was evaluated using calculating cronbachs alpha is 082 whereas it was 086 for this study sample facial emotion recognition we used the nepsyii affect recognition subtest from photographs of childrens faces in four different tasks task 1 the child stated whether two pictures depicted faces with the same affect task 2 the child selected two pictures of faces with the same affect from among 3 to 4 pictures task 3 the child selected one of the four faces that depicted the same emotion as a face at the top of the page and task 4 the child was briefly shown a face and then selected two pictures that heshe thought represented the same emotion the total score ranged between 1 and 25 for children aged 6 or younger and between 1 and 36 for children aged 7 or older with higher scores reflecting better ability to match the same emotions raw scores were converted into standard scores reflecting each childs ability in relation to hisher own age reliability of this task for the study sample which was evaluated using calculating cronbachs alpha was 081 control variables gender parental education and migration background parents completed a short questionnaire on language exposure and demographic information through which we derived the genders and migration statuses of the children participating in the study and the parents education levels italian receptive vocabulary the peabody picture vocabulary test which was adapted and standardized for the italian language 66 was used to assess childrens receptive vocabulary the adapted versions maintain the same procedure as the original version but they introduce changes to the lexical material to obtain a similar level of difficulty it consists of a list of words presented to participants who are asked to indicate which out of four pictures best represents the target word the items are presented in order of increasing difficulty we found a basal level when the participant gave eight consecutive correct answers testing continues until the participant obtains six incorrect answers in eight consecutive items raw scores correspond to the number of correct answers minus the number of errors agespecific standard scores are provided in the manual reliability evaluated using the splithalf procedure as reported in the manual is 088 whereas the internal consistency for this sample evaluated using the splithalf procedure was 095 results descriptive statistics table 1 shows the descriptive statistics of the study variables and their correlations for each group of children we used standard scores for receptive vocabulary the raw total score for childrens peer social competence rated by teachers the accuracy score for inhibitory control and raw scores for tom and fer performance on the majority of tasks covered a large range of scores and none suffered from ceiling or floor effects additionally the distributions of all the variables approached symmetry for the children with a migration background peer social competence was significantly and positively correlated with italian receptive vocabulary and fer a pattern of significant correlations emerged between italian receptive vocabulary tom fer and parental education whereas no correlation emerged with inhibitory control among the children without a migration background we found significant and positive correlations between italian receptive vocabulary inhibitory control and fer and peer social competence additionally a pattern of significant positive correlations emerged between italian receptive vocabulary inhibitory control and social cognition processes inhibitory control tom and fer were interrelated and parental education was only correlated with childrens receptive vocabulary group comparison regarding our first research question concerning group differences in childrens peer social competence a univariate anova indicated that teachers perceived children with a migration background to be less socially competent with respect to peers than their nonimmigrant counterparts 578 p 0001 η2p 015 cohens d 081 regression analysis multiple linear regression was used to examine the associations of inhibitory control tom and fer with childrens social competence in relation to peers to assess the potential moderating effects of migration background interactions between this variable and the inhibitory control tom and fer were also added to the model we included gender parental education and italian receptive vocabulary as control variables the results are reported in table 2 standardized beta coefficients are reported the model explained nearly 19 of the variance in this model migration background and childrens ability to recognize facial emotional expressions were significant and independent predictors of childrens peer social competence additionally the twoway interactions between migration background and inhibitory control and between migration background and fer were significant to test the interaction effects we performed tests of the simple slopes using the interactions package of the r software 67 as shown in figure 1 simple slope analysis indicated that among children with a migration background higher inhibitory control and better facial emotion recognition skills were related to increased peer social competence whereas among children without a migration background teacherrated peer social competence was high irrespective of their levels of inhibitory control and facial emotion recognition abilities discussion this study extends the current literature on the correlates of social competence in childhood by analyzing the contribution of efs and social cognition processes to this important developmental domain among firstgrade children with and without a migration background by conducting this study we have attempted to overcome some of the limitations of previous work such as the paucity of research on positive social outcomes and on the transition to primary school 68 although social competence and relationship skills are increasingly important predictors of success in school 69 and a fulfilling life 70 socioemotional skills and behaviors are almost completely absent from current indi discussion this study extends the current literature on the correlates of social competence in childhood by analyzing the contribution of efs and social cognition processes to this important developmental domain among firstgrade children with and without a migration background by conducting this study we have attempted to overcome some of the limitations of previous work such as the paucity of research on positive social outcomes and on the transition to primary school 68 although social competence and relationship skills are increasingly important predictors of success in school 69 and a fulfilling life 70 socioemotional skills and behaviors are almost completely absent from current indicator reports about children 71 to date most research on children and adolescents with a migration background has focused on internalizing and externalizing problems 72 whereas much less is known about their social competence especially in countries other than the united states or canada 12 in this study we compared levels of teacherrated social competence in relation to peers between the two groups of children and assessed the contributions of a key component of ef namely inhibitory control and two domains of social cognition to peer social competence exploring moderation by migration background our results indicated that children with a migration background were rated by their teachers to be less socially competent than their nonimmigrant counterparts increased receptive vocabulary and fer ability were linked to greater peer social competence in both groups in addition among children with a migration background better inhibitory control was linked to increased peer social competence while levels of peer social competence were high among nonimmigrant students irrespective of their inhibitory control and social cognitive skills our first research question concerned possible differences in how teachers perceived their students in terms of how they relate to their peers in a school context in line with studies reporting a disadvantage in this developmental domain among immigrantethnic minoritized groups we found that children with a migration background showed lesser social skills than their nonimmigrant peers for which there was a nontrivial effect size there are at least two possible interpretations of this finding first it has been documented that the transition to primary school can be particularly challenging for children with a migration background due to a lack of preliteracy skills limited opportunities for intergroup contact with ethnic majority children and difficulties regarding second language acquisition 73 hence these children may experience peer rejection which can negatively influence their overall capacity for school adjustment 74 second it could be that teachers assessment of childrens social competence may be influenced by childrens general cognitive or verbal ability a growing number of researchers have recognized that there is a relationship between verbal ability and social competence 75 gresham and reschly 76 proposed that social competence involves both social skills and adaptive competencies gallagher 75 asserted that social competence can only be conceptualized in the context of language she noted that language and social ability are interdependent and that communication can only be understood within a given social context and vice versa rice hadley and alexander 77 found that in ratings teachers described children with language difficulties as being less intelligent and socially competent thus the fact that firstor secondgeneration immigrant children generally have a lower mastery of a societys language 78 might have contributed to the betweengroup differences assessed by teachers furthermore it has been shown that teachers tend to misjudge immigrant students classroom behaviors and skills 7980 due to implicit prejudice and stereotypes which can also lead to selffulfilling prophecy effects hence even though these findings could be interpreted as reflecting real existing group differences the lessfavorable teacher perceptions of immigrantorigin children may also indicate an underestimation of these childrens perceived social skills our second research question was intended to probe the contributions of inhibitory control tom and fer to childrens social competence in relation to peers exploring moderation by migration background the findings revealed that an increased ability to recognize facial emotional expressions was linked to greater social competence as rated by teachers supporting previous research reporting that childrens accuracy in detecting facial cues related to different emotions plays an essential role in social competence as it facilitates the understanding of others emotional states allowing one to regulate their behavior accordingly 81 however contrary to our expectations we did not record any significant effect of inhibitory control or tom on the outcome variable regarding the inhibitory control previous research has shown that children who are able to control their impulses according to situational demands tend to interact more successfully with peers 82 in our study this ability seemed to play a role only among children with a migration background serving as a protective factor in the context of potential difficulties related to marginalization or less popularity within a classroom this result is in line with previous research suggesting that effortful control may protect children from poor social outcomes 83 in relation to tom the available evidence suggests that being able to imagine others mental states is linked to better social competence although the findings are mixed with some researchers failing to replicate this pattern 84 the null results found in our study may reflect the shared links of tom with language ability which was controlled for in our analyses indeed it has been suggested that the associations between comprehension of false beliefsand social competence reported in prior research are often spurious as they reflect childrens verbal ability 85 another possible explanation is the difference in the measurement of social competence and tom in available studies in terms of moderation while the levels of peer social competence were high among the nonimmigrant students irrespective of their inhibitory control and social cognitive skills the results indicated that among immigrantorigin children better inhibitory control and fer skills were related to greater social competence whereas low levels of these abilities were linked to decreased teacherrated peer social competence in other words the beneficial role of childrens ability to control their impulses and to recognize facial emotional expression in their successful interaction with peers was evident only among children with a migration background this pattern supports the view that against these childrens potential vulnerability in relation to their school adjustment which is attributable to a number of environmental stressors efs and social cognitive processes may represent important resources that boost their social skills 79 even at this delicate developmental stage when efs are not yet fully evolved 14 our results are in line with those of previous studies showing that bilingual exposure promotes better performance in selected aspects of efs such as inhibitory control 8687 specifically these childrens everyday exposure to multiple languages and cultural milieus may facilitate the inhibition of automatic responses as well as the identification of facial emotional cues to adapt their behaviors to different social expectations and situations experienced at home and at school 52 this effect however was not found for tom indicating that this complex ability may interact with other variables not considered in this study o explain levels of peer social competence among first graders with and without a migration background conclusions overall our study provides novel evidence concerning the influence of inhibitory control tom and fer on childrens social competence in relation to peers highlighting patterns of associations that differed as a function of a migration background among firstgrade children however some limitations need to be acknowledged when interpreting the results first the crosssectional design of this study does not allow for the drawing of conclusions regarding causality longitudinal studies assessing the variables associated with peer social competence over the primary school years are warranted in order to shed light on how changes in efs and social cognition processes may influence the unfolding of childrens social competence in relation to peers in this crucial developmental period second the outcome variable was rated exclusively by teachers raising the possibility of informant bias 89 ideally future studies may include parent self andor peerreport measures to obtain a more complete picture of childrens social competence in relation to peers given that behavior can be situationspecific and different raters may observe behavior at different times and in different contexts 9091 moreover observational methods in the school context might be useful to increase ecological validity 92 third the children of immigrant descent analyzed herein originated from several countries thus preventing us from addressing possible effects of cultural background on the study variables due to issues of statistical power as there is evidence that social skills are differentially emphasized and valued across cultures 93 further research may focus on specific ethnic groups in order to disentangle the influence of immigration and culturerelated variables on first graders social skills and the correlates of peer social competence fourth although efs also include cognitive updating and flexibility in our study we focused solely on inhibitory control given its theoretical and empirical relevance in modeling childrens ability to control their impulses in response to social expectations furthermore only one task was used in this work to assess inhibitory control in order to limit childrens fatigue since previous research has shown that experimental measures address relatively specific processes future research should include more tasks to assess inhibitory control also the other two components may be measured to ascertain the specific contribution of each ef to first graders peer social competence despite these limitations our findings contribute to a better understanding of the factors involved in how children with and without a migration background interact with their peers in the transition to primary school in light of their potential disadvantage in terms of social competence in the school setting due to both teacher bias and migrationrelated factors early interventions targeting social competence may be useful in order to reduce behavioral and emotional problems among children throughout their primary school years 34 furthermore schoolbased training programs addressing inhibitory control and fer skills would help boost immigrantorigin childrens ability to successfully interact with peers indeed being effective in social interactions requires children to learn how to master many skills that underlie social competence such as perspective adoption social problem solving and facial emotion recognition more research is needed to identify additional variables that may promote social competence among both immigrantorigin and nonimmigrant children especially in the presence of poor inhibitory and emotional recognition skills to conclude our study has shown the importance of assessing peer social competence at the beginning of primary school and the role of efs and social cognition processes thereby allowing for the increased comprehension of the possible differences between children with and without a migration background data availability statement the data presented in this study are available on request from the corresponding author informed consent statement informed consent was obtained from all subjects involved in the study

executive functions and social cognition ie the mental operations that underlie social interaction are essential for childrens successful interactions yet their role in peer social competence among children with and without a migration background is still underexplored this study investigated the influence of inhibitory control and two domains of social cognition theory of mind and facial emotion recognition on childrens peer social competence exploring moderation by childrens migration background first graders in italy n 321 m age 64 years 45 girls and 39 with a migration background completed standardized tests while teachers rated students peer social competence the results indicated that immigrantorigin children were perceived as being less socially competent than their nonimmigrant counterparts among children with a migration background better inhibitory control and facial emotion recognition skills were linked to increased peer social competence following the presentation of these results we will discuss the implications for both developmental theory and practice

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patten 2013 and projections indicate that this understudied population will continue to grow as such identifying and understanding determinants of alcohol use behavior in this population is becoming an increasingly important public health issue moreover some studies have reported that hispanics are more likely to engage in heavy drinking and experience alcoholrelated disparities that include higher rates of chronic liver disease and citations for driving under the influence of alcoho1 most studies examining sociocultural determinants of alcohol use behavior among hispanic populations have emphasized the potential impact of acculturation on alcohol use however scholars have repeatedly called for investigations to examine more clinicallymodifiable factors that may explain such health risk behaviors accordingly the aims of the present study were to examine the association of immigration stress with alcohol use severity among recently immigrated hispanic adults and examine the moderating effects of gender immigration status and social support immigration stress elucidating the effects of sociocultural determinants may help improve the design and implementation of evidencebased clinical interventions for alcohol use among recent immigrants one factor that may be particularly relevant to this population is cultural stress broadly cultural stress has been described as a constellation of factors that contribute to the stress experience of being a hispanic immigrant in the united states indicators of cultural stressors include but are not limited to acculturation stress and ethnic discrimination some conceptual models have proposed that exposure to cultural stressors may increase the risk of substance use including alcohol use among hispanics although the proposed link between cultural stress and alcohol use has been examined more extensively among adolescents empirical studies with adult hispanics also indicate that cultural stressors such as acculturation stress and ethnic discrimination are associated with higher levels of alcohol use most research on cultural stress and alcohol use has been conducted with combined hispanic immigrant and nonimmigrant samples and investigations among recent adult hispanic immigrants are scarce this gap in the literature is significant because researchers have suggested that among hispanics recent immigrants experience higher levels of cultural stress compared to later generations or immigrants who have been in the us for several years research in this area may also advance by examining cultural stressors that are more specific to the experiences of recent hispanic immigrants one construct that may be especially relevant to this population is immigration stress which encompasses traumatic events during the migration process fear of being deported family separations or limited contact with family due to migration and discrimination due to both immigration status and hispanic ethnicity our review of the literature only identified two prior studies that examined the effects of immigration stress on alcohol use among hispanic immigrants however neither of those studies found statistically significant associations between immigration stress and alcohol use these null findings may be explained in part because both studies included participants who had resided in the us for several years thus it is possible that some components of immigration stress diminished over time and the effects of immigration stress on alcohol use weakened gender and immigration status a discussion of associations of cultural stress and alcohol use should consider the potential moderating effect of gender compared to hispanic women hispanic men report experiencing some cultural stressors such as ethnic discrimination more frequently this may be explained in part because immigrant hispanic men are more likely than women to seek employment and thus be more exposed to the deleterious effect of discrimination in the workplace to the best of our knowledge no prior studies have examined if there are gender differences in levels of immigration stress or if the association between immigration stress and alcohol use varies across gender however literature on other cultural stressors such as acculturation stress and ethnic discrimination has indicated that they have a stronger adverse effect on mental health and substance use behavior among men than women one explanation for this differential effect is that hispanic women may have larger and more diverse social networks and are more likely than men to use constructive coping strategies that may buffer the adverse effects on health risk behaviors such as alcohol use immigration stress may also be associated with higher alcohol consumption among men because men are more likely to use alcohol to cope with stress participants in our sample had resided in the us for one year or less thus the association between immigration stress and alcohol use may be particularly pronounced among men because drinking norms for men in the us and latin america tend to be relatively similar however drinking norms for women are more conservative in latin america compared to the us in addition to gender sociopolitical factors such as immigration status for instance being a documented immigrant or undocumented immigrant may influence levels of immigration stress perhaps the most notable reason being that undocumented immigrants experience heightened stress due to the possibility of being deported immigration status may also limit access to health services for undocumented immigrants which in turn may increase the use of maladaptive strategies to cope with immigration stress given that immigration status can be a sensitive topic of discussion research studies seldom inquire about it thus little is known whether immigration status may modify the relationship between immigration stress and alcohol use finally it should be noted that compared to other hispanic immigrants cuban immigrants are less likely to be deported because they may seek political asylum once they enter the united states and can apply for resident status one year after immigrating social support social support is a multidimensional construct that refers to an individuals social network and the degree to which members of the social network serve particular functions one functional dimension of social support is emotional support which provides empathetic understanding and promotes the expressions of feelings other functional dimensions are informational support which provides advice information guidance or feedback and tangible support which includes the provision of material aid or behavioral assistance lastly positive social interaction support is the availability of people to engage in social activities and affectionate support is the availability of people that can provide affection social support is a key component of the stress buffering model which proposes that higher levels of social support help an individual cope with stressors more effectively thus mitigating the effect of stress on maladaptive outcomes such as substance use quantitatively the stress buffering model can be examined by testing the interaction between social support and stress prior research suggests that enhancing social support among hispanics may function as a protective factor against excessive alcohol use however no prior studies have examined if social support buffers the effect of immigration stress on alcohol use behaviors present study based on the body of work reviewed above the following hypotheses were proposed hypothesis one higher levels of immigration stress would be associated with higher alcohol use severity hypothesis two gender immigration status and social support would moderate the association of immigration stress with alcohol use severity specifically immigration stress would have a stronger adverse effect on men compared to women similarly immigration stress would have a stronger adverse effect on undocumented immigrants compared to documented immigrants lastly higher levels of social support would mitigate the adverse effect of immigration stress on alcohol use severity method participants and procedures the sample consisted of 527 recent hispanic immigrants living in miamidade county this study was approved by the institutional review board of florida international university inclusion criteria were being between the ages of 18 and 34 years old selfidentifying as hispanic having immigrated to the us from a latin american country within one year prior to interview residing within miamidade county and intending to stay in the us for at least 3 years most participants reported being male the sample had a mean age of 2695 and had resided in the us for 675 months with regard to country of origin 42 of participants emigrated from cuba 176 from colombia 125 from honduras 87 from nicaragua and the remainder were from other latin american countries the sample included undocumented immigrants however no cuban immigrants in the sample were undocumented table 1 presents the means standard deviations and frequencies by gender for all variables used in subsequent analyses table 2 shows bivariate correlations for variables used in the regression analyses respondentdriven sampling was the primary recruitment strategy this technique is an effective strategy to recruit participants from difficulttoreach populations each participant was encouraged to refer three individuals from his or her egocentric social network who met eligibility criteria seeds were recruited with informational flyers posted in neighborhoods with a high proportion of hispanic inhabitants community health centers and health fairs targeting hispanics this procedure was followed for a maximum of seven enrolled participants per seed trained and supervised bilingual research staff obtained written consent from all participants and conducted all interviews in spanish all interviews were confidential and were completed at a location agreed upon by both the research staff and participant each interview required approximately one hour to complete for their participation participants received 50 measures demographicsselfreported demographic information include age months in the us gender education level employment status partner status and country of origin a key demographic variable was immigration status prior to inquiring about immigration status participants were informedreminded that a certificate of confidentiality was obtained from the national institutes of health to further secure confidentiality participants were then asked to selfreport their immigration status in the us at the time of the assessment a total of fourteen possible categories were provided including temporary or permanent resident temporary work visa and undocumented or expired visa these categories were then recoded into a dichotomous variable language proficiencyenglish proficiency was assessed by asking participants how well do you speak english similarly spanish proficiency was assessed by asking participants how well do you speak spanish response choices for both items were on a 5point likerttype scale ranging from 1 to 5 preimmigration alcohol usefrequency and quantity of alcohol use prior to immigrating was documented using the spanish version of the timeline followback interview these data were obtained using a calendar format to provide temporal cues to facilitate recall of days when alcohol was consumed alcohol use frequency was calculated by summing the total number of days alcohol was consumed during the last 90 days prior to immigrating alcohol use quantity was calculated by the average number of standard drinks consumed on days of alcohol use during the last 90 days prior to immigrating social supportdimensions of social support were measured using the medical outcomes study social support survey this measure included four subscales emotionalinformational support tangible support affectionate support and positive social interaction support response choices for all subscales were on a 5point likerttype scale ranging from 1 to 5 mean scores indicated higher levels of social support for each respective subscale emotional informational support is a sevenitem subscale and a sample item is someone to confide in or talk to about yourself or your problems the reliability coefficient for emotional informational support was tangible support is a fouritem subscale and a sample item is someone to take you to the doctor if you needed it the reliability coefficient for tangible support was affectionate support is threeitem subscale and a sample item is someone who shows you love and affection the reliability coefficient for affectionate support was positive social interaction support is a threeitem subscale and sample item is someone to do something enjoyable with the reliability coefficient for positive social interaction support was immigration stress immigration stress was assessed with the corresponding scale of the hispanic stress inventory which consists of 18 selfreported items that have been validated in spanish in this scale participants first indicated if they had or had not experienced a particular stressor if a stressor was endorsed then a followup question was asked to appraise how stressful that particular event was by responding on a 5point likerttype scale ranging from 1 to 5 stress items that were reported as not occurring by participants were coded as 1 for data analyses mean scores indicated higher levels of immigration stress a sample item is i have felt that i will never regain the status and respect i had in my home country the reliability coefficient for the immigration stress scale was alcohol use severity alcohol use severity postimmigration was measured with the alcohol use disorder identification test which has been validated in spanish the audit consists of 10 selfreported items with varied response choices on a likerttype scale ranging from 0 to 4 summed scores range from 0 to 40 with higher scores indicating higher alcohol use severity a sample item is has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down the reliability coefficient for the audit was analytic planthe analytic plan included three steps first we computed descriptive statistics and correlations for all variables used in the regression analyses second we estimated the association of immigration stress with alcohol use severity using hierarchical multiple regression all variables were entered into the hmr model in a specified order so that each predictor contributed to the explanatory variance of the outcome variable after controlling for the variance explained by the previous variables predictor variables were grouped into three broad domains and entered in the following order demographic variables preimmigration alcohol use dimensions of social support and immigration stress immigration stress was the last variable entered in the model to determine the extent to which it uniquely predicted alcohol use severity above and beyond the other predictors in the third step of the analytic plan using process v213 we conducted moderation analyses to examine if gender immigration status and dimensions of social support influenced the direction andor strength of the association of immigration stress with alcohol use severity it should be noted that process only produces confidence intervals for unstandardized regression coefficients therefore standardized regression coefficients were estimated separately all moderation analyses were conducted with 10000 bootstrap iteration and controlled for the demographic variables used in the hmr preimmigration drinking behavior and dimensions of social support not used in the interaction term results table 1 reports descriptive statistics by gender for all study variables and table 2 shows bivariate correlations for all study variables hierarchical multiple regression table 3 presents the unstandardized and standardized regression coefficients from the hmr analysis results indicate that 531 of the variance of alcohol use severity was accounted for by all predictor variables entered in the regression model the first block of the model included demographic variables that accounted for 183 of the variance of alcohol use severity δr 2 183 f 1139 p 001 the second block added preimmigration drinking behavior which accounted for 313 of the variance of alcohol use severity δr 2 313 f 15776 p ≤ 001 the third block introduced dimensions of social support adding 22 of the explained variance of alcohol use severity δr 2 22 f 578 p ≤ 001 after controlling for all other predictor variables in the regression model the fourth and final block added immigration stress which accounted for 12 of the variance of alcohol use severity δr 2 12 f 1327 p ≤ 001 standardized beta coefficients from the final regression model showed that gender spanish proficiency number of drinking days prior to immigrating number of drinks prior to immigrating affectionate social support and immigration stress had statistically significant associations with alcohol use severity no other variables in the model were statistically significant moderation analyses the first moderation model indicated that gender moderated the association between immigration stress and alcohol use severity adding 10 to the explained variance above and beyond the hmr δr 2 10 f 723 p ≤ 01 conditional effects indicated that higher levels of immigration stress had an adverse effect on alcohol use severity for men but not among women the second moderation model indicated that immigration status did not moderate the association between immigration stress and alcohol use severity therefore conditional effects could not be interpreted the following moderating effects were observed for dimensions of social support emotionalinformational support moderated the association between immigration stress and alcohol use severity which added 10 to the explained variance above and beyond the hmr δr 2 10 f 697 p ≤ 01 conditional effects indicated that the effect of immigration stress on alcohol use severity was lower at the mean level of emotionalinformational support compared to lower levels of emotionalinformational support there was no statistically significant effect detected at the upper level of emotionalinformational support tangible support moderated the association between immigration stress and alcohol use severity adding 10 to the explained variance above and beyond the hmr δr 2 10 f 589 p 02 conditional effects indicated that higher levels of tangible support buffered the effect of immigration stress on alcohol use severity for instance the effect of immigration stress on alcohol use severity was at lower levels of tangible support in turn the effect of immigration stress was lower at the mean level of tangible support and the effect was lowest at the upper level of tangible support affectionate support moderated the association between immigration stress and alcohol use severity adding 10 to the explained variance above and beyond the hmr δr 2 10 f 911 p ≤ 01 conditional effects indicated that higher levels of affectionate support reduced the effect of immigration stress on alcohol use severity the effect of immigration stress on alcohol use severity was at lower levels of affectionate support at the mean level of affectionate support and at the upper level of affectionate support positive interaction support moderated the association between immigration stress and alcohol use severity which added 13 to the explained variance above and beyond the hmr δr 2 13 f 1458 p ≤ 001 conditional effects indicated that the effect of immigration stress on alcohol use severity was lower at the mean level of positive interaction support compared to lower levels of positive interaction support there was no statistically significant effect detected at the upper level of positive interaction support discussion the present study advances in our understanding of the link between immigration stress and alcohol use in the understudied and underserved population of recent hispanic immigrants findings may be of public health and clinical relevance because they suggest that higher immigration stress was associated with higher alcohol use severity immigration stress had a stronger effect on men compared to women immigration status did not moderate the relation between immigration stress and alcohol use severity and social support mitigated the effect of immigration stress on alcohol use severity this study adds to the sparse literature on cultural stress specifically immigration stress and its association with substance use behavior among recent hispanic immigrants based on these findings we recommended that health service providers working with hispanic immigrants consider respectfully inquiring about their general experiences as immigrants and if needed conduct or refer for a formal assessment of cultural stress health service providers from various disciplines should be aware of the needs and barriers of this underserved population because immigrants may be more receptive to seeking help from general health providers than from mental health service providers further access to these health services could be increased by developing community partnerships with sites that are perceived as safe and familiar the role of gender immigration stress may have had a stronger adverse effect on the alcohol use severity among men than women for several reasons first consistent with other research on cultural stressors men reported higher levels of immigration stress than women although differences in employment status have been cited as a factor that may explain why men report higher exposure to some cultural stressors in our sample we did not find any statistically significant gender differences in employment status yet it has been suggested that independent of employment status hispanic men encounter cultural stressors more frequently in the us because they may be perceived as threatening whereas hispanic women may be perceived as exotic furthermore exposure to some cultural stressors may affect men more negatively because they may threaten notions of masculinity and may lower selfperceptions of social status and power on the other hand women may report less immigration stress because they may perceive advancement in social status after immigrating due to gains in independence and decisionmaking ability another reason the link between immigration stress and alcohol use may have been stronger among men is that men are more likely to use alcohol to cope with stress while women are more likely to develop internalizing symptoms thus service providers may want to discuss genderspecific attitudes about alcohol and target alcohol use expectancies especially among men the role of immigration status immigration status did not moderate the association between immigration stress and alcohol use severity this finding suggests immigration stress was associated with higher alcohol use severity regardless of immigration status one explanation for this could be that the measure of immigration stress in this study was not limited to difficulties directly linked to immigration status it is also likely that context matters immigration stress might not have functioned as a moderator given the geographic location of the study miamidade county unlike most counties in the united states has a population that is 662 hispanic and 513 of the people are immigrants furthermore the city of miami located in miamidade county is considered a sanctuary city meaning that there are no policies designed to prosecute undocumented immigrants it may be the case that immigration status plays a stronger role in regard to immigration stress and alcohol use in cities that have laws that are perceived as hostile toward undocumented immigrants perhaps the best strategy to examine the influence of geographic context is via a multisite study the role of social support consistent with the stress buffering model results from this study indicate that various dimensions of social support weaken the effect of immigration stress on alcohol use severity thus health service providers working with recent hispanic immigrants individually may encourage clients to increase and utilize their social support networks and individuals with small social networks in the us may benefit from communicating with transnational social networks group interventions that aim to provide social support through the family may focus on training family members to be supportive other studies have indicated that higher levels of immigration stress were associated with lower levels of family cohesion this is worth noting because lower family cohesion may be linked to lower perceptions of social support thus interventions that aim to improve family cohesion may in turn increase perceptions andor availability of social support limitations some limitations should be considered when interpreting the findings of this study first due to the crosssectional design a causal or directional order of the associations found cannot be made in our analyses we attempted to reduce this limitations by controlling for preimmigration alcohol use behavior with the use of the timeline followback interview second our study utilized selfreport measures that are vulnerable to participant misrepresentation and error nonetheless selfreports of alcohol use tend to converge well with biological measures among the general population and hispanics third generalizability was limited because a nonprobability sampling technique was used and all participants lived in south florida thus the distribution of immigrants by country of origin differed from other areas in the united states therefore additional studies are needed with more diverse participants that reflect the broader hispanic population fourth the parent study did not include measures of internalizing symptoms which is a limitation because women may be more likely to develop internalizing symptoms than consume alcohol in response to stress lastly the parent study did not include a validated measure of acculturation thus acculturation could not be examined in the present analyses we attempted to reduce this limitation by including items of language proficiency and length of stay in the united states both of which serve as proxy measures that correlate highly with validated measures of acculturation conclusion despite the limitations noted above the present study adds to the limited literature on cultural stress specifically immigration stress and alcohol use among recently immigrated hispanic adults results indicated that higher levels of immigration stress were associated with higher alcohol use severity findings from this study also highlight that the effects of immigration stress may vary across gender and that social support may play a role in buffering the adverse effects of immigration stress thus the design of alcohol use interventions for recent hispanic immigrants may be enhanced if they are genderspecific and help increase levels of social support

objectiveidentifying and understanding determinants of alcohol use behavior among hispanic immigrants is an increasingly significant public health concern although prior research has examined associations of cultural stressors with alcohol use among hispanics few studies have tested these associations among recent adult immigrants as such this study aimed to a examine the association of immigration stress on alcohol use severity among recently immigrated hispanic adults ≤ 1 year in the us and b examine the moderating effects of gender immigration status and social support methoda hierarchical multiple regression and moderation analyses were conducted on a sample of 527 participants in south florida resultsresults indicated that after controlling for demographic variables preimmigration drinking behavior and dimensions of social support the association of higher immigration stress with higher alcohol use severity was statistically significant moderation analyses indicated that immigration stress had a statistically significant association with alcohol use severity among men but not among women also dimensions of social support consistently reduced the deleterious effect of immigration stress on alcohol use severity conclusionthis study adds to the scarce literature on cultural stressors and alcohol use among recent hispanic immigrants findings suggest that it may be important to design genderspecific interventions and that increasing levels of social support may offset the effects of immigration stress on alcohol use

19903_0

introduction we are confronted with the challenge of stewardship in the anthropocene where humans are a primary driver of environmental change 12 in this era stakeholder participation collaboration and learning are important features of management and governance approaches needed to enhance social and ecological outcomes 345 yet to the best of our knowledge it has not been empirically proven that these features lead to enhanced evaluation of outcomes nor are their interactions well understood empirically linking management and governance interventions to outcomes is a pressing need in natural resource settings 6 evidencebased conservation 7 and environmental decisionmaking 89 the importance of forging connections among participation learning and collaboration is reflected in diverse resource management and governance approaches 2 10 11 12 13 for example adaptive comanagement or adaptive governance approaches emphasize the importance of stakeholder participation in decision making activities as well as a need to harness the power of collaboration draw upon diverse knowledge types and facilitate the institutional flexibility to respond to ecosystem change 12 13 14 however empirically validating the relationships among these features and in combination with evaluating outcomes is complicated and contested gaining insights on these variables their connections and contributions to evaluating outcomes in adaptive and collaborative management processes in a systematic way is an identified knowledge gap and an ongoing need 15 16 17 18 to advance scholarly research and to support decision making in environmental stewardship practice thus our research focuses on establishing and understanding the causal relationships among participation social processes that occur in governance and evaluations of outcomes using the individual stakeholder perspective stakeholder participation while greater stakeholder participation is not appropriate under all circumstances 1920 arguments persist that participation is linked to advancing deliberative decision making increasing efficiency and enhancing effectiveness 20 21 22 23 improving stakeholder involvement in making decisions about the environment is now embedded in policy discourses across scales to enhance governance 2319 however claims about stakeholder participation and social and ecological outcomes are often presumed but rarely proven a synthesis of studies that do evaluate participation 23 suggests improvements in quality of decisions are strongly contingent upon the qualities of the associated process collaboration multiparty solutions have provided an avenue to overcome impasses and tackle complex problems engaging diverse individuals in an interactive and iterative problemsolving process may lead to better decisions increase implementation and build capacity for the future 34 extensive research over the past decades has documented a wide range of cases of multiparty collaboration relating to the environment this research has offered valuable insights into qualities of collaboration which influence success such as transparency 28 social capital 29 willingness to compromise 6 and leadership 630 however metaanalyses and reviews of collaborative environmental governance have revealed a mix of positive and negative outcomes 3132 learning the shift towards ecosystembased and adaptive management has stressed the need to learn from largescale experiments and learn by doing 3334 learning has become a normative goal in environmental management 3536 and it is considered an essential element in promoting desirable changes in behaviours in pursuit of sustainability 5 social learning or learning that extends beyond the individual through social interaction to become situated within larger social units 36 is a widely adopted perspective within this scholarship social learning is manifested by collective action forging learning partnerships creating learning platforms and instilling learning ethics 37 there is very limited empirical evidence linking the promotion or enhancement of social learning to stakeholder participation 2336 and assumptions about the effectiveness of social learning in collaborative processes are largely untested 38 outcomes understanding the impacts of governance and management is essential for learning and adapting decisions and actions 8 these impacts can be identified as the results and effects of governance and management 28 collectively considered outcomes results are the tangible and intangible outputs of governance and management within and beyond the boundaries of the system 2839 effects are the ecological and social consequences of management and governance including ecosystem services and enhanced livelihoods 2839 evaluating outcomes is complicated and contested perceptions of stakeholders have been recognized and used as an indirect measure of environmental outcomes and their potential as a source of bias is an identified concern the potential presence of other variables of influence adds difficulty to correlating environmental outcomes and governance processes 44 and the potential for confounding variables and attribution issues are similarly present for social outcomes bennett 7 has recently challenged notions of what counts as evidence clarifies the contributions of perceptions research and calls for increased incorporation of evidence from social and natural sciences to enhance decisions we validate the relationships among participation collaboration and learning in relation to evaluating outcomes as well as address critical gaps in knowledge about their interrelationships in environmental management and governance using a path analysis modeling approach specifically we concentrate on how participation and features of learning and collaboration influence evaluations of outcomes by the stakeholders involved our approach assumes that individuals longterm engagement in an environmental management and governance process is dependent upon their beliefs in the ability of that process to deliver desirable outcomes and that individuals engaged in the range of activities related to environmental management and governance are bestpositioned to evaluate outcomes from it we conducted the research at the individual level collecting responses from four biosphere reserves two in sweden and two in canada for the analysis biosphere reserves represent an appropriate context in which to conduct this research as members engage in governance and management activities in support of the dual aims of biodiversity conservation and sustainable development 45 thus they explicitly aim to achieve ecological and social outcomes we investigated three potential causal pathways among participation process and evaluating outcomes the first model combines learning and collaboration into a single process variable in the second and third models learning and collaborative qualities respectively were examined for their individual roles in the causal pathway methods this section details the methods used for this study including the cases respondents measures and analysis the instruments used to collect data additional detail on data preparation and the model data are available in s1s3 appendices brock university research ethics board approved this research cases four brs were selected for study frontenac arch and georgian bay in canada and kristianstads vattenrike and o ¨stra va ¨tterbranterna in sweden these brs were chosen based on their relative similarity in terms of size location in highincome countries and active governance processes the individual was selected as the unit of analysis and the decision to focus on these four brs helped to minimize external variability as much as possible while providing a large enough sample of individuals engaged in management and governance interventions from the cases to conduct the analysis respondents br managers identified individuals in their respective brs who were engaged in the management and governance process these individuals were invited to participate in the study by attending a workshop and completing a questionnaire prior to participating in the workshop written informed consent was provided in all cases the final sample included 66 individuals who provided responses to all sections of the questionnaire respondents affiliations ranged from local and regionalprovincial government to environmental nongovernmental organizations to private business and landowners respondents engaged in range of activities related to management and governance of the brs and thus their perceptions reflect their unique experiences in relation to the processes and multiple outcomes measured in this study measures a questionnaire was administered that included questions about the specific activities in which individuals participated quality of collaboration learning and evaluation of outcomes of the governance and management process the items corresponding to each of these sections are provided in s1 appendix for activities respondents were asked to identify specific activities in which they have participated based on seven categories preparation of biosphere related materials for unesco practical actions in the landscape projects that involve monitoring social events mapping of the biosphere reserve activities related to management and planning and activities related to governance or decision making the total number of identified activities was calculated for each individual in all other sections of the questionnaire respondents were asked to rate their agreement with provided statements on a fivepoint likert response scale collaborative qualities items reflected those of established importance in the literature such as transparency and deliberation 28394647 learning was measured using a typology of cognitive normative and relational learning 3948 results comprise evaluation of tangible and intangible products that immediately or indirectly come about from the management and governance process effects are evaluations of their consequences consisting of ecological sustainability and enhanced livelihoods 2839 total scores were obtained for each of the five sections of the questionnaire by summing the responses to items resulting in summary scores for each variable for each respondent for descriptive statistics of the means and distributions of responses to each section please see s4 appendix path analysis path analysis is a structural modeling approach that estimates direct and indirect effects among a set of variables 49 three models were examined using mplus version 7 for windows 50 evaluations of outcomes were specified to be the dependent variable in each model the total number of activities each individual engaged in was used as the predictor at the start of the path analysis and a dummy variable representing the brs was used as a covariate to eliminate any group effects that is to eliminate any possible impacts membership in a particular br might have on the analysis details regarding the analysis including the correlation matrix and model results are provided in s2 and s3 appendices the process variable was used as potential mediating variable in the first model thereafter the process variable was unpacked into its component parts learning and collaborative qualities learning was used as a potential mediating variable in the second model and collaborative qualities in the third model thus models 2 and 3 were used to explore the relative contributions of learning and collaborative qualities to the relationship between activities and outcomes the goal of the analysis was to understand the indirect effects and direct effects the significance of indirect effects was examined through 95 confidence intervals using maximum likelihood estimators with 1000 bootstrap samples such that any effects that did not include 0 in the ci were considered to be significant results the first model examined the relationship between activities process and evaluations of outcomes activities and process together explained 563 of variance in evaluations of outcomes and activities alone explained 226 of variability in process the direct effects of activities on evaluations of outcomes was not significant but the indirect effect of activities to outcomes through process was such a higher level of participation was related to higher scores on process measures and in turn greater scores for outcomes in the alternative models examined the process variable was substituted with either learning or collaborative qualities activities explained 195 of variance in learning and 412 of variance in evaluations of outcomes similar to the results of the first model only the indirect effect of activities on evaluations of outcomes was significant in the third model activities explained 234 of variance in collaborative qualities and 483 of variance in evaluations of outcomes however neither the direct nor indirect effects were significant thus it appears that effects of activities on evaluations of outcomes is influenced more by the path through learning compared to quality of collaborations it is worth noting that no group effects related to membership in a particular br were found in any model discussion evidence to support the importance of a quality management and governance process insights derived from the analysis unveil the dynamics on the ground as perceived by stakeholders engaged in management and governance in brs as captured in the first model participation in more activities led to higher rating of process variables and in turn more positive evaluation of social and ecological outcomes our finding gives insight into previous studies where participation in more management and governance activities is assumed to lead to improved decisions and strongly depends on the quality of the process 23 this finding regarding the importance on the quality of the process itself is not surprising however the question of what constitutes a quality process has given rise to syntheses of principles and attributes in resource and environmental management as well as in environmental governance and resilience scholarship our findings complement these insights from qualitative studies and confirm empirically the combination of collaboration and learning as foundational to better perceptions among stakeholders about outcomes from environmental management and governance we were able to account for a substantial amount of the variance of evaluated outcomes in our first model using the combined process variable the findings resonate with governance and management efforts more broadly the brs can be considered as early movers and motivators in addressing the stewardship challenge 2 7373 and thus provide an excellent context in which to conduct this research commenting on management and governance effectiveness oversteps our results but our findings contribute two valuable insights first we broaden the basis for evidence about outcomes beyond a single source such as a br manager to include stakeholders second we are able to enhance knowledge regarding the extent of variance of outcomes explained by participation and process variables insights into these approaches almost exclusively come from qualitative case studies and reviews of the literature but see stollkleeman et al 55 and schultz et al 21 for exceptions that revealed a belief by managers about the importance of community participation especially in association with acceptance of the organizationdesignation and conservation program success although tremendous value is derived from the richness of studying cases and context is clearly important several limitations have been observed in the literature to date that hamper the comparability of research and the ability to draw causal inferences 1639 our study has directly addressed these limitations the modeling and statistical analysis employed here offer tools for further application in adaptive governance as well as a broader suite of approaches to environmental collective action learning contributes more than collaboration to perceived outcomes deconstructing the first model and examining the effects of learning and collaborative qualities separately showed that participation in more activities contributes to greater learning scores but not to better perceptions of collaborative qualities therefore the effects of activities on evaluating outcomes appear to be driven by learning rather than quality of collaboration however since the overall model where the process variable included both learning and collaborative qualities is significant these analyses highlight the relative importance of each process subvariable these findings enrich the dialogue among scholars about how a group of actors come to address collective action problems when managing linked systems of people and nature first the frequency of engagement in activities is important those who engaged in more activities tended to learn more and provide more positive evaluations of outcomes second and related specifically to the group processes collaborating in a quality process is seen as the means to addressing collective action problems but also addressing collective action problems is reliant upon learning and learning comes about through a quality process the pathways revealed through our analysis augment these existing causal presumptions and align with recent assertions by lubell 5960 that solving collectiveaction problems requires complex institutional systems that facilitate key processes of learning cooperation and distribution of benefits and costs shedding light on conceptual and analytical considerations conceptual tensions and analytical complications surround research about approaches to environmental management and governance in relation to outcomes we elected to use selfreported information by the individuals who participated in the activities of the brs our choice is predicated upon the logic that the individuals involved in the initiative are best positioned to reflect upon the process as well as evaluate the outcomes of interest and this choice is supported by research that shows that stakeholders with different experiences and knowledge bring different perceptions of the same resources 61 we statistically control for br level effects with regards to processes and outcomes so that analysis throughout is at the individual level moreover we utilize a multiitem approach for rating outcomes as opposed to a singleitem effectiveness measure to hedge against inflated perceptions by stakeholders as found by selin et al 6 these decisions in our analytical approach were made to enable a focus on the features influencing evaluation of outcomes by the stakeholders involved utilizing independent measures of environmental outcomes is complementary to our approach and a laudable ideal as is pursuing innovative research designs that present opportunities to limit confounding variables enthusiasm for independent measures must be tempered with awareness of the inherent difficulties in understanding and attributing environmental 9 as well as social impacts the indirect path in our first model is consistent with findings in collaborative environmental management of positive evaluations of an initiative by active participants 6 although a multiitem approach was utilized to enhance the validity of the measures and potentially counter inflation of evaluations it is not possible to rule out the halo effect which occurs when there are high levels of trust among individuals inflating perceptions of their collective impact 62 the indirect path is also consistent with the broader phenomena of cognitive dissonance where respondents engaging in more intensive endeavours exaggerate the associated positive outcomes 63 the direct path from participation to evaluation of outcomes was not statistically significant this opens interesting opportunities to expand the model and probe additional features which may be exerting influence on the evaluation of outcomes such as personal attributes or specific institutional and political conditions within which governance occurs finally we utilized one portion of a more extensive dataset in which individuals are nested within brs attaining and utilizing a larger and longitudinal dataset opens a host of possibilities for conceptual and analytical advancement specifically aggregated variables such as outcomes could be tested as separate variables an understanding of feedbacks could be developed and analysis could be conducted at a level andor at multiple levels capturing multilevel interactions implications for practice and policy our findings suggest that stakeholder engagement in multiple activities influences their experiences in environmental management and governance and in turn their evaluation of the outcomes it highlights the importance of a positive experience in environmental stewardship efforts for continued engagement 64 and specifically identifies the critical role of learning 65 participation by volunteers in particular has been considered essential to the functioning of environmental stewardship programs 6466 with learning highlighted as an important motivator for engagement accordingly practices that create opportunities for engagement of stakeholders in multiple activities and for learning to occur are likely to improve outcomes as evaluated by those stakeholders as bennett 7 584 reminds us it is positive perceptions not just objective scientific evidence of effectiveness that ultimately ensure the support of local constituents thus enabling the longterm success of conservation our research offers first steps to in a larger effort to identify important practical guidelines that enhance engagement in and outcomes from environmental stewardship however it is important to note that the relatively small sample size while certainly adequate for the models tested here would benefit from a large sample to improve both the power of the analysis and the ability to test relationships among more variables accordingly further research to build a nuanced understanding of participation in different kinds of activities types of learning and specific collaborative qualities that are most influential on perceived outcomes and how virtuous cycles of engagement are created is needed research of this kind when undertaken with a very large sample of environmental stewardship stakeholders in a range of contexts can provide guidance for practitioners in terms of how to encourage participation and nurture a positive management and governance process to enhance social and ecological outcomes conclusions participation collaboration and learning are advanced as important features of approaches to contemporary environmental management and governance the findings from our research afford evidence that their importance can be empirically determinable in relation to the evaluation of outcomes our work to untangle the dynamics and relative contributions of these essential features to evaluation of outcomes advances the understanding and importance of stakeholder perceptions 7 empirical connections between interventions with outcomes 9 and innerworkings of socialecological governance approaches taking up the stewardship challenge 2 we show here that the scope of inquiry should be extended beyond collaboration 6067 to a broader suite of approaches for managing and governing socialecological systems insights about pathways to address collective action problems appear somewhat fragmented in the literature and further research is required to close this gap andor discern multiple processes facilitating management and governance arrangements 5960 efforts to advance our understanding of these pathways will greatly benefit from an expanded acceptance of what constitutes evidence as well as more effective use of qualitative and quantitative measures from natural and social sciences 7 ultimately such a research agenda may enable us to empirically connect management and governance interventions to outcomes and therefore offer 1 an evidencebased argument for necessary changes 89 and 2 a richer understanding of the features influencing the stakeholder views that are critical for longterm success 7 all data necessary to replicate the findings of this study are available within the paper and its supporting information files additional data is available on request from authors however all identifying characteristics shall be removed to protect the identities of those individuals involved

multistakeholder environmental management and governance processes are essential to realize social and ecological outcomes participation collaboration and learning are emphasized in these processes to gain insights into how they influence stakeholders evaluations of outcomes in relation to management and governance interventions we use a path analysis approach to examine their relationships in individuals in four unesco biosphere reserves we confirm a model showing that participation in more activities leads to greater ratings of process and in turn better evaluations of outcomes we show the effects of participation in activities on evaluation of outcomes appear to be driven by learning more than collaboration original insights are offered as to how the evaluations of outcomes by stakeholders are shaped by their participation in activities and their experiences in management and governance processes understanding stakeholder perceptions about the processes in which they are involved and their evaluation of outcomes is imperative and influences current and future levels of engagement as such the evaluation of outcomes themselves are an important tangible product from initiatives our research contributes to a future research agenda aimed at better understanding these pathways and their implications for engagement in stewardship and ultimately social and ecological outcomes and to developing recommendations for practitioners engaged in environmental management and governance

19904_0

introduction the goal of social network analysis is to characterize the structure of social relations within a network in this analysis it is standard to represent the network as a graph g of nodes n and connecting edges e where the nodes represent network members and an edge represents a connection between two members the relationship represented by an edge depends on the type of network under consideration for this reason an edge may also be weighted carrying information or data relevant to the network for instance in a communication network the frequency or length of communication between pairs of people can be incorporated into the network as the weights of the networks edges in practice however network weights are often binary zeroone weights in which a one represents an interaction and a zero no interaction in a network the members often consists of different modes or distinct types of members if there is only a single type member the network is referred to as a singlemode network in a twomode network often referred to as a bipartite network interactions form between members of two distinct groups for example in an actorstomovies network each actor is linked to the movies the actor has played in highermode social networks are also possible in which network members are clearly divided into multiple types beyond these different modes social networks often exhibit hierarchical organization in which network nodes divide into groups ie communities that further subdivide into smaller groups of groups and so on over multiple scales an important aim of social network analysis is to uncover the hierarchical structure of a given network a typical strategy has been to first break these networks down into smaller groups then to analyze the position or relative importance of a member in a given group because of the importance of understanding the hierarchical organization of networks numerous methods have been proposed to determine the position of a member within a given group or more generally the network at large here we propose a new approach of uncovering the hierarchical structure of a network this approach is based on the theory of isospectral network transformations which allows one to reduce the size of a network while maintaining the networks spectral properties the way in which a network is isospectrally reduced depends on a given criteria or rule that states which network nodes are important and which are less important to the network any criteria that selects a specific set of nodes can be used for this purpose which makes this process quite flexible a network hierarchy is created by sequentially reducing a given network via this method of isospectral reduction that is at each stage in this process the network is reduced those nodes that are deemed less important are removed from the network at each stage those nodes that remain after each isospectral reduction are considered successively more important than those that removed at a previous stage the result is a network hierarchy in which the network members have been sequentially partitioned into a number of groups each of which is considered more important to the network than the previous group naturally the hierarchy depends on the particular criteria used to select important and unimportant nodes in this sense the sociologist familiar with a given network is the most natural candidate for developing a useful criteria for obtaining the networks hierarchical structure using this procedure in this paper we apply this method of hierarchical analysis to the southern women data set this data set yields a twomode network consisting of eighteen women and the meetings they attended over the course of nine months and is one of the studied networks in social science we find that the results of our hierarchical analysis of this network are similar in a number of ways to previous results regarding this network but also provide new information that is complementary to these findings the paper is organized as follows in section 2 we introduce the southern women date set and the associated dgg network in section 3 we present the results of our analysis describing the hierarchical structure of the dgg network and the singlemode versions of this network based on the method of isospectral reductions in section 4 we describe the method used to find the hierarchical structure presented in section 3 which include the method of isospectral reduction and the conversion of an nmode network to a smaller singlemode network in section 5 we describe the procedure of isospectrally reducing a network in section 6 we analyze the dynamics the dgg network as it evolves over time in section 7 we give some closing remarks southern women data set one of the earliest social networks to be analyzed is the southern women data set or the dgg network the dgg network is built from fourteen social events attended by eighteen women in 1936 in the town referred to as old city this data is shown in table 2 as an 18 × 14 matrix representing those eighteen women w w 1 w 18 and which of the fourteen events e e 1 e 14 they attended additionally the dates of each meeting e 1 e 14 were recorded making it possible to analyze the formation and evolution of the networks topology ie analyze the networks dynamics because of the relatively small size of this data set and some of the not so obvious patterns it contains the group and hierarchical structure of this data has been analyzed numerous times the methods used in this analysis include the use of network correspondence normalized degree closeness centrality betweenness centrality eigenvector centrality etc borgatti 2009freeman 1992fielda et al 2006opsahl 2013doreian et al 2004freeman and white 1993kuznetsov et al 2007freeman 2012 e 1 e 2 e 3 e 4 e 5 e 6 e 7 e 8 e 9 e 1 1 1 1 1 1 0 1 1 0 0 0 0 0 w 2 1 1 1 0 1 1 1 1 0 0 0 0 0 0 w 3 0 1 1 1 1 1 1 1 1 0 0 0 0 0 w 4 1 0 1 1 1 1 1 1 0 0 0 0 0 0 w 5 0 0 1 1 1 0 1 0 0 0 0 0 0 0 w 6 0 0 1 0 1 1 0 1 0 0 0 0 0 0 w 7 0 0 0 0 1 1 1 1 0 0 0 0 0 0 w 8 0 0 0 0 0 1 0 1 1 0 0 0 0 0 w 9 0 0 0 0 1 0 1 1 1 0 0 0 0 0 w 10 0 0 0 0 0 0 1 1 1 0 0 1 0 0 w 11 0 0 0 0 0 0 0 1 1 1 0 1 0 0 w 12 0 0 0 0 0 0 0 1 1 1 0 1 1 1 w 13 0 0 0 0 0 0 1 1 1 1 0 1 1 1 w 14 0 0 0 0 0 1 1 0 1 1 1 1 1 1 w 15 0 0 0 0 0 0 1 1 0 1 1 1 0 0 w 16 0 0 0 0 0 0 0 1 1 0 0 0 0 0 w 17 0 0 0 0 0 0 0 0 1 0 1 0 0 0 w 18 0 0 0 0 0 0 0 0 1 0 1 0 0 0 table 1 the southern women data set is shown as a zeroone matrix consisting of eighteen rows and fourteen columns representing the women w w 1 w 18 and events e e 1 e 14 in the data set respectively here a one in the i jentry of the matrix indicates that the ith individual w i attended the jth event e j a zero indicates an absence at the event additionally the date of each event during the year 1936 is given madritscher et al 2011brusco 2011snasel et al 2009xu et al 2010li and pang 2012zaversnik et al 2001liu and murata 2009everett and borgatii 2013gihosh and lerman 2009aitkin et al 2014 of these findings twentyone of them were surveyed by freeman in 2003 in each of these twentyone investigations an attempt was made to analyze the group structure of the womens social interactions in eleven of these methods a hierarchical analysis was also given the results of this analysis are shown in table 2 which aside from the last row is a recreation of figure 10 from freeman 2003 p 25 each row of table 2 represents a different approach to creating a hierarchy of the women in the southern women data set homans 1950 bonacich 1978 doreian 1979 bonacich 1991 freeman and white 1993 freeman and white 1994 borgatti and everett 1997 skvoretz and faust 1999 roberts 2000 and newman 2001 in each row the women are first divided into two groups then ranked according to a specific analytic procedure the more important or core members are shown to the left in each group the double vertical lines show the divisions in each method that differentiate core members in each group from peripheral members for instance the first row of table 2 is the hierarchy devised by the authors of the original study of the southern women data set here the authors specify that women in the first group have the core members w 1 w 4 followed by the first level of peripheral members w 5 w 7 then the second level of peripheral members w 8 and w 9 in each study represented in table 2 the authors follow this convention of first breaking the women into two groups and constructing a hierarchy within each group in the following section we similarly break the members of the network corresponding to the southern women data set into groups of core and peripheral members using the method of isospectral reduction allows us to rank not only the women in this network but also the events they attended the result is a hierarchical analysis of both the women and events in the dgg network if we restrict this analysis to just the women in the network and partition them into groups similar to what is done in previous investigations the result is the hierarchy wcbw17 shown in the last row of table 2 we comment on the differences and similarities between our hierarchy and the others shown in this table in the following section where the results of our analysis are given results the dgg network shown in figure 1 as the graph g dgg has thirty two nodes which represent both the eighteen women w w 1 w 18 and fourteen events e e 1 e 14 in the southern women data set in the graph there is an edge between w i and e j if w i attend event e j so that our results can be compared to previous results these nodes are further divided into six subgroups by color according to the scheme described in group one which consists of the nodes g 1 w 1 w 7 w 9 are the women who attended events e 1 e 1 e 5 and events j e 6 e 9 events e 1 are referred to as the first set of group events and events j are referred to as the joint meeting group two which consists of the nodes g 2 w 10 w 15 w 17 w 18 are the women who attended the second set of group events e 2 e 10 e 14 as well as the joint meetings j the third group of women g 3 w 8 w 16 are those women who only attended the joint meetings in section 31 we first describe the hierarchical structure of the individuals and events in the dgg network obtained using the method of isospectral reductions in section 32 we go on to describe the hierarchical structure of the two singlemode networks associated with the dgg network hierarchical structures of the dgg network here we analyze the hierarchical structure of the dgg network g dgg consisting of both individuals and events our analysis of the dgg network reveals an eight stage hierarchical structure both of the set of women w w 1 w 18 and the set of events e e 1 e 14 using terminology similar to what has been e 1 e 2 e 3 e 4 e 5 e 6 e 7 e 8 e 9 e 10 e 11 e 12 e 13 e 14 w 1 w 2 w 3 w 4 w 5 w 6 w 7 w 9 w 8 w 16 w 10 w 11 w 12 w 13 w 14 w 15 w 17 w 18 the dgg network g dgg 2 where there is an edge between w i and e j if w i attended e j following freeman and duquenne yellow and orange nodes represent the first and second set of group events e 1 e 1 e 5 and e 2 e 10 e 14 respectively red nodes represent the joint meetings j e 6 e 9 the blue purple and green nodes represent the first second and third groups of women g 1 w 1 w 7 w 9 g 2 w 10 w 15 w 17 w 18 and g 3 w 8 w 16 respectively established in previous investigations of the dgg network we let h core h 1 h 2 denote the core and the first second etc peripheral levels in the hierarchical structure of the dgg network respectively we find that h core w 1 w 4 e 3 e 5 e 8 h 1 e 9 h 2 w 14 h 3 w 13 e 10 e 12 h 4 w 12 w 15 h 5 w 5 w 7 w 9 w 11 e 4 e 11 h 6 w 8 e 1 e 2 e 13 e 15 h 7 w 16 w 18 form the hierarchical structure of the women and events in the dgg network obtained using the method of isospectral network reductions adopting the notation used in table 2 we write this hierarchy as h h core h 1 h 7 which is shown graphically in figure 2 this hierarchy differs from previous hierarchies in that it compares both the women w and events e of the dgg network however it can be used to create a hierarchy of the women by restricting this hierarchy to the women w we have h 1 2 3 4 14 13 12 15 5 6 7 9 10 11 8 16 17 18 written as in table 2 the hierarchy restricted to events is similarly given by h 3 5 6 7 8 9 10 12 4 11 1 2 13 14 2 although the method of isospectral reduction can be used to break the women of the dgg network into groups ie the core and peripheral members as shown in these groups are quite different from those found in previous investigations one reason is because in these earlier studies the women were first placed into groups then the hierarchy of each group was determined in our method both processes e 3 e 5 e 6 e 7 e 8 e 9 e 10 e 12 e 4 e 11 e 1 e 2 e 13 e 14 w 1 w 2 w 3 w 4 w 14 w 13 w 15 w 12 w 5 w 6 w 7 w 9 w 10 w 11 w 8 w 16 w 17 w 18 h core h 1 h 2 h 3 h 4 h 5 h 6 h 7 hierarchical structure of the dgg network are done simultaneously however if we for instance restrict our hierarchy given in to the groups 1 the result are the hierarchies h 1 2 3 4 5 6 7 9 and h 14 13 12 15 10 11 17 18 g 1 w 1 w 7 w 9 and g 2 w 10 w 15 w 17 w 18 indicated in figure corresponding to group g 1 and group g 2 respectively these are the hierarchies shown in the last line of table 2 interestingly for the first group g 1 this hierarchy places the women w 1 w 4 ahead of the women w 5 w 7 w 9 which is also consistent will nearly all of the hierarchies in table 2 except bch 78 and bch 91 similarly for the second group g 2 this hierarchy places w 12 w 14 ahead or equal to w 11 and w 15 which is consistent with most hierarchies in table 2 another way of analyzing the hierarchies given in figure 2 and in is to compare them against the more active women and the more popular events of the dgg network an individual in a network such as the dgg network can be classified as being more active if they attended more events than the average person in the network similarly an event can be classified as more popular if it is attended more than the average event in the network in the dgg network the more active individuals are w 1 w 4 w 12 w 15 and the more popular events are e 5 e 9 one can see that the women and events shown in figure 2 in each level of the hierarchy are quite consistent with those individuals and meetings that are more active and more popular in the network respectively for example the women that are part of the network core h core are the more active members in the group g 1 having attended an average of 75 events each the women that are part of the peripheral levels h 1h 4 are the more active members of the group g 2 having attended an average of 65 events each the individuals in the lower peripheral levels of the network are increasingly less active having attended an average of 4 3 and 2 events for those women in h 5 h 6 and h 7 respectively a similar trend can be seen to some degree in the network events here the events in h core h 1 h 3 h 5 and h 6 have an average attendance of 92 12 55 4 and 3 respectively one might expect that each of the joint events j e 6 e 9 would be part of the core h core however e 9 is not in the core whereas one of the most highly attended meetings of the group g 1 namely e 3 is in the core it is worth noting that w 1 w 4 attended at least as many more popular events than less popular events in contrast w 12 w 15 each attended fewer of the more popular events than they did the less popular events moreover more than half the participants in the more popular events e 5 e 8 are those who are more active in fact these more popular events have a higher attendance by the more active individuals than from those that are less active hierarchical structures of the womentowomen and eventstoevents networks aside from finding the hierarchical structure of the dgg network we can also find the hierarchical structure of the singlemode networks that are associated with it these are the womentowomen and eventstoevents networks shown in figure 3 as the graphs g w and g e respectively the womentowomen network consists of the eighteen women in the dgg network where there is an edge between two women if they attended the same event at some point the eventstoevents network consists of the fourteen events in the dgg network where there is an edge between two events if one women attended both events the method of isospectral reduction can also be used to find the hierarchical structure of these networks this results in the hierarchies h 1 2 3 4 6 7 8 9 10 11 12 13 14 15 16 17 18 5 for the womentowomen network and h 6 7 8 9 1 2 3 4 5 10 11 12 13 14 for the eventstoevents network the womentowomen network is almost fully connected as can be seen in figure 3 not surprisingly then the sequence of isospectral reductions used to find the core of this network only removes a few individuals from the network before each of the women has the same number of neighbors and the process terminates those that are removed are w 5 w 17 w 18 in the eventtoevent network the joint meetings j e 6 e 9 form the connections between the group meetings e 1 of the first group and the group meetings e 2 of the second group because of the role that the joint meetings play in the network these are the events that ultimately form the core of the eventtoevent network under isospectral reduction together the cores the dgg network and its singlemode reductions are h core w 1 w 4 e 3 e 5 e 8 h core w 1 w 4 w 6 w 16 and h core e 6 e 9 when analyzing a network it is natural to think that the nodes with many neighbors should be part of the networks core however in the full dgg network the nodes with the largest degree are e 7 e 8 and e 9 but e 9 is not part of the network core h core the reason is that the individuals who participated in this event were less active in the overall network it is worth emphasizing that our analysis of the dgg network is an example illustrating how one can mathematically find the core or more generally the hierarchical structure of a network and use this to explain which nodes are most important to the network methods suppose a network is given by the graph g in which n is composed of n members an alternative way of representing the network is by an n × n square matrix m whose i jentry is the weight of womentowomen network g w eventtoevent network g e e 1 e 2 e 3 e 4 e 5 e 6 e 7 e 8 e 9 e 10 e 11 e 12 e 13 e 14 w 1 w 2 w 3 w 4 w 5 w 6 w 7 w 8 w 9 w 10 w 11 w 12 w 13 w 14 w 15 w 16 w 17 w 18 figure 3 the womentowomen network g w and eventtoevent network g e associated with the dgg network are shown the edge from node i to node j in g and is zero if there is no such edge the matrix m m is referred to as the weighted adjacency matrix of the network the eigenvalues of m are referred to ass the spectrum of the network for example the adjacency matrix m of the dgg network has the block form m 0 a a t 0 in which a is the 18 × 14 matrix of zeros and ones shown in table 2 describing which individuals attended which events and where a t is the transpose of the matrix a the hierarchy describing the structure of the dgg network given in section 3 is based on the theory of isospectral network transformations specifically on the theory of isospectral reductions using this method one can reduce the size of a network while preserving the networks spectrum in this section we first describe this method we then go on to show that the twomode dgg network represented in table 2 by a nonsquare matrix can be compressed into a singlemode network in two ways one for each mode of the network the two resulting networks are the membertomember network and the eventtoevent network associated with the dgg network both of which can be isospectrally reduced we finish the section by describing how any multimode network can be converted to a singlemode network in this manner isospectral network reductions the method of isospectral reduction can be applied to any network via an isospectral network reduction it is possible to uniquely reduce a network given by a graph g over any subset s of its node set n the result is a smaller network given by the reduced graph r s whose node set is the set s and whose edges e s are computed using the networks original set of edges e the reason this is referred to as an isospectral reduction of the network is that if m is the matrix associated with g the matrix r s associated with the reduced network r s although smaller has the same eigenvalues as m the main goal of this paper is to demonstrate how isospectral reductions can be used to deduce the hierarchical structure of a network to demonstrate this we have applied this technique to the dgg network the specific way in which we have reduce this network is to let µ be the rule that selects all nodes of a graph that do not have minimal degree ie those nodes that do not have the minimal number of neighbors over the whole graph for instance µ are the nodes of the dgg network that have degree more than two which are all the nodes except w 16 w 18 using this rule we let r 0 g dgg be our initial unreduced graph and define the kth isospectral reduction of r 0 to be the graph r k r s k for 1 ≤ k ≤ 7 this process can be thought of as sequentially removing those nodes that have minimal degree from the graph at each stage this reduction process it is worth reiterating that this process does not simply remove those vertices that have minimal degree at every stage if this process rather an isospectral reduction is used which preserves the path and cycle structure of the network by modifying the networks weights the reason this process terminates after seven steps is that µ is empty meaning that every node of this graph has minimal degree hence the graph r 7 cannot be further reduced using the rule µ the results of this sequence of reductions is shown in figure 3 the tables in figure 3 show the degree of each node in each reduction r 0 r 1 r 7 those nodes without an asterisk in r k1 are the nodes that belong to the set µ for k 1 2 7 those with an asterisk are the nodes removed in the following reduction this sequence of reductions describes which of the vertices are most important in the network with respect to the criteria µ with those that are less important being removed before those that are more important the way in which we determine which nodes are in the core and peripheral levels of the network is to designate those removed in the first stage of this process as the group h 7 those removed in the second stage as the group h 6 and so on until those that remain in the final stage make up the core h core of the network it is worth emphasizing that the reduction rule µ used to determine the hierarchy described in section 3 is only one of many criteria that could be used to find a hierarchy of the dgg network or for that matter any network in fact any node characteristic could be chosen as a criteria for creating a network hierarchy including various measures of centrality number of cycles through a node etc of course the most natural candidate for developing such a criteria is the sociologist who is familiar with the network this method is in this sense a flexible and computationally inexpensive method for determining the hierarchical structure of any network of interest conversion to a singlemode network here we describe how any multimode network can be reduced to a number of smaller singlemode networks to start given a nonsquare n × m matrix a associated with a twomode network the n × n matrix aa t is the matrix associated with the first mode of this network whereas the m × m matrix a t a is the matrix associated with the second mode of the network for example the 18 × 14 matrix a given in table 2 associated with the dgg network can be converted into the 18 × 18 square matrix m w aa t representing the womentowomen network shown in figure 3 the matrix a can also be used to create the 14 × 14 matrix m e a t a representing the eventtoevent network also shown in figure 3 these matrices are shown in tables 41 and 42 respectively the corresponding networks are figure 4 the sequence of isospectral reductions r 1 r 2 r 7 of the dgg network g dgg r 0 using the rule that nodes with minimal degree are removed at each step edge weights and node labels are neglected expect for the labels of the core nodes and the degree of each node in each of the reduced networks is shown node with minimal degree are given an asterisk r 0 g dgg r 1 r 2 r 3 r 7 w 1 w 2 w 3 w 4 e 3 e 5 e 6 e 7 e 8 w 1 w 2 w 3 w 4 w 5 w 6 w 7 w 8 w 9 w w 1 w 2 w 3 w 4 w 5 w 6 w 7 w 8 w 9 w 10 w 11 w 12 w 13 w 14 w 15 w 16 w 17 w 18 w 1 8 6 7 6 3 4 3 3 3 2 2 2 2 2 1 2 1 1 w 2 6 7 6 6 3 4 4 2 3 2 1 1 2 2 2 1 0 0 w 3 7 6 8 6 4 4 4 3 4 3 2 2 3 3 2 2 1 1 w 4 6 6 6 7 4 4 4 2 3 2 1 1 2 2 2 1 0 0 w 5 3 3 4 4 4 2 2 0 2 1 0 0 1 1 1 0 0 0 w 6 4 4 4 4 2 4 3 2 2 1 1 1 1 1 1 1 0 0 w 7 3 4 4 4 2 3 4 2 3 2 1 1 2 2 2 1 0 0 w 8 3 2 3 2 0 2 2 3 2 2 2 2 2 2 1 2 1 1 w 9 3 3 4 3 2 2 3 2 4 3 2 2 3 2 2 2 1 1 w 10 2 2 3 2 1 1 2 2 3 4 3 3 4 3 3 2 1 1 w 11 2 1 2 1 0 1 1 2 2 3 4 4 4 3 3 2 1 1 w 12 2 1 2 1 0 1 1 2 2 3 4 6 6 5 3 2 1 1 w 13 2 2 3 2 1 1 2 2 3 4 4 6 7 6 4 2 1 1 w 14 2 2 3 2 1 1 2 2 2 3 3 5 6 8 4 1 2 2 w 15 1 2 2 2 1 1 2 1 2 3 3 3 4 4 5 1 1 1 w 16 2 1 2 1 0 1 1 2 2 2 2 2 2 1 1 2 1 1 w 17 1 0 1 0 0 0 0 1 1 1 1 1 1 2 1 1 2 2 w 18 1 0 1 0 0 0 0 1 1 1 1 1 1 2 1 1 2 2 table 3 the 18 × 18 womentowomen matrix m w aa t associated with the dgg network is shown the i jentry of m w is the number of events which both w i and w j attended for i j the i jentry of m w represents how many meetings w i attended shown in figure 3 the hierarchical structure of these networks found in section 41 are computed using the rule µ also described in section 41 m                       0 a 12 a 13 a 1n a 21 0 a 2n a n11 0 a n1n a n1 a n2 a nn1 0                       where the transpose a t i j a ji for each i j the matrix m converted to its imode over its jmode is the matrix m i j a i j a ji hence there are n2 different ways of converting m into the single mode matrix m i j each of which corresponds to a network which can be isospectrally reduced using any rule that is deemed useful isospectral network reductions the tool used throughout this paper to reduce different variations of the full dgg network is the method of isospectral reductions this theory has been previously applied to the analysis of network stability survival properties in open dynamical systems and to gain improved eigenvalue estimates of matrices to name a few useful applications in this paper we have used these techniques to find the hierarchies and specifically the cores of the dgg and its associated networks although these techniques can be applied to any network of interest including the singlemode conversion of multimode networks described in the previous section in this section we formally describe an isospectral reduction of a network because a graph and its adjacency matrix are equivalent ie one can be found from the other an isospectral network reduction can be described as an isospectral matrix reduction which is easier to describe than the equivalent notion of an isospectral graph reduction suppose that m is the n × n e 1 e 2 e 3 e 4 e 5 e 6 e 7 e 8 e 9 e 10 e 11 e 12 e 13 e 14 e 1 3 2 3 2 3 3 2 3 1 0 0 0 0 0 e 2 2 3 3 2 3 3 2 3 2 0 0 0 0 0 e 3 3 e 11 0 0 0 0 0 1 2 1 3 2 4 2 1 1 e 12 0 0 0 0 0 1 4 5 5 5 2 6 3 3 e 13 0 0 0 0 0 1 2 2 3 3 1 3 3 3 e 14 0 0 0 0 0 1 2 2 3 3 1 3 3 3 table 4 the 14 × 14 eventtoevent matrix m e a t a associated with the dgg network is shown the i j th entry of m e is the number of women who attended both events e i and e j in the case that i j then the i j th entry of m e is the entry representing how many women attended e i adjacency matrix associated with a network given a subset s of the networks nodes the goal is to reduce this network to a smaller network whose nodes are the set s and whose adjacency matrix denoted by r s has the same eigenvalues as the original matrix m this can be done as follows for an n × n matrix m let n 1 n if r and c are subsets of n let m rc be the r × c submatrix of m with rows indexed by r and columns indexed by c for a subset s of n we let s be the compliment of s in n then the isospectral reduction of m over the set s is the s × s matrix r s m s s m s s 1 m s s where λ is a parameter needed to preserve the spectral structure of the matrix under reduction that is we reduce the network given by a graph g associated with the matrix m to the smaller network given by the graph r s associated with the matrix r s which is given by the importance of the set s is that it corresponds to the nodes that remain in the network after the network is reduced the nodes s are those nodes that are removed from the network as it is reduced it is worth noting that the set s can be any subset of the networks nodes so long as s is not empty in our main example the node set over which we reduced the dgg network were those nodes that did not have minimal degree which we referred to as using the rule µ this was also the rule used to create hierarchies of the singlemode versions of the dgg network the way in which the core of a network is found is by sequentially reducing the network over a specific rule once a network is reduced with respect to some rule it can again be reduced with respect to the same rule this sequence of reductions stops once an additional reduction does not modify the graphs structure this happens precisely when the nodes s chosen by a given rule happen to be the entire node set of the network or the empty set the importance of this set s is that it forms the core of the network with respect to the chosen reduction rule the consecutive reductions of a network supply us with additional information since those nodes that are reduced after a number of reductions can be viewed as more important to the network than those that are immediately removed this allows us to create a hierarchy of nodes based on this sequence of reductions moreover by combining isospectral reductions with the method described in section 41 it is possible not only to find the hierarchical structure of a network but to find the hierarchical structure of a single mode of an nmode network since there are n 1 ways to reduce an nmode network to its ith mode the cores of each of these reductions can be compared with each other with respect to any reduction criteria e 3 e 1 e 4 e 7 e 9 e 6 e 8 e 11 e 12 e 10 e 13 e 14 w 1 1 1 1 1 1 0 1 1 1 w 2 1 1 1 1 0 1 0 1 1 w 3 1 1 1 0 1 1 1 1 1 w 4 1 0 1 1 1 1 0 1 1 w 5 1 0 1 0 1 1 0 0 0 w 6 1 0 1 0 0 0 0 1 1 w 7 1 0 0 0 0 1 0 1 1 w 9 1 0 0 0 0 1 1 0 1 w 10 1 1 0 1 0 1 0 0 0 w 11 0 1 0 1 0 1 1 0 0 w 12 0 1 0 1 0 1 1 1 1 w 13 1 1 0 1 0 1 1 1 1 w 14 1 1 1 0 1 1 1 1 1 w 15 1 0 0 1 1 1 1 0 0 w 17 0 1 0 0 1 0 0 0 0 w 18 0 1 0 0 1 0 0 0 0 w 8 0 1 1 1 w 16 0 1 0 1 dynamics the topology of most real networks are inherently dynamic in that they evolve and change over time in social networks these structural changes occur as a result of the formation or the dissolving of relationships the topology of the dgg network is dynamic in that each time there is an event the network grows specifically at each new event new nodes are added to the network which represent the event and any individuals that attended an event for the first time the edges added to the network after each event indicate which individuals attended this event bergerwolf and saia have previously studied the dynamics of this network using metagroups in their study the authors investigated the networks dynamics by chronologically ordering the networks events and analyzing how the similarity between two events e i and e j evolves over time where the similarity is measured by the generalized jaccard measure similarly we begin our analysis by first restricting our attention to the set of events e 1 e 2 and then to the joint events j we then order the events within these sets chronologically as shown in table 5 as can be seen in the table groups g 1 and g 2 who participated in events e 1 and e 2 respectively demonstrate behaviors that are quite different in particular the women in the first group g 1 all attended their first group meeting e 5 but thereafter the groups total attendance to the group meetings forms an oscillating pattern given by the sequence 8 3 6 3 4 in contrast the second group g 2 shows an essentially monotone decline in total attendance after it peaks at their second meeting at six attendees the number of total attendance for this second group at each event is given by 4 6 5 3 3 notably at the joint meetings members of the groups g 1 and g 2 also demonstrate distinct behaviors the total attendance of g 1 at each of the joint meetings given by the sequence 6 3 6 7 has an average of 55 and a variance of 3 in contrast the total attendance of g 2 at each of the joint meetings given by the sequence 4 7 1 5 had a lower average of 425 and a higher variance of 625 indicating that the individuals in g 2 attended the group meetings less frequently and were more sporadic in their attendance the two individuals in the third group g 3 w 8 w 18 are distinguished from the other members of the dgg network in that they only attended the joint meetings in fact speaking chronologically both women missed the first event and attended the second and fourth events of the joint meetings the only difference in their attendance is that w 8 attended the third meeting while w 16 did not discussion in this paper we have analyzed both the dynamics and structure of the dgg network to analyze the structure of this network we have employed the method of isospectral network reductions to determine the hierarchical structure of the dgg network as well as the structure of the smaller singlemode womentowomen and eventstoevents networks associated with this network this has allowed us to find the dgg networks core members and events in various ways beyond determining the core members of the dgg network this method of sequentially reducing a given network also allows us a way of ranking the importance of any network node depending on the particular criteria we use in this paper the particular criteria we use to create a hierarchy of the dgg and associated network is the rule that removes nodes with a minimal number of neighbors via the method of isospectral reductions importantly this method is fundamentally different from simply removing these nodes from the network it also adds edges between remaining nodes which preserves information regarding the nodes that were removed by sequentially removing nodes we rank their importance in that those that are removed earlier are less important than those that are removed later significantly the method is quite flexible in that any criteria for selecting a unique set of nodes from a network can be used to rank the importance of the networks nodes from the point of view of applications such a rule can be used to compare the hierarchical structure of a number of related networks eg a number of different social networks in fact various rules can be used to generate and compare different hierarchies of the same network what is important though is that such rules be designed by experts in the particular field eg sociologists so that the resulting hierarchies are meaningful acknowledgements this work is partially supported by nsf grant dms1600568 by the dod grant hdtra1150049

we employ the recently developed theory of isospectral network reductions to analyze multimode social networks this procedure allows us to uncover the hierarchical structure of the networks we consider as well as the hierarchical structure of each mode of the network additionally by performing a dynamical analysis of these networks we are able to analyze the evolution of their structure allowing us to find a number of other network features we apply both of these approaches to the southern women data set one of the most studied social networks and demonstrate that these techniques provide new information which complements previous findings

19905_0

introduction capturing a clear picture of violence against women both in numbers and in severity has proved a major challenge in social sciences because of the difficulties in accessing the affected population and the data generally being based on retrospective accounts numerous national prevalence studies 1 mainly carried out in the 90s and early 2000shave partly solved this challenge quantifying vaw and showing its social impact curiously and despite this knowledge the statistical distribution of vaw has never been taken into consideration although it might provide a deeper insight into a major social problem which is still unsolved this fact is even more surprising as powerlaw distributions are omnipresent in many human activities 2 inter alia in other violent social phenomena such as the number of casualties in wars 3 the severity of terrorattacks 4 5 or human insurgency 6 this confirms the fact that research on vaw is treated and published separately from other studies on violence slowing down the progress of scientific research and social knowledge as interand transdisciplinary synergies are rarely exploited to partly overcome this gap between different disciplines we investigate in a secondary analysis with data from the german prevalence study on vaw 7 whether the distribution of the number of times a women is victim of a certain type of violence and its severity scale can be described by a discrete powerlaw distribution materials and methods description of data set we carry out a secondary analysis with data from the research study health wellbeing and personal safety of women in germany 7 it was the first representative survey on vaw in germany forming part of the national action plan published in 1999 by the german federal government to combat vaw the representative study is based on 10264 interviews conducted nationwide from february until october 2003 with women aged 16 to 85 residing in germany the data was drawn from a basic representative sample the rate of yield in the gross random sample adjusted for neutral omission amounted to 52 the average age of the interviewees is 467 years and the age distribution of the whole sample including all women and the subsample of women experiencing violence at least once is shown in figure 1 the subsample includes all women who declared to be a victim in at least one of the questions studied in the current article the women were interviewed extensively as to their experiences with violence their feelings of personal safety and their psychosocial and physical health situations following other international prevalence studies 8 9 the data were collected in a twostep approach to better illuminate grey areas related to sensitive and problematic types of violence and abuse such as sexual violence or violence occurring in family contexts and partner relationship first a standardized 6090 minutes facetoface interviews took place either in the interviewees homes or in some cases at other locations second these oral interviews were supplemented by selfadministered written questionnaires on family and partner violence completed by the interviewees themselves after finishing the oral interviews central forms of violence included in this study are physical violence sexual violence sexual harassment and psychological abuse women were first asked about their experience of each of these four forms of violence since the age of 16 by way of a generalized question in the oral interview this was followed if any abuse record was confirmed by further questions on frequency and impact of the violence victimabuser relationship and further details about the concrete situations in which it occurred physical sexual and psychological abuse were then addressed in the written questionnaire related both to violence by current or former male and female partners as well as abuse experienced in childhood and adolescence up to the age of 16 access to data set the data of the prevalence study are stored at the data archive for the social sciences gesis leibniz institute for social sciences this data archive provides data service for national and international comparative surveys making data sets accessible to interested researchers for further information on and direct access to the data set used in this study one can contact directly the data archive services data set is stored and available under the following codes za4193 for the main study and za4194 for the supplementary study description of data used in secondary analysis we limit our analysis on the frequency and severity of violence other data provided by the study such as the frequencies of other types of violence eg sexual harassment at work or the severityscales of sexual violence had to be excluded because it offers too generic fragmented or scarce information lacking precise quantitative data or including only a few items in the severitylist three different types of questions regarding the frequency of violent experience can be found in the dataset n the first group does not ask for precise numbers but for adverbs such as often occasionally rarely once and never we did not analyze these questions due to its lack of numeric precision n the second group includes binned answers about the total number of times the women have been victims of a certain type of violence in their entire lifetime in this case possible answers only include the following 7 frequency ranges never once 23 times 410 times 1020 times 2040 times and more than 40 times note that the boundaries of the ranges are overlapping eg a person being victim 10 times could correspond either in the 410 or the 1020 bin this seems to be a deficiency in the design of the questionnaire for our analysis we assume the following bins 0 1 23 410 1120 2140 40 n the third group of questions asks for the interviewees precise estimate of number of violent events suffered in figure 2 we depict three questions of the second group with the binned data and in figure 3 we show the data of two exemplary questions of the third group with open answers furthermore figure 2 refers to violent events suffered during the womens lifetime period while figure 3 shows the number of sexual abuses suffered until age 16 and of sexual violence experienced during the last year a fourth group of questions deals with the severity of violent experiences ie the specific item of violence as women are victimized by kicking slapping pushing forced sexual acts etc the possible answers are never once or several times we merged the once and several times answers obtaining dichotomist yesnodata whether the women have experienced a specific violenceitem in the context of domestic violence or physical violence the ranksize distributions of the number of women who have experienced a certain item are then the subject of analysis the questions present the following items lists to the interviewees ccdf of the number of reports per woman of physical violence partner violence and sexual violence since the age of 16 adjusted power laws have exponents 149 147 and 157 respectively the latest data point has been placed at x 80 to continue the logarithmic binning of the previous 2 bins this has been done purely for illustration and has had no influence in the reported powerlaw fits nor in the statistical test as this data bin has been omitted there doi101371journalpone0040289g002 data aggregation and overlap not all women participating answer all questions the exact size of the dataset ie the number of women who answer the questions described above is given in table 1 the table also gives the number and corresponding percentage of women who report having been victim at least once of a specific type of violence depending on the question this percentage varies between 30 of women who have experienced at least once in their lifetime physical violence and 08 who have been victim of sexual violence in the 12 months before the study the number of women who report being victim in two different specific questions is given in table 2 the types of violence asked for in the different questions are not exclusive nor is one a clear subset of another eg cases of partner violence may also reported under sexual violence or physical violence and vice versa consequently any kind of data aggregation is not possible with the current data methodological approach we investigate whether the distribution of the number of times a woman is victim of a certain type of violence can be described by a discrete powerlaw distribution that is whether the probability of being a victim x times is proportional to x 2a or more exactly whether p x 2a f where f is the generalized zeta function and x min 0 the lower bound of the powerlaw behavior the complementary cumulative distribution function or ccdf is in this case p f f the ccdf of empirical data allows to reduce the usually large fluctuations of the less frequent items in the tail of a powerlaw distribution if we furthermore approximate the discrete powerlaw distribution with its continuous counterpart we can use that p x 2a1 ie a power law with an exponent which is smaller by 1 than the exponent of the underlying distribution parameter estimation and statistical test for the datasets of group 2 and 3 we use maximum likelihood estimations as proposed by clauset et al in 2 to extract the exponent a of a powerlaw fit of the data to test the hypothesis that the corresponding distributions follow power laws we use the discrete powerlaw test proposed in 2 we fixate x min 1 for this two datasets for the datasets of group 4 we test the hypothesis that the underlying data can be described by a power law with exponent a 1 with a kolmogorvsmirnoff test note that the result of a kstest is invalid when the fitted distribution uses parameters estimated from the data however we do not perform a parameter extraction in the case of the datasets of group 4 the results of the two statistical tests are given in table 3 limitations of the data the data set is quite noisy due to its survey provenance as discussed in the vast literature on survey methods on health sexual and marketing topics 10 11 12 13 there exist specific biases related to selfreporting of negative and undesirable events such as errors based on rounding effects underreporting selection and recall processes victims often avoid recalling the negative and unpleasant events or they are not able to remember any of the violence they experienced as they suffer a complete memoryloss although there is no proof of the existence of such biases in the used data its influence can be assumed and could partly explain the noisiness of the data and the deviations of the ideal powerlaw distributions which coincide with rounded numbers such as 10 or 100 in the case of the 12 months prevalence the distribution drops towards the right as the frequency of incidents is limited through the restricted time lapse of 365 days nevertheless and until better data is available the prevalence studies give still the best insight into a little known phenomenon physical violence figure 2 not applicable the results of the ks test are only valid in the case of the data presented in figure 4 the test procedure provided by clauset et al 2 is not applicable on rank frequency distributions we fixate x min 1 if not stated otherwise doi101371journalpone0040289t003 results our results indicate that although both the frequencies and the severity of vaw resemble powerlaw distributions rigorous statistical testing accepts this hypothesis with a significance level of 01 only for the case of the victims of sexual violence during the last 12 months and with some restrictions for the severity of physical violence more exactly maximum likelihood estimation fits a power law with exponent of approximately 15 on the distribution of the number of times women are victims of physical partner or sexual violence during their lifetime figure 2 depicts in logarithmic scale the corresponding complementary cumulative distributions which show the proportion of women who report having suffered at least xtimes the corresponding form of violence the larger than expected values of the reported frequencies in the 410 times bin are the main cause that the powerlaw fits are rejected as a valid model for the underlying distribution the powerlaw approximations of the distributions of the number of times women suffer sexual abuse in childhood before the age of 16 and sexual violence during the last 12 months are steeper power laws with exponents around 18 in this case the powerlaw hypothesis is accepted for the distribution of sexual violence during the last 12 months with significance level 01 but rejected for the distribution of sexual abuse lowering the significance level to 001 would accept the powerlaw hypothesis as well in the later case the highly skewed distributions show that vaw represents a diverse and unequal social phenomenon characterized by the inexistence of a typical and average case and the frequent existence of outliers which carry most events while most are below average the steeper powerlaw coefficient for sexual violence implies that it is less likely to observe women reporting large frequencies than for the two other types of violence this might be caused by the less common and more stigmatized character of sexual violence another type of powerlaw like distribution is found in the frequencyrank distributions of the different items of domestic violence by current partners and general physical violence a kstest confirms the powerlaw fit for physical violence at a 01 significance level and for domestic violence at the 001 level if the most frequent item and the items with very low frequencies are omitted it is interesting to notice that the order of the items seems to coincide with a hypothetical ordering by severity the less severe items are more frequent and the following items are mediated by the experience of pain fear and fear of death and the use of objects and weapons such as represented by the answers n o p q and r for experienced events of physical violence during the last 12 months and n o p q r s and t for domestic violence suffered by current partner during entire relationship the distribution drops towards the left of this data this might be explained through a specific cultural bias in which violent acts such as burns or the use of weapons are less frequent as they are either known from other cultural contexts as in the first case or because of the specific german firearms law as in the second case a power law with exponent 1 is often found for word rankfrequency distributions and can be explained by optimizing the amount of information transmitted in a given language 14 recent research findings on vaw 15 describe the perpetration of gender violence as an act of normative power exerted by the aggressor on the victim through naming and defining the violent event in his own terms negating the victim any communicative power and the use of her own words the exponent 1 fits to this recent qualitative finding and supports the claim to understand vaw at least partlyas a communicative event which depends mainly on a power struggle of defining the act as violent or not discussion this is the first time that a study investigates whether vaw follows a power law we find evidence that at least the frequency distribution of experiencing sexual violence during the last 12 months follows a power law rejections of the powerlaw hypothesis for other frequency distributions may be caused by the large amount of noise and effects caused by the selfreported data like underreporting due to the victims memoryloss roundingeffects selection or recall processes of negative and undesirable events future studies which manage to overcome this limitation in the data might well find a better coincidence for the described phenomenon with power laws or related distributions consequently the way data is collected should help to reduce the noise apart from avoiding overlapping time intervals the impossibility to aggregate the data is a further inconvenient which should be ameliorated in future research furthermore although a powerlaw fit cannot be confirmed in most cases at the significance level of 01 recommend by clauset et al in 2 vaw seems to be a highly skewed heavy tailed phenomenon quantifying the increased risk of extreme victimizations while these highrisk areas are generally omitted if a gaussiandistribution is assumed as is generally done in social sciences note especially that all the exponents of the powerlaw fits reported here are lower than 2 which implies that the mean and standard deviation do not exist in a strict mathematical sense as they are infinite 16 if the power law nature of vaw were confirmed by future studies this would imply that any means and standard deviations calculated from these surveys would not have any descriptive value consequently as we raise this suspicion with our study they should not be used to compare different studies or even different instances of the same study hence our findings have a major impact on the handling of the prevalence data on vaw the discussions on standards and good practices in data collection on vaw 17 and the permanently carried out prevalence studies all around the world show the crucial importance of this new insight considering vaw from a social and systemic perspective a powerlaw resemblance especially with exponent 1would point to the specific communicative value of vaw for the victims and for society paradoxically power laws often emerge in contexts where diversity freedom of choice and preferences generate inequality and diversity while violence is generally considered a morally and legally condemnable event not getting associated with any act of preference and positive choice a possible hypothesis to explain this paradox is a specific communicative link between power and violence in a society which is characterized by power and power play power is associated with a rather positive value and as seen previously and from a constructivist point of view violence can be understood as a communicative act of power hence the existence of powerlaw distributions in vawdata would become understandable the surprising link between violent and nonviolent forms of human behaviour as discussed in 6 could be partly explained through such findings this might provide a further argument to describe the still mysterious interplay between social and hereditary factors which seem to influence womens proneness to vaw 18 and offer a new element in the vivid research on resilience factors 19 moreover the strong heterogeneity of the victimization data completely opens up new insights for policy modelling because a single and unique prevention or intervention strategy cannot cover the large variety in the different dimensions of victimizations ignoring the heavy tails of the distributions thus it should be reconsidered under this new perspective and reoriented towards specific cohorts or niches on the frecuency scale an insight which is of particular importance in times of social cuts and policy reorganization the calculation of recognized measures of diversity and statistical dispersion such as the gini coefficient 20 might offer new aspects for the analysis of resilience factors 17 all these possible insights may help policy makers to better assess the extent and distribution of vaw distinguishing the risk of different population groups 21 in order to set up specific and more adequate prevention and intervention programs in conclusion the heavy tail of vaw challenges both researchers and policy makers and opens up new perspectives for interdisciplinary cooperation

background violence against women despite its perpetuation over centuries and its omnipresence at all social levelsentered into social consciousness and the general agenda of social sciences only recently mainly thanks to feminist research campaigns and general social awareness the present article analyzes in a secondary analysis of german prevalence data on violence against women whether the frequency and severity of violence against women can be described with power laws principal findings although the investigated distributions all resemble powerlaw distributions a rigorous statistical analysis accepts this hypothesis at a significance level of 01 only for 1 of 5 cases of the tested frequency distributions and with some restrictions for the severity of physical violence lowering the significance level to 001 leads to the acceptance of the powerlaw hypothesis in 2 of the 5 tested frequency distributions and as well for the severity of domestic violence the rejections might be mainly due to the noise in the data with biases caused by selfreporting errors through rounding desirability response bias and selection biasfuture victimological surveys should be designed explicitly to avoid these deficiencies in the data to be able to clearly answer the question whether violence against women follows a powerlaw pattern this finding would not only have statistical implications for the processing and presentation of the data but also groundbreaking consequences on the general understanding of violence against women and policy modeling as the skewed nature of the underlying distributions makes evident that violence against women is a highly disparate and unequal social problem this opens new questions for interdisciplinary research regarding the interplay between environmental experimental and social factors on victimization

19906_0

introduction with the acceleration of urbanization in china more and more young adults leave the land to find work in towns and cities which leads to some social problems typically leftbehind children whose mother or father or both parents leave the countryside to work in towns and cities for more than 6 months are a special group of children that needs much more attention millions of children have been left behind in countryside each year and leftbehind experiences is related to many aspects of child development in shortand longterms such as behavior problems peer relationships and attention bias in light of both the basic and applied value of a clearer account of how leftbehind experiences is related to child development studies which explore pathways from family life to school life of leftbehind children need further exploration notably extensive research has suggested that leftbehind children felt much more loneliness and social anxiety than children without leftbehind experiences and loneliness was associated with social anxiety moreover a growing body of studies have indicated that selfesteem was related to loneliness and social anxiety however few studies have explored relationships between loneliness at home social anxiety at school and selfesteem in leftbehind children the attachment theory posits that patterns of relationships between parent and child may be generalized to other relationships or situations which may provide a framework for exploring studies in leftbehind children specifically lack interactions between parents and leftbehind children may contribute to high levels of loneliness at home which may influence the levels of selfesteem and in turn lead to high levels of social anxiety at school therefore we attempt to explore pathways from loneliness at home to social anxiety at school and to examine roles of selfesteem in those pathways in chinese leftbehind children the relationships between loneliness and social anxiety loneliness is an enduring condition of emotional distress which influenced by lacking interactions and supports withfrom parents or others leftbehind children may have less interactions with parents and other family members may not provide psychological supports for children which may contribute to high levels of loneliness social anxiety as a developmental maladaptation contains emotional and behavior problems such as over anxious about communicating with strange others which typically occurs in earlyto midadolescence leftbehind children may suffer high levels of social anxiety during childhood meanwhile associations between loneliness and social anxiety in leftbehind children have been explored by a growing body of studies for example duan found that loneliness was positively associated with social anxiety in 187 chinese leftbehind children wang and yao confirmed these results in 442 chinese leftbehind children children with leftbehind experiences have less interactions with parent which may contribute to loneliness at home and loneliness in family life may spread to school life which may increase the levels of social anxiety at school however few studies have explored relationships between loneliness at home and social anxiety at school in leftbehind children therefore the current study attempts to explore relationships between loneliness at home and social anxiety at school in a sample of chinese leftbehind children we hypothesize that loneliness at home is positively associated with social anxiety at school in a sample of chinese leftbehind children selfesteem as a mediator the relationships between loneliness and selfesteem have been explored by a growing body of studies for example li l et al found that loneliness was negatively associated with selfesteem in a sample of chinese children song et al also found loneliness was negatively associated with selfesteem in a sample of chinese leftbehind children and chen and yu confirmed these relationships in a sample of overseas chinese leftbehind children moreover some studies have found relationships between selfesteem and social anxiety for example wu et al found that selfesteem was negatively associated with social anxiety with a sample of chinese high school students you et al confirmed these relationships based on a sample of chinese college students meanwhile wang et al reported selfesteem was negatively associated with social anxiety in chinese leftbehind children although the associations between loneliness selfesteem and social anxiety have been explored by previous studies few studies have explored roles of selfesteem in the relationships between loneliness and social anxiety particularly in a sample of chinese leftbehind children leftbehind children may have less interactions with parents that may contribute to high levels of loneliness at home which may contribute to low levels of selfesteem and these low levels of selfesteem may spill over to school life which contribute to high levels of social anxiety at school we hypothesize thus that selfesteem mediates the relationships between loneliness at home and social anxiety at school in chinese leftbehind children the current study although the associations among loneliness social anxiety and selfesteem have been explored by extensive studies pathways from loneliness at home to social anxiety at school in chinese leftbehind children need further exploration moreover leftbehind children is an important issue for social development in china which may raise the importance for exploring chinese leftbehind children therefore the current study attempts to explore relationships between loneliness at home and social anxiety at school and to examine roles of selfesteem in those relationships in a sample of chinese leftbehind children which may confirm the spillover effects of family life we hypothesize that loneliness at home is positively associated with social anxiety at school and selfesteem mediates relationships between loneliness at home and social anxiety at school among chinese leftbehind children frontiers in psychology 03 frontiersinorg materials and methods measures childrens loneliness scale the cls developed by asher et al is a 16item selfreported scale used to access loneliness for children the way of scoring each response is a 5point scale individuals who get high score of this scale may have high levels of loneliness the chinese version of cls was administered in the current study to access loneliness at home and the cronbachs alpha of this scale was82 in the present study according to the item parching which is used to make better fit for the models the scale of loneliness was to broken into 4 parts based on factor analysis loneliness 1 loneliness 2 loneliness 3 and loneliness 4 social anxiety scale for children the sasc is a 10item selfreported tool to access social anxiety for children including subscales of fear of negative evaluation and social avoidance and distress the way of scoring each response is a 3point scale individuals who get higher scores may suffer higher levels of social anxiety the chinese version of sasc was administered in the current study to access social anxiety at school and the cronbach alpha of this scale was73 in the present study rosenberg selfesteem scale the ses developed by rosenberg is a 10item selfreported questionnaire used to access selfesteem in this study participants were asked to rate each item on a 4point scale ratings were averaged to form a total score on this measure and individuals who get higher scores have higher selfesteem the chinese adaption of the ses was administered in the current study and the cronbachs alpha of this scale was73 in the present study covariate variables the demographic variables of participants were controlled using regression analysis during the data analysis such as gender grade the number of children in the family leftbehind type parents education years and family income procedure there were several steps to conduct the current study first the first author chose two primary schools in jiangsu province with a convenience sampling and then presented aims and processes of the current study to the headmasters and received their permission to conduct the current study in their schools second the first author randomly chose two classes for fourth fifth and sixth grade respectively in each primary school and totally 12 classes were recruited in the current study third a total of 303 leftbehind children finished the questionnaires within 20 min and all of leftbehind children caregivers and teachers signed informed consent before data collecting process all participants have a right to decline participation without any negative influences finally participants received a small gift worth 5 rmb the study was also approved by the ethics committee of the authors institution and materials and process in the current study were safe for participants data analysis before data analysis normality missing values and outliers were examined and the questionnaires with missing data results descriptive analysis descriptive statistics and correlations are presented in table 2 loneliness at home was positively correlated with social anxiety at school selfesteem was negatively correlated with loneliness at home and social anxiety at school additionally the common method variance did not influence the result in the current study the relationships between loneliness at home and social anxiety at school average scores were used to determine structures of loneliness at home social anxiety at school and selfesteem and all coefficients were standardized estimates sem was used to make a direct model which to measure relationships between loneliness at home and social anxiety at school the results indicated that loneliness at home was positively associated with social anxiety at school in leftbehind children all model fit indexes were acceptably mediating effect of selfesteem in relationships between loneliness at home and social anxiety at school the mediation analysis has two steps according to wen and his colleagues one step is to develop a direct model the second step is to develop a mediation model which input the mediator into the direct model as we had noted above the direct model between loneliness at home and social anxiety at school in leftbehind children was verified then the mediation model was developed with bootstrapping method biascorrected percentile method the sem results showed that structural models provided acceptable good fit to the data and the sem results indicating relationships between variables are presented in figure 1 in the mediation model loneliness at home was positively associated with social anxiety at school and negatively associated with selfesteem selfesteem was negatively associated with social anxiety at school the results of biascorrected percentile method showed that the 95 confidence intervals of indirect effects was 002 010 and the 95 ci of direct effects was 031 049 selfesteem partial mediated relationships between loneliness at home and social anxiety at school among leftbehind children discussion the current study explored relationships between loneliness at home and social anxiety at school and examined roles of selfesteem in those relationships in a sample of chinese leftbehind children which may broaden studies of leftbehind children and provide suggestions for protecting leftbehind children the results showed that loneliness at home was positively associated with social anxiety at school and selfesteem partial mediated those relationships in chinese leftbehind children the results showed that loneliness at home was positively associated with social anxiety at school in chinese leftbehind children which were consistent with previous studies variables m sd 1 2 3 which may estrange themselves from others at school in turn may increase the levels of social anxiety in school lives meanwhile according to attachment theory leftbehind children who have less interactions with parents may have biased attachment patterns which may influence internal working models about self and others and resource control strategies in turn contribute to high levels of social anxiety at school these findings suggest that experiences in family such as leftbehind experiences may influence individuals school life moreover the results showed that selfesteem partial mediated relationships between loneliness at home and social anxiety at school in chinese leftbehind children which were in lined with our hypothesis less interactions with parents may contribute to high levels of loneliness in leftbehind children and leftbehind children with high levels of loneliness may feel high levels of personal discrimination which may contribute to low levels of selfesteem and these levels of selfesteem may increase the levels of social anxiety at school life further interactions with parents may influence development of selfesteem which suggests that leftbehind experiences may impair selfesteem and the impaired selfesteem may contribute to high levels of social anxiety at school these findings suggest that loneliness not only has direct effects on social anxiety but also has indirect effects on it via selfesteem in chinese leftbehind children the implications of these findings are significant underscoring the role selfesteem involved in adjustment of leftbehind children and pointing to potentially modifiable mechanisms specifically increasing the levels of selfesteem may reduce levels of social anxiety at school in leftbehind children for example teachers may give more supports for leftbehind children which may raise their skills for interpersonal communication moreover strengthening relationships within peers may increase selfesteem of children with leftbehind experiences additionally we should pay attention to leftbehind children and call for parents giving children the high quality of companion several limitations should be acknowledged in this study first selfreported scales were only used to measure all variables in the present study which may contribute to the biased information from the participants several approaches should be applied to collect data in future research to ensure the accuracy of the information such as experiments questionnaires or interviews second crosssectional design was used to examine relationships between loneliness at home and social anxiety at school which may not verify the relations causally longitudinal studies should be conducted to confirm the relationships between loneliness at home social anxiety at school and selfesteem third the current study did not compare outcomes of children based on kinds of leftbehind which may ignore the differences in outcomes based on kinds of leftbehind future studies should take leftbehind types into consideration and provide efficient strategies for protecting leftbehind children conclusion the current study explored relationships between loneliness at home and social anxiety at school and examined roles of selfesteem in those relationships in a sample of chinese leftbehind children the results showed that loneliness at home was positively associated with social anxiety at school and selfesteem partial mediated those relationships in chinese leftbehind children findings suggest that loneliness not only has direct effects on social anxiety but also has indirect effects on it via selfesteem in chinese leftbehind children for example the government and schools may use strategies to increase levels of selfesteem in leftbehind children which may decrease levels of social anxiety at school moreover the current study may also broaden the studies of chinese leftbehind children that combination of family and school life which may provide relative new perspectives for the field of study data availability statement the original contributions presented in the study are included in the articlesupplementary materials further inquiries can be directed to the corresponding author ethics statement the studies involving human participants were reviewed and approved by beijing normal university written informed consent to participate in this study was provided by the participants legal guardiannext of kin publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher supplementary material the supplementary material for this article can be found online at fpsyg20221014794full supplementarymaterial

although research examining loneliness and social anxiety has been conducted few studies have explored pathways from loneliness at home to social anxiety at school in chinese leftbehind children the study attempts to explore associations between loneliness at home and social anxiety at school and to examine roles of selfesteem in those relationships among a sample of chinese leftbehind children date were collected from 303 leftbehind children aged 1014 years and the chinese versions of childrens loneliness scale social anxiety scale and rosenberg selfesteem scale were used to measure loneliness at home social anxiety at school and selfesteem respectively results showed that loneliness at home was positively associated with social anxiety at school selfesteem played a partial mediation role in associations between loneliness at home and social anxiety at school findings suggest that high levels of selfesteem may influence pathways from loneliness at home to social anxiety at school in chinese leftbehind children and increasing levels of selfesteem may be used in preventions for loneliness of chinese leftbehind children

19907_0

outcomes differ between ethnic groups with the most socially disadvantaged groups being most at risk what this study adds this paper finds an association between maternal financial strain and risk of preterm birth that is as high as that for smoking it also suggests that there is a difference in risk factors between ethnicities preterm birth is a major cause of neonatal and infant mortality and morbidity in high income countries there has been minimal decline in the rate of preterm birth in the last few decades 29 small for gestational age is also associated with an increased risk of perinatal mortality and morbidity and poor long term health outcomes such as obesity hypertension and other cardiovascular diseases 49 the consequences of these poor perinatal outcomes present a significant public health issue requiring an exploration into primary prevention the highest rates of ptb and sga occur in the most socially disadvantaged groups within the population 30 in the united kingdom south asian mothers have a slightly higher rate of preterm birth compared to white british mothers and their babies are twice as likely to be born with a low birthweight 21 known risk factors for sga and ptb include smoking alcohol use diabetes hypertension maternal age and body mass index 131527 previous studies have suggested that maternal psychosocial health may also be associated with ptb and sga 22 it is unclear however whether these associations are specific to the particular populations studied or if they are generalizable to other population groups the development of appropriately targeted prevention strategies requires more analysis of relevant population groups our primary aim was therefore to explore ethnospecific risk factors for ptb and sga in particular in relation to psychosocial health within an urban multiethnic socially disadvantaged cohort methods born in bradford is a longitudinal multiethnic community birth cohort study which aims to examine how environmental psychological and genetic factors impact on maternal and child health and wellbeing 35 recruitment took place between 2007 and 2010 at the bradford royal infirmary all women who attended a routine glucose tolerance test were invited to take part in the study and written consent was obtained baseline data were collected through an interview administered questionnaire held in a designated room there were three phases of data collection with slight variants to the baseline questionnaire with the general health questionnaire 28 12 being administered in phases 2 and 3 the interviews were conducted in english mirpuri or urdu the questionnaire covered a wide range of socioeconomic questions regarding financial security and lifestyle factors it also included items from the ghq28 a commonly used screening tool for psychological distress 12 over 80 of women who attended the clinic were recruited and the cohort is broadly representative of the citys maternal population 35 ethics approval for the data collection was granted by bradford research ethics committee dependent variables ptb was defined as birth occurring at less than 37 weeks gestational age based on the estimated date of delivery calculated by the dating scan or last menstrual period sga was defined as a birthweight less than the 10th customised centile using grow software from 2013 htm 8 these categorisations were derived from maternal characteristics birthweight and gestational age data recorded in the electronic maternity system at the bri independent variables information on diabetes hypertension parity and body mass index came from eclipse and the remaining data from the baseline questionnaire data on diabetes status at booking and any subsequent diagnosis of gestational diabetes were combined to form one binary variable defining diabetic status data on hypertension status at booking subsequent pregnancyinduced hypertension and or preeclampsia were combined in the same way we calculated bmi using weight and height at first booking and created categories based on the who criteria 31 underweight normal overweight and obese although there is suggestion that ethnic specific bmi categories might be a more appropriate measure of obesity 32 it has been found in this cohort that lowering the bmi obesity threshold for south asian women does not improve the predictive ability to identify adverse pregnancy outcomes 6 conventional categories were therefore applied the definition of ethnicity in bib was based on the uks 2001 census categories and comprised a question asking which ethnic group the mothers considered themselves to belong to we then classified women as white british pakistani or other ethnic origin for those women completing the baseline questionnaire in english the ghq28 was administered as part of a selfcompletion module at the end of the interview for participants enrolled during phases 2 and 3 for those who chose to have the interview in mirpuri or urdu the questions were read aloud and the interviewer coded the response we did not create a summary score threshold for distress because the measurement properties of the ghq28 may not be equivalent between ethnic groups in this cohort 10 instead we scored the instrument using the ghq methods 2526 and derived two indicators of distress first we used a nonparametric threshold to indicate women at risk of distress using the first 21 questions and set this at the 85th centile score within each ethnolanguage group second we took four out of the seven questions from the severe depression subscale of the ghq28 which have been found to broadly relate to the same concept across ethnolanguage groups 2526 and created an indicator which we term hopelessness more than 35 of south asian women in bib did not know or did not report their household income but they were much more likely to answer questions on financial security how well would you say you or you and your husbandpartner are managing financially these days we categorised those who reported living comfortably doing alright or just getting by as financially secure and those who responded finding it quite difficult or very difficult as struggling financially financial security has a psychosocial meaning that goes beyond material wealth and involves the extent to which the respondent perceives their income to be enough for the family cost of living we created a binary indicator of area deprivation from national quintiles of index of multiple deprivation classifying those in the most deprived quintile against all others in line with other studies marital status was classified as a binary variable married and not married 28 the binary variable for education compared those with fewer than 5 gsces unknown or equivalent qualification that could not be classified with those who achieved 5 gcses or higher we also generated binary variables for smoking and drinking alcohol at any time during pregnancy missing data in this analysis we included 9680 singleton nonanomalous births where the mother completed the baseline questionnaire and gave birth at the bri we used the data from the first enrolled pregnancy for women who enrolled in the study more than once during the recruitment period we did not analyse data from 72 women for whom the language in which the questionnaire was administered was not stated and where we also had no data on ethnicity nearly onethird of women were missing at least one covariate which we assumed were either randomly missing or missing dependent on observed covariates to utilise the entire sample with corrected variance we imputed missing covariate data using chained equations as implemented in stata 13 we included all covariates and outcomes in our imputation model along with design variables for the risk of distress variable we performed a simple imputation for those missing up to 4 items we included these along with respondents who had completed all the ghq28 data and categorised risk of psychological distress as a binary variable for all these respondents combined we set those missing 4 or more ghq28 responses to zero and performed multiple imputation on both these cases and those with all scores missing of all the participants in this category 812 were enrolled in phase 1 where the ghq28 was not presented for the risk of hopelessness variable we categorised risk on all complete cases and imputed risk as a binary variable for all others for the overall model we imputed on the whole dataset and included ethnicity as a variable during the imputation process statistics we tabulated sociodemographic status by ethnic group we then fitted unadjusted logistic regression models for the association between a covariate and each outcome of interest for the sample as a whole and stratified by ethnic group we then fitted fully adjusted multivariate models for the whole sample and also stratified by ethnic group we calculated odds ratios with 95 confidence intervals and p values set at 005 for statistical significance in this paper we present models based on the imputed dataset we ran all models again using data from complete cases finding results broadly similar to the imputed models results participant demographics the demographic characteristics of the cohort are shown in table 1 with 40á6 reporting to be white british 44 pakistani and 154 other ethnicity the overall rate of ptb was 5á4 a lower proportion of pakistani women experienced ptb compared to either white british or other ethnic groups the rate of sga at 16 was higher than the 10 baseline and was similarly raised within each ethnic group more than 20 of the cohort was classified as obese with the highest rate being amongst white british women a disproportionate number of women lived in the most deprived quintile as defined by the imd including 79á6 of pakistani women and 50á9 of white british women almost 17 of women smoked at some time in the pregnancy again with a considerable difference seen between white british and pakistani women diabetes was more prevalent amongst pakistani compared to white british women whereas hypertension was slightly less prevalent fewer white british women were at risk of hopelessness compared to either pakistani or women of other ethnicities more than 10 of all participants felt that they were behind with their bills and 7á6 reported that they were not managing financially small for gestational age univariate and multivariate analyses for the whole cohort are presented in table 2 the evidence found that a number of psychosocial factors were associated with increased risk of sga on univariate analysis these associations however were not sustained after full adjustment for other variables in multivariate analysis hypertension and smoking in pregnancy were both associated with a more than twofold increased risk of sga and pakistani ethnicity was found to be associated with a 50 increased risk of sga diabetes on the other hand was found to be protective of sga in addition in multivariate analysis women who were at risk of mental distress were found to have a 20 reduced risk of sga preterm birth there was evidence that diabetes and hypertension in pregnancy were associated with a significantly increased risk of ptb also being underweight and smoking in pregnancy were found to be positively associated with risk of ptb a number of socioeconomic factors showed univariate association with increased risk of ptb living in the most deprived quintile and having less education remained significantly associated after adjustment for potential confounders furthermore women who reported that they were not managing financially were found to have a 45 increased risk of ptb stratified analysis white british for white british women risk of distress was not found to be positively associated with risk of sga however for those who smoked there was an almost threefold increased risk smoking was also shown to be associated the bold represents significant results with ptb although the strength of association was not as strong in multivariate analysis obesity in white british women was found to be protective for ptb pakistani in pakistani women risk of distress was found to be protective of sga this association persisted after full adjustment there was little evidence of an association between other psychosocial factors and sga smoking diabetes and hypertension were all found to be positively associated with increased risk of preterm birth other ethnic groups for women of other ethnic origins hypertension smoking in pregnancy and living in the most deprived quintile were all associated with an increased risk of sga migrating to the united kingdom after the age of 16 was found to be protective of sga hypertension in pregnancy and being underweight were both strongly associated with increased risk of ptb for this group with no other factors reaching statistical significance discussion this study provides an insight into different factors that impact on perinatal outcome in an ethnically diverse and economically deprived population overall there was a lower than expected rate of ptb in the cohort compared to the national average 24 this may have been in part due to recruitment taking place at around 2628 weeks gestation excluding women who went into extreme preterm labour and the exclusion of multiple pregnancies from the analysis conversely there were a greater proportion of sga babies than the national average for the uk population the higher rate in this sample possibly reflects the high prevalence of risk factors associated with sga within the pregnant population of bradford as a whole bradford is a socially deprived city with twothirds of the population living in the most deprived quintile as defined by the nationally derived imd this study is consistent with other that have described an association between hypertension in pregnancy and both sga and ptb within all ethnic groups 2 in line with other studies which have suggested that diabetes in pregnancy increases the risk of indicated preterm birth we also found an association between diabetes and ptb 37 the bold represents significant results our findings showed a significant association between financial strain and risk of ptb with a similar degree of association to smoking financial concerns have been shown to be independently associated with an increased risk of psychological distress in pregnancy 2526 although social deprivation has long been associated with poor perinatal outcome 7 no other studies have examined the subjective assessment of financial management and perinatal outcomes the report by the royal college of paediatrics and child health highlights the role of poverty and in particular social inequality in increasing the risk of poor perinatal and infant outcomes 34 the relationship between poor psychological health and adverse perinatal outcomes in particular ptb is becoming an area of increasing interest 16 women who show signs of depression as assessed by the edinburgh postnatal depression scale have been found to have an increased risk of ptb and sga 19 a recent international cohort study also noted an association between stress and anxiety in pregnancy and an increased risk of sga 17 the apparently protective effect of maternal distress on risk of sga in the pakistani cohort is surprising particularly as it was not evident on univariate analysis an explanation for this may be that the ghq28 does not identify maternal distress well at this stage in pregnancy that there are different cultural norms in the way the distress is described or that it is a chance finding the other variable we derived from the ghq28 showed trends in the expected direction and although we did not use a validated measure of hopelessness and there is likely to be variation in the relationship between hopelessness and mental disorder there is alignment between the two 536 a protective association was found between obesity and ptb amongst white british women in this study but not within the other ethnic groups previous studies have shown different findings with regard to the association between obesity and ptb with some indicating an increased risk 37 and others a lower risk 18 it may be that the risks are population specific relating to different pathophysiological pathways with a reduced risk for spontaneous ptb and an increased risk for indicated ptb 23 therefore when adjustments are made for related factors such as hypertension and diabetes as in this study the protective effect of being obese but healthy is more clearly visible than in other studies where reasons for indicated prematurity may not have been excluded from the adjusted analyses the bold represents significant results smoking is a wellestablished known risk factor for increased risk of sga 15 a high proportion of white british women smoked at some stage in their pregnancy and this was found to be the most significant risk factor for sga amongst this population rr 278 however in the pakistani population no association was found rr 111 migration after the age of 16 was also found to be protective of sga for nonpakistani ethnic groups a healthy migrant effect which suggests that babies born to foreignborn women may have better outcomes than those born to nativeborn women has been previously described and debated 333 and may relate to differences in health behaviour amongst newer migrants 14 the findings from this study reinforce the need for careful analysis of the ethnic geographic and socioeconomic context of the populations observed strengths and limitations this was a large multiethnic cohort study which was shown to be representative of the population of bradford as a whole data were collected prospectively and linked datasets allowed for the collection of relevant perinatal outcomes this allowed us to control for a wide range of covariates although a number of perinatal outcomes were captured it was not possible to distinguish between spontaneous and medically indicated preterm birth which limited detailed analysis of specific risk factors in addition there were a number of missing data particularly relating to the ghq28 and the process of imputation may have impacted on the findings although when we ran models using only those with the complete dataset the findings were not significantly altered a further limitation to this study is that responses to the ghq28 in multiethnic populations may vary between different ethnic groups and language of administration independent of the level of actual distress 2526 other research has reported variation in the expected psychometric properties of the ghq28 in pregnant nigerian women 1 and reduced reliability of the questionnaire when applied late in pregnancy 20 we potentially mitigated language and interpretation effects by deriving centiles from scores computed within ethnolanguage groups to categorise risk of distress and limited the risk of hopelessness variable to questions that had been shown to relate to similar concepts across ethnolanguage groups 2526 we cannot however the bold represents significant results rule out the possibility that increased measurement error due to pregnancy or our multiethnic sample or both factors affected our results conclusion this study confirms certain known risk factors for adverse pregnancy outcome however it also identifies some previously undocumented and unexpected findings this includes an association between maternal financial strain and risk of ptb that is as high as that for smoking which if generalisable has important social implications it also discerns additional relationships in specific subgroups an unexpectedly lower rate of sga in the offspring of women of pakistani origin who reported distress and a reduced rate of ptb amongst white british women who were obese there is a need for further ethnicspecific studies to understand the mechanistic pathways for psychosocial stress and poor pregnancy outcome in order to better inform public health policy

objectives preterm birth ptb and small for gestational age sga are major causes of perinatal mortality and morbidity previous studies indicated a range of risk factors associated with these poor outcomes including maternal psychosocial and economic wellbeing this paper will explore a range of psychosocial and economic factors in an ethnically diverse population methods the uks born in bradford cohort study recruited pregnant women attending a routine antenatal appointment at 2628 weeks gestation at the bradford royal infirmary 2007 2008 2009 2010 this analysis includes 9680 women with singleton live births who completed the baseline questionnaire data regarding maternal sociodemographic and mental health were recorded outcome data were collected prospectively and analysed using multivariate regression models the primary outcomes measured were ptb 37 weeks gestation and sga 10th customised centile results after adjustment for sociodemographic and medical factors financial strain was associated with a 45 increase in ptb or 145 95 ci 106198 contrary to expectation maternal distress in pakistani women was negatively associated with sga or 065 ci 048088 obesity in white british women was protective for ptb or 067 ci 045098 previously recognized risk factors such as smoking in pregnancy and hypertension were confirmed conclusions this study confirms known risk factors for ptb and sga along with a new variable of interest financial strain it also reveals a difference in the risk factors between ethnicities in order to develop appropriate targeted preventative strategies to improve perinatal outcome in disadvantaged groups a greater understanding of ethnospecific risk factors is required

19908_0

introduction within geography and the environmental humanities significant recent attention has been directed towards the concept of charisma derived from the work of geographer jamie lorimer charisma refers to the features of a particular organism that configure its perception by humans and subsequent evaluation it is a relational property contingent upon the perceiver and the context… charisma then relates to the ease with which a particular entity is perceived and the affective responses experienced by the observer upon that reception importantly charisma is significantly related to context it emerges in relation to the parameters of different technologically enabled but still corporeally constrained human bodies inhabiting different cultural contexts whether an entity is salient or silent generates strong or weak affective responses or whether those responses are positive or negative is then not entirely determined by inherent properties of the organism but rather upon by the whole ecological setting within which that organism is immersed and perceived it has been widely argued that an entitys charisma plays a crucial role in processes of knowledge production firstly charisma partially determines what comes to be studied with charismatic entities receiving the most attention secondly charisma partially determines how an entity is studied with affective responses suggesting particular courses of action finally charisma determines where entities are studied with work being undertaken in contexts where relevant properties for study are the most prominent importantly charisma is also valuable in elucidating how particular affective relations assume a consistent form and pattern within given sociotechnical assemblages and the concept has been used to this end across morethanhuman geography and the environmental humanities perhaps due to the original focus upon the nonhuman however the concept is yet to be engaged within a medical context in this article we suggest that charisma is a concept of potential utility to the social studies of medicine by showing how individualised affective encounters can be linked with larger ecological materialdiscursive and sociotechnical structures or ecologies there has been a wellrecognised turn to affect emotion and the body which has been taken up within the social studies of medicine and an increasing recognition that posthuman and nonhuman perspectives have much to offer analyses of the medical and human sciences we argue that charisma furthers these endeavours by offering a valuable route into grasping the interrelations between affect and ecology and how it is the objects of medical research come to be seen and acted upon in the manner that they are in the following sections we describe key similarities and differences between the theory of charisma being drawn upon here and max webers work on the charismatic leader with which those in the social studies of medicine may be more familiar in the body of the paper we further elucidate the proposed tripartite structure of charisma and do so with specific reference to the case of autism drawing upon interviews conducted with leading psychologists and neuroscientists we show that autism is perceived as particularly charismatic by researchers that this shapes research trajectories and that autisms charismatic features become salient within particular ecological settings1 finally in the conclusion we argue that not only does charisma offer important conceptual insight for those studying affective and contextdependent aspects of medical work but also that studying charisma within medical settings provides conceptual insight that has thus far not been achieved with geography by in particular highlighting the noninnocence of charisma differentiating weber while the conception of charisma being drawn upon here has its roots in geography and the environmental humanities the term also has a sociological lineage most notably in the work of max weber affinities with this sociological heritage are noted p 152 but it is crucial to recognise that the concept worked with here differs in significant ways given these changes it is important to note their nature and how this contemporary body of thought differs from that previously used in the social studies of health the primary concern of weber was the charismatic leader what demonstrates a leaders charismatic qualities is that the instructions they give out are not followed because of the inherent rationality of their arguments it is they who make their arguments seem believable rather than the fact that the arguments are inherently so neither are these leaders followed on the basis of tradition these individuals come to occupy powerful political positions but it is not simply on the basis of these positions that they are followed rather it is specifically personal characteristics which make a leader charismatic there are similarities between webers conception of charisma and that provided by lorimer firstly followers are drawn to the charismatic actor whether that actor is winston churchill or a particular nonhuman animal secondly lorimer like weber juxtaposes charisma with rationality just as weberians may see churchill as having something more than rational argument lorimer sees scientific or environmental work as involving more than rational problem solving finally lorimer like weber sees charisma as a valuefree term charismatic actors are not necessarily good both dictators and cockroaches have an undeniable charisma and neither will everyone respond to them in the same way a subject may be charismatic for many but not all there are however important differences between the work of weber and lorimer firstly and obviously lorimer is concerned with research subjects rather than leaders so charisma for lorimer is not about following orders secondly for weber the importance of charisma is timelimited people who seem to have charismatic authority appear primarily during periods of great unsettledness and upheaval and ultimately charisma is absorbed into the institutions of a community giving way to traditional and rational forms of authority this is not so for lorimer the charismatic qualities of actors play a permanent role in logics and epistemologies of science for weber charismatic authority is extraordinary and to be juxtaposed with the everyday forms of rational and traditional authority by contrast lorimers charisma does not give way to rational action but is rather a permanent part of the knowledge creation process this usage as well as the analytical purchase of lorimers conception of charisma should be contextualised in relation to the broader project of departing from anthropocentric epistemologies and ontologies which has been central to the environmental humanities and morethanhuman geographies affect has played a vital role in this context as a site of transspecies communication that can foster epistemic surprise by creating room for nonhuman actors to challenge or even redefine existing understandings of their capacities however although much of this work has focused on humananimal engagements it is important to note that both lorimer and other geographers who have engaged with charisma have sought a symmetrical framework that is a framework which may be readily applied to humans and nonhumans alike thus while the majority of work on charisma has examined nonhumans there is no reason why this must be the case the key question for those interested in healthcare is one of utility and not applicability in the following sections we attempt to demonstrate this utility by showing how adopting the framework offered here can aid in the understanding of how researchers act upon autism spectrum conditions as an especially informative example analysis charisma in the sense being deployed here is understood as having a tripartite structure and we here detail that structure by drawing upon data obtained through interviews with neuroscientists and psychologists who research autism autism consists of a dyad of firstly sociocommunicative impairments and secondly restricted interests and repetitive behaviours while a good deal has been written about affect in relation to autism we do not want to suggest that autism is unique amongst clinical entities in the applicability of charisma quite the contrary we are arguing for its general utility of course the charismatic qualities of autism are particular to it and we comment and draw attention to these particularities but the intention is to stress that general utility of the concept for the social study of health via its ability to make visible the highly mundane affects of medical work and to link these affective responses to broader ecological and sociotechnical structures while we encourage the division to viewed heuristically there are three different types of charisma in this framework ecological corporeal and aesthetic these forms of charisma all refer to affective relations that emerge within specific materialdiscursive assemblages in clinical settings we suggest that each form of charisma offers purchase for understanding why particular phenomena emerge and are comprehended and responded to in consistent ways across particular sites or through particular practices to the extent that they seem obvious even though in other sociocultural contexts these phenomena are not visible at all or responded to quite differently ecological charisma inside and outside the clinic an entitys ecological charisma is determined by the ability to apprehend it within a particular context thus ecological charisma relates to the anatomical geographical and corporeal properties of an organism that configure the ease with which it is perceived by a human subject in possession of all their senses organisms which are diurnal landbased and of a reasonable size will consistently be more charismatic to humans than those which are nocturnal sea dwelling and minute an entitys ecological charisma is therefore relatively stable across time and space an observation that extends to clinical entities some of which are easy to apprehend while others reveal themselves in contexts which are not suited to the medical gaze if at all this point is important despite a degree of stability ecological charisma is not a rigid feature of an entity but is instead an emergent property that arises from a structured engagement with its environment an environment which includes those who encounter and perceive that entity that some entities become easily recognisable only when they are observed within a particular context and without need for systematic diagnostic activities is well recognised in some fields and referred to as an organisms jizz comprehending an organism through a gestalt jizz requires an apprehension of a coalescence of its attributes and as part of a broader set of ecological relationships rather than through the arduous study and memorizing of an organisms distinct diagnostic characteristics this gestalt based context determined form of identification is most readily associated with plane spotting birdwatching and various subfields of botany studies have however reported similar forms of seeing within a diverse range of clinical settings shaw for example notes that a diagnostic intuition is essential to practice within a genetics clinic featherstone and colleagues capture the essence of this gestalt perception with their notion of the spectacle of the clinic noting that in any particular case a wellrespected and experienced genetic specialist has the status to pronounce on whether a look that fits a particular syndrome is present autism makes a particularly interesting case study through which to examine ecological charisma because it demonstrably requires a very particular materialdiscursive ecology to be seen but once within that ecology is particularly evident throughout interview it was simultaneously claimed that autism is both instantly recognisable and somehow eludes scientific description this we suggest is because autism is most easily seen within a particular ecology which facilitates recognition of its gestalt this is well demonstrated in the following extract from a professor when they are asked how they feel about a particular diagnostic technique the autism diagnosis observation schedule or ados which is used within their laboratory its probably the best thing weve got i mean i like the child versions better than the adult version i think that the adults that are very able that have done a lot of developing… especially the ones that come in here because they travel around on their own a lot of them live independently and i think that some of them dont meet criteria using ados and theyre clearly autistic what we are drawing attention to here is the claim that an individual can be clearly autistic and yet failed to meet criteria within a diagnostic setting the professor makes a similar point later in the interview in relation to a complaint about a lack of scientific publications concerning ageing in autism professor …i mean if you look at the number of papers that are published on adults there are really not that many interviewer and why do you think that is professor well from my experience its because well certainly on the auditory work weve done its that they dont really perform very differently to adults without autism what seems to be being described here is a struggle to make autism visible with conventional diagnostic tools which attempt to quantify the condition nonetheless the professor is in no doubt that their participants are clearly autistic understanding how an individual comes to be seen as autistic we suggest therefore requires a broader appreciation of contemporary ecologies outside of the laboratory for it is within these ecologies which autism is apparently evident the belief that autism is best seen in a social setting and that the only hope of seeing autism within the laboratory is to introduce this ecology is further considered by a lecturer below i think the problem with autism is that when youre capturing something about a social dynamic and its about somebodys abilities falling down within a social setting well experimentally thats quite difficult to replicate so i suppose the other way of looking at it is if you can think better about capturing real life in an experimental setting because theyre bad at recognising emotion when its in the context of something very dynamic thats happening in a short period of time in a real life interaction whereas if you give something and they have five seconds to work it out and its a still image theyre going to be fine so theres so much data thats contradictory and not well understood and i think a big problem is that its something about the social context that we just dont have inherent in an experimental task again within this extract the lecturer considers the possibility of capturing something about a social dynamic within a laboratory setting experimentally this social dynamic is something which is quite difficult to replicate indeed it may be that the social context is something that just isnt inherent in an experimental task understanding autism therefore requires a consideration of the ecology within which it possesses charisma for it is this charisma which makes autism evident and of interest to researchers what makes autism an interesting case is that while certain other diagnostic classifications may become evident within a technoscientific ecology it is in a broader sociocultural milieu that autism is most readily identified and acted upon yet while autism is especially striking in this regard a growing body of work has illustrated the broader applicability of this argument within patientcentred medicine for instance the domestic has gained prominence as a privileged site wherein particular disorders can not only be made visible but measurable and consistent in ways that feed back into clinical developments aesthetic charismas role in diagnosis the second and third subtypes of charisma aesthetic and corporeal charisma involve relational properties that emerge when shared structures of feeling bubble up within particular constellations of people technologies and other nonhumans these forms of charisma therefore are bound up with particular affective logics that guide how people react in relation to particular species and landscapes and we would suggest when engaging with particular clinical phenomena in specific contexts aesthetic charisma refers to entities that are visually striking and prompt strong emotional responses in those who engage with them in conservation work for instance this could refer to charismatic megafauna such as cute and cuddly pandas or fierce and deadly tigers responses that are manifested as aesthetic charisma are generated by …the distinguishing properties of an organisms visual appearance that trigger affective responses in those humans it encounters aesthetic charisma requires ecological charisma but is not determined by it the emotional responses generated by aesthetic charisma in other words are to an extent tied to an entitys ecological charisma but are mediated by particular sociocultural norms structures and settings features that may be viewed as pathological in one setting may be viewed quite differently or disregarded entirely in another aesthetic charisma also has a distinct hierarchy with entities and ecologies that generate strong emotional responses having resources directed towards them whilst lesscharismatic entities are neglected or even seen as expendable this framework thus offers scope for reflecting on the attention and resources directed towards specific medical conditions and explains why a certain actor consistently generates awe and attracts resources whilst another is ignored and marginalised as discussed previously autism is most charismatic within dynamic social contexts and far less so during attempts at quantification and measurement what is clear moreover is that when autism is seen within particular contexts it can prompt emotional and visceral reactions in researchers that prompt action these emotional responses are discussed in more detail below but are also evident in the following extracts here a postdoctoral researcher was asked …is there anything else which youd like to add or that you think weve not discussed any bits of your research which you think are interesting the response was the following one thing i did do is get a second rater to look at my videos and code them in terms of quality and quantity of facial expression use and thinks like that and he was a very proficient sign language user the children in the study were deaf and i didnt tell him which groups were which i just kept everything kind of anonymous well as anonymous as you can when youre looking at someone but he didnt know the group information at all and i asked him just out of interest can you tell me who you think is in the asd group and he was able to even though theyre not coming up as massively different in a lot of their communication he was able to say they were autistic children and they were the ones who didnt have autism so there is something that seems to be there that doesnt necessarily come up that makes you have that kind of gut instinct and i know thats only one person looking at videos but there was something i felt i couldnt put my finger on with those children you knew just looking at their communication something that comes across and ive heard this with quite a lot of people talking about individuals with autism that you just get this kind of you know but you dont know you cant really put your finger on what it specifically is key elements of aesthetic charisma are evident here tied to the above discussion on ecological charisma it is evident that autism is most charismatic sui generis and that grasping the whole renders it more than and quite distinct from the sum of its parts as discussed above this is clearly an important part of autism sciences epistemology there is this something that seems to be there that doesnt necessarily come up and you know but you dont know and this is related to a visceral emotional gut instinct this description of autisms aesthetic charisma is similar to that offered a professor who again argues that autism is instantly recognisable without recourse to particular diagnostic techniques theres no denying that within this great range of the autism spectrum theres a big chunk where autism is enormously recognisable i mean what people will say fairly flippantly is that the person in the reception can tell you whether theyre going to get a diagnosis or not or you know from seeing them walking down the street towards the reception door they can tell so theres a sort of sense that autism the core autism is really very very recognisable in this extract the professor claims that a receptionist would be able to identify correctly individuals with autism before they have spoken or before they have even entered the room this experience that autism is enormously recognisable understandably leads a great number of researchers to the conclusion that there must must be something in it again we suggest that thinking these extracts through reference to ecological and aesthetic charisma help us to understand how clinicians researchers and diagnosticians know and then act on autism such a conclusion is supported in the following extract from a further professor clinically i think there is something quite striking because it seems to be the thing that lots of us whove been involved in clinical work with children with autism for more than twenty years and research for the best part of twentyfive years clinically there is a sort of notion that when you see that constellation of developmental and behavioural characteristics together you know it seems to one like a thing it belongs in some nosological system so some notion that the medical model is demonising individuals in a way that is going to be disadvantageous to them to some sort of notion that disorders like autism are primarily a social construct are both rather silly i think i think probably most sensible people wouldnt hold either of those extreme sort of views twenty years of clinical experience leads to the conclusion that autism is a thing that to claim that autism is a social construct is rather silly and something that sensible people wouldnt think when one sees the constellation of symptoms align and once one has experienced that charisma denying its reality even in the face of diagnostic uncertainty and unquantifiability becomes untenable corporeal charisma corporeal charisma is distinguished from other forms of charisma by being generated by particular proximal encounters wherein affections and emotions are engendered by different organisms in their practical interactions with humans this form of charisma therefore engages with recent work that has shifted the focus away from the visual towards other sensory embodied experiences that produce affective engagements the primary differences between corporeal and aesthetic charisma however emerge from where the encounters take place rather than on the basis of any qualitative difference in line with an increasing body of work that has emphasised the role of the body in generating knowledge this form of charisma also plays a significant role in certain forms of expertise lorimer for instance suggests that charisma manifests itself in two different aspects of expert knowledge first there is an account of epiphany which refers to the sort of common autobiographical reference made by many of the conservationists that refers to their first moment of being affected by their future object of study he notes that these accounts are frequently made sensible through retrospective narration as shaping subsequent professional or voluntary practice while an epiphany seems to be a moment of being affected therefore framing it in terms of corporeal charisma is a means of connecting the personal to a particular pattern of response and as something that is made intelligible through future sociotechnical arrangements and a subsequent accumulation of expertise a slightly different facet of charisma dubbed jouissance is understood in terms of the more everyday forms of affective labour that are negotiated in subsequent more mundane work with a given entity that corporeal charisma plays an important role in the epistemology of autism is well demonstrated in the following extracts in the first a senior lecturer describes their first contact with autism as a teenager volunteering in a psychiatric hospital that experience of working with these children with autism stuck in my mind i just found it very very compelling and fascinating of course there wasnt nearly as much know then about autism as there is now but theres just something about the kind of mysterious nature of the way they are and i remember this is from way back when i was an undergraduate but i remember this kind of experience of having this child take me by the hand and use my hand to get things that he wanted in the second extract a professor describes one of their first experiences working with autism i went and during the summer holidays collected data for them two researchers from people with autism children mainly some adults who had extraordinary memory skills and then other children and adults with autism who were matched for ability but didnt have memory skills and so that was my first experience of really what autism was as opposed to reading about it and it really blew my mind actually how different the reality was and to go into some of the special schools and see you know a playground full of children all moving and making sounds often very unusual sounds and not usually playing together and not responding to you in the way you would expect you know and ordinary child or a child with intellectual disabilities to and its just completely fascinating and after that i thought that autism was utterly fascinating but so upsetting… these extracts are strikingly similar to both each other and to descriptions of corporeal charisma firstly these descriptions are both very much premised upon proximity the researchers cannot be there without being there and knowledge is articulated as going beyond the visual in the first instance the fact that the senior lecturer was taken by the hand and that the child used their body to achieve their goals is central to the story and an embodied empathy is core to understanding for the professor the ability to see autism was premised upon being physically in the presence of those with the condition this was crucial and contributed to the realisation of how different the reality was from what they had read in books intimately tied to this physical proximity is the affective nonrational nature of the experiences the senior lecturer refers to their meetings as being unquantifiable and emotional and as compelling fascinating and mysterious likewise the professor describes the moment of encounter as utterly fascinating but so upsetting crucially these bodily inarticulatable experiences have retroactively been made sense of on the basis of these interviewees expertise and knowledge about autism articulated as a moment of epiphany these epiphanies can be juxtaposed with the everyday experience of jouissancewhich can be seen within the affected encounters described elsewhere in the autism literature chloe silverman for instance discusses love as a form of labor in the everyday care practices and commitments that are undertaken not only by parents but also psychologists and clinicians who research autism des fitzgerald similarly foregrounds the way that the search for a neurobiology of autism is traced through the feelings and the body of the unapologetically individual and familiar autism neuroscientist it is these everyday somatic engagements coupled with moments of epiphany that constitute corporeal charisma as understood within clinical and medical settings discussion in this article and working through the example of autism we have argued that the concept of charisma has much to offer sociological studies of health and illness adopted from the work of geographer jamie lorimer which has received wide uptake within geography and the environmental humanities charisma encompasses both the ecological and the affective dimensions to a bodys behaviour and has been described as being crucial in determining how and where we come to know particular objects of investigation we have here systematically elucidated the tripartite nature of charisma as discussed in the literature through reference to autism and sought to show how charisma allows new understandings of how this contemporary diagnostic classification comes to be seen and worked on by medical and scientific practitioners as discussed studies examining charisma play close attention to affect examining the role of affect has of course been an increasing area of interest within healthcare settings with a burgeoning body of work focusing on the affective properties of individuals drawing attention to the role of corporeal relations and foregrounding affective labour what charisma offers analyses of healthcare contexts beyond these existing examples we suggest is a sense of how particular affective relations emerge as consistent patterns of response within a particular ecological setting and over time and space charisma goes beyond studies of affect therefore as it does not purely characterise affect as being a property of individual biology and wetherell for a critical discussion neither does it solely refer to the process of being affected nor can charisma be attributed to the affective environment of a particular site but rather demands that attention be paid to the entire assemblage charisma shifts the focus onto how affective relations become tangible and assume a distinct logic within particular ecological settings and marked by particular material and discursive factors the example of autism makes this broader utility clear for while existing studies have shown that autism epistemologies are radically shaped by the affective responses of parents and researchers what has not been foregrounded is that these affective responses are intimately tied to particular ecological settings this observation most readily applies not only temporally but also spatially interviewees described spaces where autism is seen and felt more readily than others strikingly the laboratory was described as a space where autism is hard to grasp whereas individuals can be seen as clearly autistic in other spaces it is not just a question however of asking what charisma can contribute when related to healthcare settings exploring the dynamics of this affective relational contextually determined account of charisma within a healthcare context also offers important conceptual elaborations first within accounts of ecological charisma at present there is an emphasis on the material and biological properties of organisms and physical environments indeed this emphasis has been reinforced by the concepts uptake across geography and the environmental humanities the broader conceptual context that underpins this relational morethanhuman account of charisma however is contingent on a collapse between the material and the semiotic sociological studies of medicine have of course long drawn attention to the importance of symbolic discursive and classificatory work and thus entanglements between the material and the semiotic seem likely to receive wellneeded attention within such settings if these concerns were fed back into accounts of nonhuman charisma in conservation contexts then further emphasis on the discursive could prove useful in asking questions about for instance the role of nationalism usevalue and other decidedly cultural constraints in contributing to the different forms of charisma attached to particular entities second while work in geography has previously discussed the noninnocence of charisma noninnocence has primarily been articulated through those who have been left behind the noncharismatic species that have been ignored in conservation efforts what healthcare settings foreground is the potential noninnocence of charisma for charismatic organisms themselves analyses of healthcare have long detailedwhether through processes of medicalisation or subjectification the ambivalence of falling under the gaze of medical professionals if medical attention is at times unwanted then charisma may be likewise analyses of charisma within healthcare settings can thus contribute to a growing body of literature which problematizes oft celebrated affective and relational engagements and draws attention to the inherent violence in carework insights from the clinic may contribute to this body of work moreover by shifting the emphasis towards the ambivalent implications of charisma for entities deemed especially charismatic capitalist animal and environmental activism her work has been published in journals including convergence subjectivity and theory culture and society about the authors greg hollin is a lecturer at the school of sociology and social policy university of leeds his work is broadly concerned with the sociology of science and medicine his research on autism has been published in history of the human sciences and social science and medicine eva giraud is a lecturer in media communication and culture at keele university her work explores the relationship between social movement studies with a focus on criticalactivist perspectives participatory methodologies and nonhierarchical communication practices and nonanthropocentric theories she is currently finishing a research monograph which discusses these themes in relation to the practices of contemporary anti

here we argue that charisma a concept widely taken up within geography and the environmental humanities is of utility to the social studies of medicine charisma we suggest draws attention to the affective dimensions of medical work the ways in which these affective relations are structured and the manner in which they are intimately tied to particular materialdiscursive contexts the paper differentiates this notion of charisma from webers analyses of the charismatic leader before detailing three forms of charisma ecological which relates to the affordances an entity has corporeal related to bodily interaction and aesthetic pertaining to an entitys initial visual and emotional impact drawing on interview data we then show how this framework can be used to understand the manner in which psychologists and neuroscientists have come to see and act on autism we conclude the article by suggesting that examining charisma within healthcare settings furthers the concept in particular by drawing attention to the discursive features of ecologies and the noninnocence of charisma

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introduction even before the onset of the covid19 pandemic prominent researchers policymakers and international bodies including the who repeatedly warned that surging vaccine hesitancy may upend decades of progress in improving child and adolescent health 1 2 3 risks associated with expanding vh are especially acute in lowand middleincome countries where disease outbreaks what is already known on this topic ⇒ vaccine hesitancy is among the biggest threats to global health and the fallout of suboptimal vaccination rates is particularly acute in lowand middleincome countries ⇒ decisions regarding childhood vaccination are commonly negotiated among caregivers intrahousehold disagreements regarding a preferred course of action can spark conflict ⇒ little is known regarding the intrahousehold decisionmaking process and the bargaining power available to household members what this study adds ⇒ based on qualitative data from the philippines we developed a framework outlining intrahousehold bargaining power when negotiating childhood vaccination ⇒ in the context of vaccination genderbased power imbalances serve as an underlying structure for intrahousehold bargaining but stakeholders can draw on a range of other sources of bargaining power to influence the decision ⇒ physical presence at the time of vaccination decision is a key source of intrahousehold bargaining power together with interest in the topic access to household resources and previous caregiving and vaccination experience ⇒ these sources of bargaining power interact dynamically and can vary between households and over time bmj global health place additional burden on alreadystrained health systems scholars have repeatedly argued that developing new and effective approaches to increase vaccine confidence requires a comprehensive understanding of factors influencing vh and the decisionmaking processes behind vaccination 3 4 5 although literature outlining individual vaccination attitudes has expanded in recent years less is known regarding how the decision to vaccinate is negotiated between individuals this is particularly problematic in the context of routine childhood vaccination where decisions commonly are not made by the vaccinated individual themselves but by childrens caregivers in such contexts conflicting opinions regarding vaccination can spark intrafamilial discussion and conflict 6 evidence suggests that within households different household roles rooted in religious cultural and gendered norms influence who has a say in deciding whether a child is vaccinated 8 9 10 factors positively influencing vaccination uptake include the fathers educational background 11 the father being the one making the decision in favour of vaccination 11 12 and higher womens empowerment 13 however the influence of different household members can vary greatly across settings pregnant mothers in morocco reported a strong influence of their families on the vaccination decision 14 while immigrant mothers in canada conveyed that their husbands played no substantive role 15 a recent metaethnography found that womens lower social status routinely manifested as a barrier for vaccination uptake including by limiting access to resources and driving fears of negative consequences 8 additionally one systematic review suggested a potential role of grandparents in the vaccination decision in part based on their firsthand experience with vaccinepreventable diseases but highlighted a dearth of literature 16 the available evidence therefore indicates different household members with various types of agency and expertise potentially influencing the vaccination decision but little is known regarding the nature of intrahousehold bargaining that underpins later vaccination decisions one qualitative study investigated parental vaccination decisionmaking in the usa but focused on the parentdyad and how parents negotiated the decision with others and less on cases where parents themselves disagreed 17 although evidence for the role of intrahousehold bargaining in the decisionmaking process for childhood vaccination is limited substantial evidence from other fields of child health highlights the key importance of bargaining between household members a study in ethiopia 18 mirroring findings from other studies in western africa 19 20 found that mothers commonly identify childhood illness but have to bargain with other household members to seek care mothers are commonly constrained in their bargaining power by structural and cultural factors constraints highlighted across studies as limiting womens bargaining power for child health are a reduced agency to access or make decisions involving financial costs as well as deeply gendered decisionmaking which often favours mens opinions over womens 10 18 21 financial agency is potentially less relevant in the context of childhood vaccines which in many settings are available free of charge at health facilities the evidence regarding extensive and often gendered intrahousehold bargaining for child health however merits attention to bargaining processes when decisions about childhood vaccination are being made considering the urgent need for novel approaches for vaccine promotion efforts understanding these bargaining processes could provide valuable insights for programme planners and policymakers including regarding potential target actors or ways to empower household members in favour of vaccination in this article we present data from a qualitative study among vaccine hesitant caregivers in the philippines to outline the power dynamics underpinning intrahousehold bargaining for childhood vaccination theoretical background the outlined literature gap with regard to intrahousehold vaccination bargaining may be linked to methodological and economical challenges for collecting intrahousehold data 22 but also to historical and from the end of the 20th century onwards heavily critiqued conceptualisations of households as unified pooling cooperatives 22 23 24 traditionally scholarship related to general intrahousehold bargaining often focused on the influence of gender and gender roles on resource allocation with a particular emphasis on male control over financial resources 25 more recent literature argues that access to resources should be seen as just one facet of power because even how this study might affect research practice or policy ⇒ researchers and implementers should consider the likelihood of intrahousehold disagreement and decisionmaking processes in their vaccine promotion efforts ⇒ application of our framework in design and implementation work would facilitate addressing actors with substantial bargaining power to consider vaccination or empowering those actors already in favour of vaccination but currently possessing limited bargaining power to enact this preference ⇒ we encourage development and testing of approaches specifically designed to leverage bargainingbased opportunities including for example efforts to encourage grandparents engagement for vaccination to invoke fathers interest in childhood vaccines or to strengthen maternal agency based on their own caregiving experience bmj global health where women can access household finances their say in how money is spent can be limited 21 scholars thus urge for intrahousehold bargaining research that reaches beneath the surface of gender inequalities to more complex interrelated dynamics 21 while several established frameworks conceptualise genderbased asymmetries 26 analytical starting points for examining intrahousehold asymmetries that extend beyond gender are limited 22 one such framework the intrahousehold disadvantages framework proposes first identifying clusters of disadvantages within a given community and then assessing via individual casestudies factors that underpin disadvantage including vulnerabilities and capabilities 22 acknowledging how all individuals possess capabilities but the balance between vulnerabilities and capabilities can vary 27 moving beyond gender the idf also considers an individuals relationship to the household head the number and birth order of children in a household disability and ill health and age as variables that can underpin power 22 based on these considerations for this article we conceptualise intrahousehold bargaining as being coined by several actors who have varying capabilities and vulnerabilities across several interrelated dimensions of bargaining power within and beyond gender methods study setting this study is part of a larger project to codevelop vaccine promotive messaging and interventions in the philippines 28 across the country routine vaccinations for children are available free of cost at government facilities as part of the national expanded program on immunization 29 although basic immunisation is formally mandatory in the philippines for all infants under a 2011 republic act 30 institutionalised repercussions on a national scale for caregivers not vaccinating their children are limited however some elementary schools require proof of routine vaccination on enrolment substituted by largescale schoolbased immunisation campaigns 31 and lowincome families aiming to obtain certain welfare benefits have to meet child vaccination and health checkup targets among other conditions 32 after a long period of high vaccine approval and vaccination rates the philippines experienced a highly publicised vaccine scare starting 2017 33 new data indicated that sanofis dengue vaccine dengvaxia which had been rolled out at schools across the country for over a year posed unknown risks for children without previous history of dengue infection 34 35 this combined with a politicisation of the ensuing discourse by several institutions resulted in a rapid erosion of trust in vaccines and vaccination uptake 33 34 leading to outbreaks of measles and polio in the country 34 36 vaccine confidence showed signs of recovery in the years prior to the covid19 pandemic 33 but pandemicassociated disruptions and public discourses as well as viral information sparked new concerns 34 additionally scholars have highlighted the particular role of social media in the philippines in the context of vaccination discourses both during the dengvaxia controversy and the covid19 pandemic 37 38 this combination of a highly publicised vaccine discourse and its fallout in a setting with traditionally high vaccine confidence coupled with vocal debates of the topic outside traditional media and the health system makes the philippines a particularly suited case to study how conflicting interests experiences and convictions inform vaccination decisionmaking within households regarding the role of bargaining in intrahousehold decisionmaking processes in the philippines scholars have highlighted how filipino households are often characterised by a comparatively large degree of egalitarianism between male and female household coheads 39 40 while a majority of available literature focuses on the relationship between female bargaining power and household finances 39 41 42 the observed role of bargaining in intrahousehold decisionmaking is likely to extend also to other contexts including to decisions regarding health and health careseeking for children data collection and analysis we conducted indepth interviews with caregivers of children whose vaccination records showed a delay or refusal of at least one routine childhood vaccine eligible participants were recruited with the help of local health workers interviews were conducted between august 2020 and march 2021 and focused on respondents vaccination experiences and narratives as well as rationales for or against vaccination members of the research team with 215 years of experience conducting qualitative research were trained for 3 days on qualitative data collection and conducted interviews following a piloted and refined semistructured guide in the context of covid19associated lockdowns we conducted interviews online after respondents provided written and videorecorded informed consent our experiences with conducting online indepth interviews and the associated challenges and mitigation approaches are published elsewhere 43 based on our experiences with online focus group discussions with a similar group of respondents which proved not to be feasible amidst a number of logistical challenges and data quality concerns 44 and as we aimed to elicit nuanced and indepth experiences from individual respondents we decided to focus on indepth interviews for the purpose of this study interviews were scheduled at a time of the respondents choosing and respondents were asked to participate from a private place they felt comfortable in due to the online nature of the interview interviewers could not always guarantee that no other individuals came into hearing distance for parts of the interviews in cases where interviewers noticed disturbances by others they bmj global health let respondents decide to continue halt or reschedule the interview no respondent preferred to reschedule or voiced privacy concerns in one case a childs father took over the interview after his wife had to leave to take care of their child this change was initiated by the mother herself and the father expressed eagerness to share his opinion about the topic taking over in the interview where his wife had left off and providing responses to the latter half of the interview questions both individuals provided informed consent and expressed no interest to reschedule and complete full interviews individually all interviews were conducted in filipino audiorecorded transcribed verbatim and translated into english in the context of routine systematic debriefings 45 held throughout data collection themes related to intrahousehold conflict and bargaining associated with the vaccination decisionmaking process emerged as highly salient after observing saturation in the context of these debriefings for themes related to intrahousehold bargaining across stakeholders the lead author inductively refined the codebook based on debriefing notes and the coding of five purposefully selected informationrich transcripts the codebook was adapted based on discussions within the team and ultimately applied iteratively to the entire dataset using nvivo v12 following the tenets of framework analysis 47 over the course of coding sources of vaccinerelated decisionmaking power emerged and codes were integrated into a working framework based on the data and engagement with the literature further information regarding the study setting and procedures are published elsewhere 28 a full coreq checklist and an author reflexivity statement 48 are included as supplemental files patient and public involvement patients and the public were not directly involved in the design of the study however following the tenets of humancentred design and qualitative research the research team consistently collected participant narratives and feedback and the results presented here give voice to these participant experiences results we conducted 44 interviews with n45 individuals interviews on average lasted 63 minutes most respondents were mothers but primary caregivers interviewed also included fathers and grandmothers respondents had an average age of 35 years and between 1 and 11 children thirtytwo respondents had at least high school education with two respondents indicating that they had received no formal education gendered authority and power formed an unequal basis on which bargaining took place among household members such as fathers and mothers but also maternal and paternal extended families several sources of bargaining power emerged which actors drew on when bargaining within households figure 1 presents the resulting bargaining and gendered authority framework structure of the framework the framework conceptualises genderassociated imbalances in bargaining power as an underlying baseline imbuing key actors with power and authority to make vaccinerelated decisions however the building blocks of bargaining and decisionmaking can reshape or refute gendered power determinants being physically present at home when a decision is made having access to resources especially monetary means possessing caregiving experience especially with regard to childhood vaccination and having inherent interest in the topic of vaccination and conviction in ones position in the figure the height of blocks represents a general tendency of power distribution within households as emerging from our respondents narratives the actual distribution of different types of bargaining power in individual households or in other contexts can vary based on the emphasis respondents placed on the different types of bargaining power in their narratives we arranged the building blocks based on their stability over time and their relevance in the vaccination context stability over time was assessed based on instances emerging from respondents accounts of the different types of power being available continuously or only in certain instances this stability is represented in figure 1 via the width and vertical order of blocks relevance of the respective source of power in the vaccination context was determined based on respondents narratives of what they perceived as being the factors frequently influencing household bargaining decisively versus factors influencing the decision only in certain situations this relevance is visualised via the shading of blocks with the more relevant sources of power being shaded darker while for example physical presence emerged as highly relevant in the context of vaccines the opposite is the case for access to resources bmj global health we begin by outlining the data on gendered authority as a latent source of power underlying household bargaining we then present power domains based on their relevance in the vaccination context in descending order followed by how these different sources of power can interact and change over time gendered authority and power gendered authority emerged as a latent source of power individuals could rely on when negotiating a decision mothers often emerged as having less authority than other household members while fathers were almost universally the clear figure of authority in households as one mother described it my husband feels that he should be superior in the family … he has more power than me as a result participating mothers reported that they were afraid to be held accountable for any negative consequences if they decided to go against their partners vaccination decision i already know that he does not like vaccinations so there was one time when i asked for his permission to go to the health center with the child he said bahala ka sa buhay mo lit its your life do what you want those words i already knew it would mean a scary fight so i just stopped similarly one mother described how despite her desire to vaccinate her child she followed her husbands opposition to vaccines because i dont want any trouble in cases where mothers previously had vaccinated their children but fathers later found out or changed their opinion fathers authority allowed them to inhibit future vaccination he said that the children are already okay … so he said that he would not allow the children to be injected again maternal grandparents often emerged as having authority over their daughters but sometimes lacked influence over their sonsinlaw one mother narrated how she had turned to her own parents for help to convince her vaccine hesitant partner but my husband doesnt allow injections my mother insisted and told him that it is for our childs health still he said no however in one case a respondent also reported how her husband was afraid of my father the childs grandfather who was opposing vaccination so he did not say anything resulting in the child not being vaccinated as long as the family was living with the grandparents paternal grandparents often had considerably more influence on the father than maternal grandparents additionally mothers often feared potential consequences if they behaved against the will of their parentsinlaw every time i bring up the idea of vaccination my motherinlaw says go ahead it is up to you inject your child but when something happens dont ask for any help from me they always say that i will be on my bmj global health own just because of the vaccine physical presence a key source of power influencing household bargaining was physical presence at the time of vaccination offer mothers emerged as often being the caregiver physically present at the household including in situations when decisions about vaccination had to be made providing them with considerable decisionmaking power as one mother described it when asked about her husbands opinion on her vaccinating the children nothing maam he was at work… i told him only when he arrived consistent physical presence at home allowed some respondents to directly overrule preferences of other actors by deciding covertly one respondent said that if her husband was present their children cant be injected because he will get angry but when he leaves then its time for me to go to the health center so he doesnt know other respondents reported that they hid the truth from him because my partner looks like he doesnt want it however such vaccination secrecy once discovered would often spark conflict hes not around that time but when we got home he questioned me why i allowed my child to be vaccinated without his knowledge respondents also relayed how deriving ones decisionmaking power from physical presence could be fleeting or heavily dependent on ones own employment situation similarly being the only one physically present might give an individual considerable decisionmaking power but at the same time make it hard because im alone here at home… its not like when you have someone to leave the other kids with mothers often described how fathers were typically working oftentimes in distant regions resulting in considerably diminished paternal decisionmaking power one recently widowed participating father described only beginning to take care of his childs medical needs after his wifes death as previously i dont know what specific vaccine my child still needs because my wife was the only one who held the record i just work the role of physical presence as a source of power although instable was particularly present in the role of grandparents or extended family several respondents reported that maternal or paternal grandparents heavily influenced vaccination decisions at times when they were living nearby or were serving as primary caregivers to children this grandchild really lived with her mother before once we are able to travel again i will return him to his mother but i want to complete his vaccination first because his mother wont take care of this mothers also explained an inability to continue vaccination if they lived with grandparents who opposed vaccination that is why when i was separated from the childrens grandparents then i had my children immunized one mother narrated how she struggled for years to vaccinate her children against the will of her own father and was only able to start vaccination once her father became unwell with high physical presence grandparents were also able to intercede on behalf of a parent casting a tiebreaking vote for or against vaccination this level of support often diminished after marriage particularly for maternal grandparents when a mother moved away to live in the paternal household the role of physical presence was also exemplified in cases where families were temporarily divided due to the high mobility requirements for purposes of employment schooling or taking care of family members such splits could result in different vaccination profiles among children of the same family depending on whom they were living with during early childhood interest and conviction many respondents reported that they saw vaccination as a topic where household negotiations were heavily shaped by the person taking interest in or holding strong convictions on the topicwhether for or against vaccination female respondents frequently described caring about vaccination as being part of their role as a mother and their own involvement in the topic as high phrasing it as im the parent im the one who takes care of them thats how i am at the same time some mothers also said their main reason for forgoing decisions about vaccination was being too lazy to go or not seeing vaccines as a priority some mothers described their husbands as not having a care or that they never had an opinion about the childs health resulting in the second respondent feeling left alone with her worries when the child developed a fever after vaccination however one participating father described how vaccination was so important to him that even if it will take the whole day why not if that is the only way to get the vaccine isnt it … even if i lose my work its worth it as long as my children will not get sick another father described feeling conflicted about vaccination at schools due to the dengvaxia controversy i thought then if i allow my children to be vaccinated i will not be able to sleep he accordingly made sure that his children were fully vaccinated at a trusted health center so that they could reject schoolbased vaccination maternal grandparents often described their high interest in the topic of vaccination as part of their duty to care for their grandchilds health and to pass knowledge to their daughters i am not a type of mother who doesnt care about her children i bmj global health made sure that all of them were seen by doctors and got the necessary care this way they saw that vaccination is important to me so they imitate it with their own kids because thats who i am i am their mother paternal grandparents mainly exerted power when caring about the topic of vaccines due to previous vaccination experiences such as severe vaccination side effects in previously vaccinated children one mother described how her motherinlaw was the biggest barrier because she really doesnt want her grandchildren to be vaccinated however one paternal grandmother also explained how she was struggling as she herself cared about vaccines while her former daughterinlaw did not this resulted in the grandmother being concerned for her grandchilds health as when he was one year old i gave him to his mother because my son and his mother separated… yes thats why he was late with the vaccine schedule because his mother didnt take care caregiving and vaccination experience especially young mothers described how they saw other typically older family members with more experience as having more power to decide about vaccination their own power increased with the amount of caregiving experience they possessed while one mother described being scared and nervous because thats my first baby another mother said i already have experience because i have three children it seems like i already know what is really being injected mothers also frequently invoked their own experiences when explaining their hesitancies towards vaccines thats why sometimes i am afraid to bring them to the health center because i am afraid that they would be hurt again fathers similarly invoked previous experiences with vaccination and vaccine side effects however some mothers described how fathers lacked experience with vaccines also from their own childhood as they were not common or not really hindi uso lit a trend in their respective province making fathers appear unsure about vaccine effectiveness and safety participants explained how both paternal and maternal extended families held considerable power due to extensive caregiving and vaccination experience describing them as mas nakakaalam lit those who are knowledgeable one mother stopped vaccination after her father got mad because the child developed a fever after vaccination and since my father knew better than me i followed him in opposing vaccination another respondent explained how grandparents preferences were hard to overcome and even though i have 4 children i still dont know what is right for the children so were just following the grandparents advice for the childrens sake access to resources control over resources was often distributed unevenly between household members but generally did not emerge as a substantive source of bargaining power with regard to vaccination mothers reported how vaccines were generally accessible free of charge unless one wanted to procure them at a private facility but transportation to the centre could incur costs however participants highlighted the challenges if vaccines were to cost money both hypothetically because they would have to then ask my husband if he agrees or because they had been vaccinating their child at a private health facility but then ran out of budget and then the injections were delayed interrelations between sources of power and dynamics over time sources of bargaining power emerged not in isolation from each other but as mutually influencing exacerbating or challenging for example physical presence could influence interest in the topic and ones own caregiving experience similarly having personal experiences with vaccination not only gave household members bargaining power but also often increased the degree to which these members cared about the topic household members who lacked high levels of gendered authority especially mothers were often overruled by fathers or extended family but could draw on combinations of other sources of power to mould the decisionmaking process the degree to which this was possible could vary considerably over the course of their life case study 1 highlights how changing circumstances within a mothers life influenced the power she exerted in intrahousehold vaccination decisionmaking names of casestudy respondents are pseudonymised case study 1 mary joy mary joy a mother of two agreed to vaccinate her first child against polio however the child developed a mild fever and was crying all night this disturbed mary joys father who was living in the same house and consequently opposed further vaccination with the father being physically present having previous childcare experience and mary joys own conviction regarding the necessity of vaccines being low the father ultimately enforced his decision later mary joy realized how important vaccination is being convinced by other mothers and perceiving her unvaccinated child as being more prone to sickness than other children however despite frequent visits to the doctor no further vaccination followed because that time my mother is his guardian because im at work the situation changed with mary joys second child whose father lives apart from the family being the sole parent physically present and having gained caregiving experience her second child is vaccinated following the recommended basic schedulesalthough she remains deeply skeptical towards newly introduced vaccines in addition to this variation over time bargaining outcomes could also vary within the same household bmj global health depending on the interlinked sources of power available to the respective household members case study 2 exemplifies a case where household context largely overlapped between two respondents who wanted to vaccinate their children but their respective relationships with the other household members previous experiences and bargaining power resulted in different outcomes case study 2 stephanie and althea stephanie a married mother of three lives in the same household as her parents her brother and her sisterinlaw althea a married mother of two both stephanie and althea would like to vaccinate their children but while sharing one household their access to power differs and shapes vaccination outcomes one of stephanies children died when he was two years old none of her children are vaccinated as both her mother and her motherinlaw strictly oppose vaccines stephanies husband is similarly hesitant but she imagines being potentially able to negotiate with him but with both her mother and motherinlaw against vaccination she feels isolated and fears potential repercussions once she interacted with the health centre to get medicines for a sick child and the facility staff also urged us to take the children for vaccination when i told my motherinlaw about the vaccines needed she was so angry she said dont take them to the health center just take medicine there is no need for the children to be vaccinated stephanie feels powerless and afraid as she cares about vaccines and not being able to vaccinate her children hurts me because i also want my children to be away from the pain so they dont get any diseases stephanies sisterinlaw althea faces similar opposition from the family matriarch especially after having moved into the same household altheas husband aligns with his mother in her vaccine hesitancy resulting in altheas 8monthold daughter not yet being vaccinated however altheas own parents advocate for vaccines allowing althea in the past to defy her husband and vaccinate their oldest son i was only with my mother and father they knew about it only my husband didnt after returning to her husband she just told him what i did and its fine with him drawing on these experiences althea intends to resist her motherinlaw because even if the grandparents of the child will not allow it i will still let my children get vaccinated because their body needs it both participants stephanie and althea are convinced of the necessity of vaccinations would like to vaccinate their children but live in a household where their respective husbands and members of the extended family oppose vaccines however their own vaccination experiences and having the support of at least one side of the family have resulted in contrasting vaccination outcomes discussion this study is among the first to outline sources of decisionmaking power that allow filipino caregivers of small children to make decisions about vaccination in cases of intrahousehold disagreement while gendered power emerged as an underlying foundation of intrahousehold imbalances other household members could make and enact decisions based on their physical presence at the household at the time when vaccination decisions are made or enacted high interest in the topic of vaccination previous caregiving or vaccination experiences and access to household resources the role of gender underlying healthrelated household decisionmaking in our data is well established in the literature both in relation to vaccination 8 and child health in general 21 our finding that different household membersbeyond parents of small childrenhave considerable bargaining power in decisions regarding child health and how gender dynamics shape the distribution of power reflects previous scholarship beyond differences between genders authors have also detailed cases of positive and negative influences of senior women particularly mothersinlaw on younger mothers 21 in kenya senior cowives have been described as possessing extensive decisionmaking capabilities when engaging in child health interventions 49 one additional factor that has been highlighted as potentially influencing such gendered power dynamics is education while not emerging as a core determinant of gendered power from our data strong evidence suggests that maternal education can increase womens autonomy in the household and has positive effects on child health 21 in addition to reshaping the gendered power imbalances within households in the context of our framework education specifically about the relevance of vaccines could also influence the degree to which individuals care about the topic the degree to which physical presence emerged as one of the key sources of power in vaccination decisionmaking was beyond what previous scholarship might suggest while acknowledging its relevance physical presence has mainly been conceptualised as one of several resources 27 in our work the decision for vaccination can be made and enacted in one individual situation and access to this source of power therefore can be much more fluid than access to traditional resources such as household finances the person physically present therefore can become a de facto household head able to make a decision in this particular moment 21 as highlighted in our results this can also allow household members to decide and enact their decision secretly while thereby ensuring their own preferred outcome the discovery of such secrecy by other household members could spark conflict and longerterm consequences remain unclear scholars have highlighted how having to keep secrets from others might increase perceived isolation and fatigue 50 and can severely impact family dynamics and result in an erosion of trust especially if found out 51 52 in the context of vaccination secrecy later discovery or disclosure could therefore not only result in conflicts but also make future vaccination less likely due to the loss of trust between household bmj global health members at the same time wilson 53 argues that based on foucaults conceptualisation of secrecy being an integral part of power 54 household members might prefer to accept secrecy or feign ignorance as to not challenge the dominant ideology applied to our findings household members could prefer to overlook vaccination secrecy as a means to maintain an appearance of sharing equal responsibility or decisionmaking power regarding their childs health we encourage future research to consider the effects of vaccination secrecy on household dynamics and future vaccination uptake respondents repeatedly emphasised that caregiving experience gave stakeholders particularly older family members considerable authority which confirms findings from other settings in senegal grandmothers experience and wisdom gave them a role in maternal and child health among others 55 a recent systematic review also highlighted that grandparents previous experiences including of vaccine preventable illnesses potentially allowed them to influence vaccination decisions but that indepth research on the topic is currently lacking 16 our study adds to this discourse by emphasising how previous caregiving experience can be a source of considerable bargaining power meriting attention on senior household members in vaccination promotion efforts at the same time while having more than one child emerged from our data as an important determinant for confidence in ones own caregiving experience for subsequent children total number of children might not be the only metric relevant for such confidence a study among spanish mothers highlighted the relevance of not being primiparous but also the number of people at home that could provide support for mothers caregiving confidence 56 similarly selfefficacy of mothers in the usa has been shown to increase both with maternal age and the number of children 57 these findings suggest a spectrum of factors influencing confidence in household members caregiving experience although we would caution against broad comparisons given the high probability of contextual differences between these settings and our study site childhood vaccination proved to be a sensitive topic among many caregivers with those heavily invested in the topic often being key stakeholders in household bargaining in line with our findings conviction has been highlighted in the context of parental decisionmaking for children suffering from cancer where parents see it as their responsibility to decide what is right for their children 58 conflicts can emerge where these convictions are challenged by another party who also cares strongly about the topic but holds an opposing view 59 vaccination programme planners should consider this high relevance of caring about the topic for example by invoking this care among those favouring vaccination in the household but also by being aware of the bargaining power of stakeholders heavily opposed to vaccination the emergence of potential sources of bargaining power that interact with each other links to ongoing intersectionality discourses intersectionality highlights how inequalities associated with individual social stratifiers do not exist in isolation from each other but instead interact dynamically 60 61 62 amid calls for a more prominent role of intersectionality research in global health 60 61 scholarship that touches on intersectionality and vaccines predominantly focuses on hpv 63 64 or covid19 65 vaccines and highlights the role of intersectionality in all aspects of the vaccine delivery continuum one principle frequently emphasised in intersectionality research is leveraging describing how groups who have a combination of advantages and disadvantages can leverage their advantages to secure entitlements 66 67 a finding reflected in our data related to vaccine decisionmaking however while our findings shed light on how emerging sources of bargaining power were not merely additive but influenced each other further research specifically focused on exploring intersectional facets of childhood vaccination bargaining would facilitate further framework refinement our study also reflects the previously highlighted prominent role of women in filipino households 39 40 including notions regarding the relevance of a mothers own set of relatives she could rely on for support 68 and how age can equalise if not supersede gender as a source of authority 69 the relevance of previous childcare in our data similarly resonates with findings regarding filipino womens authority generally increasing with the number of children 70 at the same time scholars have argued that filipino households might be more egalitarian than in many other countries but that in cases of conflict the male preference nevertheless often prevails 40 69 mirroring our findings regarding fathers gendered authority there are several marked differences between bargaining for childhood vaccination and household spending including the diminished relevance of the economic dimension in the context of vaccination and childcare being predominantly understood as the mothers responsibility 39 70 we invite further research to investigate how particular facets of the filipino setting including household characteristic and the role of public vaccination discourses in recent history influence vaccination bargaining as compared to other contexts we are not aware of extensive data on varying vaccination profiles between children of the same household in the philippines but available data suggest a high number of vaccination dropouts or children who did not receive subsequent vaccination doses after the first in the country 29 considering our finding that variations in the distribution of intrahousehold bargaining power over time can result in differing vaccination profiles we suggest researchers and policymakers to consider bargaining processes in addition to other more structural challenges for vaccination uptake when investigating approaches to ensure vaccination schedule adherence furthermore future research could shed light on differences in vaccination patterns across children within the bmj global health same household as a means to understand the variability in household vaccination decisionmaking this study has limitations first household bargaining inductively emerged during data collection and analysis therefore we did not always actively or evenly probe on bargaining power and intrahousehold decisionmaking in early interviews because topics such as household finances can be difficult to discuss 23 and might therefore not emerge evenly across interviews we encourage future research including research designed a priori to investigate intrahousehold dynamics second vaccinating children might be perceived as a socially desirable action in our setting respondents therefore could have felt compelled to overemphasise household dynamics that did not allow them to vaccinate their children despite wanting to do so third a majority of our respondents were mothers while this reflects how mothers are most often primary caregivers to small children in the philippines our data derived from other household members might have missed nuances from those members we encourage future research that specifically aims at giving voice to household members currently underrepresented in this specific discourse and that investigates the complex dynamics underlying preferences and bargaining approaches of different groups of household members finally the purpose of this study was to tease out sources of bargaining power household members drew on in the vaccination decisionmaking process and not to draw definitive links between a given source of power and positive or negative vaccination attitudes we invite future research to investigate whether specific sources of power are more likely to lead to an uptake or rejection of childhood vaccination conclusion to the best of our knowledge this study is among the first to move beyond gendered imbalances when investigating the dynamics that shape the bargaining of childhood vaccination uptake considering the relevance of vh for global health a better understanding of the circumstances in which decisions about vaccination are made and how to address actors involved in these decisions can guide strategising of vaccine confidence interventions given the gendered dynamics of decisionmaking which often limit mothers we encourage the following target not only mothers in vaccination campaigns but also other household members who have more gendered power in the respective setting leverage the high relevance of physical presence by timing accessible vaccination offers accordingly especially in cases where authoritative household members oppose vaccination inspire confidence in the own caregiving experience among household members favoring vaccination and invoke interest and conviction about the topic for example via nudging interventions 71 among household members with considerable bargaining power considering the observed diminished relevance of access to household finances in the context of vaccination but concerns that mothers relative bargaining power decreases as costs for vaccination uptake increase programme planners should also continue to ensure that financial costs of accessing vaccination remain low we invite future research that explores these potential avenues and further refines and tests our framework we particularly encourage investigations of its applicability in other settings such as contexts with differing household structures or socioeconomic backgrounds and quantitative approaches that could further tease out patterns and provide nationally representative insights we also encourage researchers to broaden the scope of the vaccination bargaining literature including in highincome countries where bargaining patterns may vary or by investigating bargaining as it relates to adult vaccination and how this can influence childhood vaccination bargaining and vice versa we welcome researchers policymakers and implementers involved in vaccine promotion efforts to engage with our framework test its applicability across contexts and modify it in terms of key actors or the weight type and interrelatedness of building blocks twitter mark donald c reñosa drnursebatman and shannon a mcmahon shannonamcmahon ethics approval this study involves human participants and was approved by ethical review board of the medical faculty heidelberg university germany institutional review board of the research institute for tropical medicine the philippines 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 upon reasonable request data are not publicly available due to the sensitive and personal nature of qualitative data and the collected information data may be available on request to authors with restrictions following ethical approval please contact the corresponding author 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 open access this is an open access article distributed in accordance with the creative commons attribution 40 unported license which permits

introduction targeted vaccination promotion efforts aimed at building vaccine confidence require an indepth understanding of how and by whom decisions about vaccinating children are made while several studies have highlighted how parents interact with other stakeholders when discussing childhood vaccination less is known about the way in which vaccination uptake is negotiated within households methods we conducted 44 indepth interviews with caregivers of children under five in the philippines who had delayed or refused vaccination interviews were conducted between august 2020 and march 2021 and were audiorecorded transcribed verbatim and translated into english notions of intrahousehold vaccination bargaining emerged early during systematic debriefings and were probed more pointedly throughout data collection results parents as well as paternal and maternal families proved to be dominant stakeholders in intrahousehold bargaining for childhood vaccination although bargaining among these stakeholders was based on engrained genderbased power imbalances disadvantaged stakeholders could draw on a range of interrelated sources of bargaining power to nevertheless shape decisionmaking sources of bargaining power included in descending order of their relevance for vaccination 1 physical presence at the household at the time of vaccination decisionmaking 2 interest in the topic of vaccination and conviction of ones own position 3 previous vaccination and caregiving experience and 4 access to household resources including finances the degree to which each household member could draw on these sources of bargaining power varied considerably over time and across households conclusion our findings highlight how bargaining due to intrahousehold disagreement coins decisions regarding childhood vaccination considering the risks for public health associated with vaccine hesitancy globally we advocate for acknowledging intrahousehold dynamics in research and practice such as by purposefully targeting household members with decisionmaking capacity in vaccination promotion efforts aligning promotion efforts with available bargaining capacity or further empowering those convinced of vaccination

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background in 2005 chronic disease deaths were double the number of deaths resulting from infectious diseases maternal and perinatal conditions and nutritional deficiencies combined 1 similarly in 2015 40 million or 70 of allcause deaths globally were a result of chronic disease 2 a figure expected to increase to 52 million noncommunicable disease deaths by 2030 3 socioeconomic status as defined by education occupation and income 4 plays a major role in the distribution of ncds 5 evidence from highincome countries shows ncd burden effectively shifts to those with lower ses over time 67 potential shift of disease burden to the poor paired with increasing ncd and communicable disease burden on clinical and prevention resources means that individuals from lower ses groups may receive inadequate care making them a priority for early prevention and monitoring in fact the world health organization ranks monitoring and surveillance of risk factors as a top priority to tackle growing ncd epidemics in lowresource settings 8 there is clear consensus in the literature that cardiorespiratory fitness or the ability of the circulatory and respiratory systems to supply oxygen during sustained physical activity measured at gold standard as maximal oxygen output or vo 2max obtained during maximal treadmill or ergometer testing 1011 is as important as pa 12 13 14 if not more important 15 for the prediction of future adverse health outcomes including adverse cardiovascular events and allcause mortality 16 crf is also often an objective measure of fitness while pa defined as bodily movement produced by skeletal muscles that require energy expenditure 9 is often selfreported behavior the objective nature of crf testing makes it the most reliable test of fitness for use in largescale populationbased studies furthermore directly measured fitness is more strongly associated with a protective cardiovascular risk profile than selfreported pa level 17 helping practitioners more accurately separate individuals with high longterm risk for ncds from those with low longterm risk as clinical and preventive resources stretch to meet increasing disease burden it becomes essential to invest in interventions for early detection and treatment of ncds thereby reducing the need for additional or more expensive treatment in the future and longterm economic burden 18 establishment of a relationship between ses and crf may be helpful in accurately targeting the most atrisk groups for timely ncd prevention and early detection and treatment to our knowledge there are currently no systematic reviews addressing the relationship between ses and crf in the general adult population the overall aim of this systematic review is to review and consolidate evidence from the literature regarding the association between ses and crf conduct a metaanalysis of the association between ses and crf using methodologically comparable data sources stratified by sex and test whether association varies with adjustment for pa using metaregression we stratify by sex because sex differences in crf are well documented 19 20 21 but also because identifying and addressing gender inequality in health is a priority for international health professionals 22 we also test for the effect of adjustment for pa because pa partially but not exclusively 23 leads to crf 24 25 26 27 and may influence the relationship between ses and crf methods protocol and registration this review was conducted as part of a larger research project investigating the personal and interpersonal correlates andor determinants of crf in adults it is a subset of a broader systematic review that was registered at international prospective register of systematic reviews crd42017055456 the systematic review protocol was published elsewhere in detail 28 instead of all determinants and correlates of crf the current review focuses on the association between ses and crf literature search and selection criteria we conducted our search for journalpublished articles in the medline embase latin american and caribbean health sciences scientific electronic library online and cochrane library literature databases we additionally searched the google scholar grey literature database in addition to electronic literature databases the reference lists of all articles selected for fulltext screening were hand searched for relevant studies not found in the electronic database search the final database search was updated on october 30 2017 no date language article type or text availability filters were applied all search results were imported into the reference management software endnote x7 and duplicates were removed the current review includes quantitative observational and experimental studies that report on the association between ses and crf in the general adult population eligible ses indicators were any acknowledged resource or prestigebased measure of position within a societal structure 329 defined according to the mesh term socioeconomic factors and equivalents the socioeconomic factors mesh term includes subheadings such as educational status employment status income occupation including career mobility poverty including poverty areas family characteristics social change social class including social mobility and social conditions individual household and areabased ses indicators as well as social mobility indicators were included eligible crf indicators were any acknowledged objective measures of crf derived from maximal or submaximal incremental cardiopulmonary exercise testing on a treadmill or cycle ergometer oxygen consumption indicators either directly measured with spiroergometric gas exchange measurements or indirectly estimated with metabolic equations were included maximal oxygen consumption is defined as the oxygen consumption in millimeter during exercise at which actual oxygen consumption reaches a maximum which cannot be increased with an increase in effort while peak oxygen consumption is the highest vo 2 value obtained on a particular test regardless of the subjects effort 3031 throughout the following we will use the abbreviation vo 2max for both vo 2max and vo 2peak indicators in addition to vo 2max the following crf indicators were included physical working capacity in watts at variable and fixed heart rate thresholds time in seconds to heartrate threshold energy expenditure in mets and total exercise duration in seconds the following exclusion criteria were applied studies measuring the impact of interventions designed to increase pa or crf studies including only children or adolescent participants or elderly participants studies with sample sizes of less than 300 participants studies where participants were not representative of the general adult population studies reporting only measures of childhood ses such as family demographics and indicators found in family life surveys and reviews letters to the editor commentaries or editorials two reviewers independently reviewed titles and abstracts of all references identified from databases and additional literature sources articles that were not excluded at this stage were further reviewed for inclusion based on the publications full text by reviewers disagreements were resolved by a third reviewer additional details about study selection are published elsewhere 28 at all stages disagreement between first and second reviewers was resolved by discussion all studies examining the association between participant ses and crf were included for data extraction and systematic review in some cases populationbased studies had measured but not reported participant ses these studies were neither excluded nor extracted but were reserved for author followup articles based on populationbased studies that were reserved for author followup were only included for systematic review if authors responded with supplementary data all other studies were excluded from the systematic review studies included for metaanalysis were only those included for systematic review with directly comparable exposures of interest data coding and assessment of methodological quality studies were coded for study characteristics methods population characteristics exposures and outcome variables main results including method of analysis and confounders adjusted as well as major limitations reported by the authors supplementary details about data extraction process are published elsewhere 28 all data were extracted by two reviewers in several cases we contacted authors requesting additional data additional author requests were made when studies presented insufficient measure of the association between ses and crf or when populationbased studies that were reserved for fulltext screening measured but did not present data on the association ses and crf risk of bias within each study was independently assessed by two reviewers using a customized version of the quality assessment tool for observational cohort and crosssectional studies by the national heart lung and blood institute at the national institutes of health usa 34 risk of bias was categorized as high when a study reached ≤ 49 requirement fulfilled score moderate when a study reached 5075 fulfillment score and low at ≥ 75 fulfillment score supplementary details about risk assessment procedure are published elsewhere 28 results of the risk of bias assessment are available in table 1 additional sensitivity analysis using risk of bias score to test the effect of study quality on the association between ses and crf was to be conducted if methodologically similar studies included for metaanalysis varied in risk of bias score statistical analysis after completion of the author requests for additional data results of the systematic review were summarized in table and narrative format comparable data was only obtained for the relationship between education and crf in order to pool results for metaanalysis we standardized education categories across populationbased studies into three main categories according to the casmin educational classificationhigh medium and low 35 we also standardized the outcome measurement using vo 2max in millimeter calculated according to the american college of sports medicine equation 35ml × min 1 × kg 1 1224 × w max × bodyweight 1 3637 or directly measured with spiroergometry individual study results were standardized using the hedges g effect size 38 calculated as es × correction factor to determine the overall association between education and crf the standardized effect sizes were then included in a random effects metaanalysis according to the dersimonian and laird 39 methodology this was prespecified due to the expected heterogeneity of outcome and exposure measurements in the underlying studies and also because it was expected that the effect of ses on crf varies by context and therefore that analysis would estimate the distribution of these effects rather than estimating one true effect of ses on crf our final metaanalysis model adjusted for the set of confounders adjusted for in all studies age pa waist circumference body mass index and alcohol consumption data analysis was performed using stata version 14 statistical software increases in crf were reported as positive values and high and medium educational categories were compared to the referent low educational category so that positive crf illustrated improvement in the comparison over the referent education category data are reported as mean ± 95 confidence interval the i 2 statistic was used as an indicator of study heterogeneity or risk of bias across studies evidence of heterogeneity was determined by a p value 01 40 to address the low power of the statistical test resulting from limited number of studies included for metaanalysis the metaanalysis was stratified by sex and included additional sensitivity analysis to test differences in the synthesized association between ses on crf with and without adjustment for pa differences were tested using metaregression previously mentioned additional sensitivity analyses were prespecified posthoc analysis adjusting nhanes data for race was performed results study characteristics a prisma flowchart depicting the article selection process can be found in fig 1 an updated search was conducted in october 2017 resulting in no new results a total of 3233 studies were identified from electronic databases and 218 articles were identified from additional literature sources after title and abstract screening 346 articles were included for fulltext screening of which 329 were subsequently excluded four articles reporting data from populationbased studies were reserved for author followup because they measured but did not report on the association between ses and crf in total 15 studies were included for systematic review and three were included for metaanalysis resulting in four populationbased studies for metaanalysis in our search we did not exclude experimental studies although it is difficult to imagine examples of experimental studies designed to modify ses in order to improve crf ultimately however all included studies were observational since no experimental studies fulfilled the eligibility criteria the associations between ses exposures and crf found in the systematic review and not significant are presented in tables 2 and3 lakka 41 macauley 128 ittermann 45 shishebor 54 1 was the research question clearly stated lakka 41 macauley 128 ittermann 45 shishebor 54 11 did the study investigate interaction between exposure variables specific details about crf measurement can be found in tables 2 and3 exposure ses indicators categorical education the most frequent indicator was presented in 11 studies 10 studies reported own education and 1 study reported longitudinal educational mobility categories other ses exposures included composite measures of ses combining several indicators residential arealevel ses own occupation income based indicators and employment status results of individual studies by exposure socioeconomic exposures excluded from metaanalysis generally showed a positive relationship between ses exposure and crf measure of interest individual studies within the primary exposure for metaanalysis education generally showed a positive relationship between high education and crf measure of interest three studies showed a ushaped relationship education four studies 41 42 43 44 observed a positive association between education and vo 2max the study 45 observed that vo 2max increased with education among women but only high education improved crf relative to low education among men exercise duration from one study 46 increased most when comparing the highest and lowest education categories two studies 4748 presented a positive association between education and crf that varied by ethnic subgroup study 47 observed a significant positive association between education and crf among hispanic americans only the study 48 observed higher positive association between education and exercise duration among white participants compared to black participants the increase in exercise duration with education was higher among white men and highest among white women but was nonsignificant among both subgroups for wl 130 black males showed increase in wl 130 with education while black women showed no significant associations for either measure of crf three studies 464950 observed a ushaped association between education and crf among the studies reporting an inverted ushaped association study 50 observed that crf increase was largest when comparing medium and low education level study 49 presented an or measure of association between education and crf and observed that participants in medium education group had higher odds of low vo 2max than participants in the high education group when compared to lowest education group this study was additionally adjusted by measures of periodontal health the study 51 observed an association between social mobility and longitudinal fitness the study observed that persistently high or upwardly mobile ses status compared to the persistently low ses status resulted in higher likelihood of increased fitness than persistence of an unfit state all other ses indicators studies 5052 reporting a significant association between crf and composite socioeconomic indices presented multivariable analysis and observed a positive association results from the study 52 varied by sex odds of high fitness were increasingly greater with higher ses index score among women while men showed nonsignificant results studies 5354 reporting on the association between crf and residential area ses conducted multivariable regression analysis and observed that median vo 2max increased and odds of low fitness decreased with higher residential area ses both studies 4150 reporting the association between participant occupation and crf observed a significant positive association between skilled occupation and crf while study 50 observed no significant association between financial strain and mets during treadmill exercise study 41 identified a positive linear association between income and vo 2max using ancova analysis finally the study 41 observed that vo 2max was higher among employed individuals direct vs indirect vo 2max measurement across all exposures studies measuring and reporting direct measures of vo 2max showed a strictly positive relationship between ses and crf while indirect measures of vo 2max showed a positive relationship overall two studies directly measured vo 2max through breath analysis and reported a positive association between ses and crf among studies estimating vo 2max four studies reported a positive association one reported an inverted ushaped association and one reported no association synthesis of results results of metaanalysis are presented in figs 2 and3 compared to individuals with low education both men and women with high education showed significantly higher crf while participants with medium education showed no significant difference in crf compared to individuals with low education risk of bias across studies our analysis standardizes both exposure and outcome to limit heterogeneity accordingly among men the fully adjusted model had low heterogeneity with a nonsignificant p value 01 while among women the fully adjusted model showed substantial heterogeneity p value 01 and i 2 value in the range 5090 55 presentation of the results from random effects metaanalysis adjusts for this heterogeneity within the fixed effects metaanalysis additional analysis metaregression testing differences in the effect of education on crf with adjustment for pa detected no significant differences studies from the us that were systematically reviewed reported differences in the association between crf and education by ethnicity of the study sample 48 thus we performed additional posthoc sensitivity analyses adjusting nhanes data by race the measures of association between ses and crf marginally increased however the trend among men and women did not vary from the original metaanalysis studies included for metaanalysis had low riskofbiasscore thus no sensitivity analysis by quality assessment score was conducted discussion in this systematic review and metaanalysis of the association between ses and crf in adults evidence from 15 populationbased studies from 8 different countries shows that predominately higher ses is associated with increased crf socioeconomic exposures such as ses indices composed of various ses indicators 5052 and residential area ses 54 generally showed a positive relationship with crf 4153 studies using education level as an exposure showed either a positive relationship between education and crf 4145 47 48 51 or a ushaped relationship 464950 metaanalysis of the most frequently reported association between education and vo 2max was based on a sample of 9435 nonsymptomatic individuals from four populationbased studies metaanalysis showed a significant positive association between education and crf for men and women when comparing the highest with the lowest of three education groups to the best of our fig 2 forest plot for the association between education and cardiorespiratory fitness among men data shown are standardized mean differences ± 95 ci subtotals presented for both fixed and random effects models reference details precede study descriptors knowledge this is the first systematic review conducted on the association between ses and crf thus it is impossible to compare our findings with previous reviews however reviews on the association between ses and pa report observations in line with our findings a positive association between ses and healthenhancing total leisure time pa 56 additionally research from both the usa and germany shows that ses is positively associated with aerobic physical activity in 2014 the percentage of us adults age 18 and over who met federal guidelines for aerobic physical activity increased as family income increased 57 with 517 of us adults meeting the 2008 federal physical activity guidelines for aerobic activity 58 similar patterns can be observed among german adults in 2014 453 of german adults met the who recommendation for aerobic activity with higher compliance among individuals with higher education 59 crf inequalities across levels of ses likely stem from differences in health behavior lower ses is associated with healthcompromising behaviors such as low levels of aerobic leisuretime pa 565960 high sugarrich and fatrich food intake and low fruit and vegetable intake 526162 and high smoking prevalence 63 64 65 66 while the previously mentioned healthcompromising behaviors are strictly negatively associated with ses the association between ses and alcohol consumption varies by dose heavy episodic alcohol consumption defined as pure alcohol intake of 60 g or more during a single occasion at least once per month 67 is associated with lower ses 68 while risky alcohol consumption or consumption of 1012 g of pure alcohol daily for women and 2024 g for men 6970 is associated with higher ses 71 lower ses is also related to obesity 72 these disadvantageous behaviors and conditions lead to poorer health and are primary risk factors for chronic diseases such as diabetes 73 74 75 76 cardiovascular disease 71 76 77 78 79 80 and cancer 7678 81 82 similarly it has been demonstrated that obesity and overweight 56 physical inactivity and smoking are negatively associated fig 3 forest plot for the association between education and cardiorespiratory fitness among women data shown are standardized mean differences ± 95 ci subtotals presented for both fixed and random effects models reference details precede study descriptors with crf 83 conversely moderate average alcohol consumption improves crf more than nonor heavy average alcohol consumption in an inverted ushaped fashion 84 overall it is likely that these health behaviors and conditions are underlying causes of the positive association between ses and crf it is also possible that the positive association between ses and crf is explained by the negative association between high ses and chronic breathlessness individuals with high ses are less likely to suffer from chronic breathlessness and by extension to have higher crf 8586 consider that 15 of participants from ship0 and 177 of participants from shiptrend reported shortness of breath at load 81 demonstrating that measured fitness may have been impacted by chronic breathlessness apart from behavioral and healthrelated factors genetic factors are also known to influence physical fitness 87 88 89 90 91 however whether the association between ses and crf could be partly explained by genetic dispositions cannot be determined based on available evidence in the literature the importance of crf for public health is reflected in the policy statement from the american heart association from 2013 calling for a national registry on crf 92 previous research has demonstrated that increased crf is associated with various health benefits leading to a significant reduction in mortality rates 93 crf can be increased through regular pa participation 9495 however not all types of pa are beneficial for crf occupational pa often corresponds with musclestrengthening activity or lowintensity tasks performed over long periods 96 and seems to be less beneficial for crf than aerobic sports and physical exercise activities mostly performed during leisure time 4197 adults with low ses are more likely to work in physicallydemanding jobs and to show a higher total energy expenditure compared to adults with high ses who are more likely to have sedentary jobs and perform aerobic physical exercise in leisure time 596098 thus it seems that adults with low ses do not show lower crf because they are less physically active 99 rather because the types of pa they perform are less often aerobic and hence less beneficial for crf and cardiovascular health 100101 as a result consideration of ses differences in working conditions is essential to address ses differences in crf health interventions striving to improve pa at the population level mostly promote aerobic pa in leisure time and thus fail to reach adults with low ses the low prevalence of aerobic pa in leisure time among individuals with low ses is also illustrated by increasing social inequality in sporting activity prevalence in the adult german population over the last decade 102 health promotion activity delivery to individuals with low ses backgrounds remains a crucial challenge however workplace aerobic physical activity interventions for manual workers are a possible solution to the challenge of reaching individuals of low ses background for crf improvement 103 in 2008 the us federal government issued physical activity guidelines for americans 104 which provided sciencebased guidelines recommending adult aerobic pa targets for achievement of substantial health benefits 105106 which were adapted by the who in 2010 the populationbased monitoring of pa guideline compliance is difficult because pa is often monitored based on selfreports making it difficult to distinguish aerobic pa from other types of pa and introducing the possibility of misclassification bias objectively measured crf applied for populationbased health monitoring purposes can be an important tool to accurately gauge health target compliance and prevent bias from selfreported pa furthermore objectively measured crf can be used to monitor chronic disease risk including cardiorespiratory disease risk 107 crf is an important tool for population health monitoring precisely because there is a large body of evidence that crf is a potentially stronger predictor of mortality than established risk factors such as smoking hypertension high cholesterol and diabetes type 2 mellitus 108 furthermore the addition of crf to traditional risk factors significantly improves the precision of risk prediction for cardiovascular morbidity and mortality 109 110 111 and addition of crf to traditional cvd risk measures improves cardiovascular risk prediction 112 clinicians use measures linking crf changes to disease decline 16 to objectively monitor individual and population health risk clinicians could also use crf thresholds 113 by education status to identify low ses groups suffering health disparity for targeted early ncd prevention potentially reducing the need for complex expensive treatments and longterm economic burden insights about the association between ses and crf could be used to monitor prioritize and by extension improve health outcomes among marginalized populations with high risk of chronic disease whose needs may not be met by traditional health promotion activities monitoring and prioritization of health outcomes among marginalized populations has been established by organizations such as who and the pan american health organization as a key priority for controlling ncd epidemics in low resource settings limitations although included studies are generally populationbased and not underpowered the current metaanalysis includes only four populationbased studies due to the limited number of populationbased studies reporting objective measures of crf in the literature accordingly the power of metaanalysis to detect a significant effect between ses and crf may be limited ability to detect differences in effect by sex with pa adjustment and by ethnicity in nhanes data may also be limited by sample size of the metaanalysis our choice of education categories may have also affected results the chosen education categories may have limited the ability to detect subgroup differences through sensitivity analysis due to combination of disparate subgroups furthermore overall results among women should be cautiously interpreted due to the high heterogeneity within this subgroup differences in the results of studies included for metaanalysis and the resulting heterogeneity may be due to use of different exercise protocols for crf measurement 114 the association between crf and various socioeconomic exposures was presented in the literature but the present metaanalysis focuses on education due to issues with heterogeneity of exposure indicators used and minimum sample size required for rigorous metaanalysis however the omission of additional ses measures in the metaanalysis does not significantly impact overarching findings because ses indicators measuring different aspects of social position show similar association with crf for example shmueli et al observed significantly different mean exercise capacity in higher vs lower ses levels across education occupation and compiled ses indicators 50 similarly lakka et al observed a positive dose relationship between education and income and higher vo 2max with higher occupational skill 41 although few studies report degree of agreement between association of various ses indicators measuring different aspects of social position with crf overall agreement between indicators can also be seen for the relationship with pa 56115 studies included for review adjusted their analysis for varying sets of covariates which may impact overall result agreement we correct for this through metaanalysis of standardized effect sizes that were derived from individual study results which had been adjusted for a standard set of covariates finally generalizability across levels of country income classification may be limited due to inclusion of only studies from highincome countries however inclusion of studies from only highincome countries also reduces heterogeneity within the metaanalysis by controlling the effect of country income classification on the association between ses and crf 116117 recommendations systematic review of the literature revealed that few populationbased studies reported ses exposures in addition to education populationlevel investigation of the effects of additional measures of ses such as income occupation or composite ses indices on crf is also necessary future research should include additional ses indicators in metaanalysis in order to gauge whether the relationship observed between education and crf is generalizable to other ses indicators investigation of differences in the relationship between ses and crf by outcome measure is also necessary to compare the effect of ses on vo 2max with the effect of ses on additional crf measures commonly cited in the literature adjustment for total pa did not significantly impact the results of metaanalysis however total pa obfuscates domain specific pa future research should investigate the effect of adjustment for domain specific pa types that are known to be differentially correlated with sessuch as occupational physical activity and leisure time pa 60 additionally sedentary behavior is an important determinant of crf 118119 but was not included as a covariate in analyses where crf was the outcome of interest future research on the association between ses and crf might include sedentary behavior as a study covariate to strengthen results while the patterns observed for the association between education and crf were fairly similar among men differences in the association between education and crf among women from germany and the usa should be explored furthermore although sensitivity analysis showed no significant difference in the effect of ses on crf by ethnicity additional research regarding the effect of ethnicity on the relationship between ses and crf would contribute to more accurate monitoring of chronic disease risk within marginalized populations 120 and help to effectively target these groups for prevention 91 121 122 123 most studies that were systematically reviewed were crosssectional thus more cohort studies are required to rigorously establish an association between ses and crf the metaanalysis disproportionately represents populations from germany due to data access constraints thus inclusion of populationbased studies from various countries across highincome countries would improve result quality and external validity included studies are from highincome countries only future research should consider whether lowand middleincome countries reflect the association observed in highincome countries and whether nutritional and pa transition processes 124 125 126 127 that take place during economic development influence the association between ses and crf conclusions despite limitations we conclude that there is fair evidence in the literature for an association between high levels of education and increased crf this could have implications for monitoring of health target compliance and of chronic disease risk among higher risk populations to detect and prevent ncds in light of shifting ncd burden from adults with high ses to adults with low ses defining crf health targets monitoring crf and pa target compliance at the population level and developing tailored health promotion measures to stimulate crfespecially among adults with low ses backgroundis necessary to improve cardiometabolic health in the general adult population and to diminish social health inequalities additional cohort studies are required to rigorously establish an association between ses and crf furthermore studies investigating the impact of ethnicity on the relationship between education and crf would help improve the efficacy of targeted ncd detection and prevention among highrisk demographic subgroups abbreviations authors contributions kjo np jz tk gbmm and jdf contributed to the conception and design of the manuscript kjo np jz ti re md and jdf contributed to the acquisition and assembly of data kjo jh ti re md tk gbmm and jdf contributed to the interpretation of data kjo jz gbmm and jdf drafted and revised the manuscript np jh ti re md and tk revised the manuscript kjo wrote the first draft and final version of the manuscript all authors critically revised the manuscript for important intellectual content and approved the final manuscript additionally all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved ethics approval and consent to participate not applicable competing interests the authors katherine j ombrellaro nita perumal johannes zeiher jens hoebel till ittermann ralf ewert marcus dörr thomas keil gert b m mensink and jonas d finger declare that they have no competing interests

background this review aims to 1 consolidate evidence regarding the association between socioeconomic status ses and cardiorespiratory fitness crf 2 conduct a metaanalysis of the association between ses and crf using methodologically comparable data stratified by sex and 3 test whether the association varies after adjustment for physical activity pa methods a systematic review of studies from medline embase latin american and caribbean health sciences lilacs scientific electronic library online scielo and cochrane library without time or language restrictions which investigated associations between ses and crf risk of bias within studies was assessed using a customized quality assessment tool results were summarized in table format and methodologically similar studies were synthesized using metaanalysis of hedges g effect sizes synthesized results were appraised for crossstudy bias results were tested for the impact of pa adjustment using metaregression results compared to individuals with low education both men and women showed higher crf among individuals with high education men 012 004020 women 019 002036 while participants with medium education showed no significant difference in crf men 003 004011 women 009 003021 adjustment for pa did not significantly impact the association between education and crf conclusions there is fair evidence for an association between high levels of education and increased crf this could have implications for monitoring of health target compliance and of chronic disease risk among higher risk populations to detect and prevent noncommunicable diseases ncds and to diminish social health inequalities

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introduction the discussed topic of the utilization and role of social software applications with the focus on the elderly people will be solved in the article elderly people have an impact not only on the economy health care but also on social relations and other important areas despite the fact that ten years ago there was no usual use of ict by elderly people the situation is in recent years evolving and changing learning and using information and communication technologies such as computer technologies and internet by the elderly is seen as an important demand for their integration in daily life and as a factor related to active aging 1 elderly people can on the internet read online news newspapers and magazines 22 find information about goods and services travel and accommodation health or search information in the encyclopedias they can also share information communicate with others and obtain the above mentioned information via social networks also people that have medical or other problems and have problems to communicate face to face may thanks to these services get again engaged in an active lifestyle 7 23 social networks help in the social isolation 24 a lot of elderly people have problems with the movement they can be in the connection with their families and other people via social networks 25 active ageing but also social isolation are the most important facts why elderly people use social networks due to a growing number of elderly people it is a necessity to create the cities that are aware of the special needs of all their citizens including the needs of aging populations 2 despite the fact that urban population is ageing there is a paucity of studies exploring how icts can support older peoples living in urban areas thus far visions of smart cities for older people have focused on removing architectural barriers and making physical environments more agefriendly by considering agerelated declines in functional abilities especially mobility 3 the aging population comes with many challenges for smart citiesacross social financial economic and political dimensions managing healthcare quality and costs for this demographic is one of the key focus areas but there are other areas that our smart cities majors and municipal councils should consider 4 the internet of everything will allow new business models based on internet of things technologies sensor technology is increasingly being used in cities to provide us with information about how traffic is flowing where water pipes are leaking and how much rubbish is going in bins how looks like the situation in utilization of social networks in the czech republic and in other countries of visegrad four by elderly people will be solved in the next part of the article development of population in the czech republic the share of seniors in the czech population has been steadily increasing since 1985 by the end of the 20th century the growth was slow states that the proportion of people over 65 years of age is in the general population 178 the current number of 188 million is about 243 thousands higher than at the beginning of 2011 also the highest increases in the age groups were concentrated in the population of the age group of seniors over 65 years those increased by 54900 during 2014 due to the aging population this issue is very serious in solving economic social and other areas literature review social software applications social media and social networks play integral role in everyday life of a lot of people all over the world this topic is also very often discussed but it is not so often connected with the elderly people internet is an evergrowing communication net that connects the most computer systems of the world it is also the growing technology which is used by people like the information storage sharing and easy access computer and internet are large communication vehicles of nowadays and future that provide an easy quick cheap and safe access to a lot of information 9 a sociologist j a barnes is considered to be the author of the definition of the social network the term social network is associated with the internet and directly with the social networks on the internet 10 social network on the internet is considered to be a group of people who communicate and share documents and information on users the social network concept is described and defined by boyd and ellison social networking is defined as a web service that allows individuals to create a public or semipublic profile within the bounded system create a group of users with whom they share a connection and browse the list of own connections and that created by other users of the system the nature and terminology of these connections may be different network from the network 11 social media refers to the means of interactions among people in which they create share and exchange information and ideas in virtual communities and networks 12 furthermore social media depends on mobile and webbased technologies to create highly interactive platforms through which individuals and communities share cocreate discuss and modify usergenerated content it introduces substantial and pervasive changes to communication between organizations communities and individuals 13 kaplan and haenlein 14 define social media as a group of internetbased applications that build on the ideological and technological foundations of web 20 and that allow the creation and exchange of usergenerated content on web 20 summit presented oreilly and battelle web squared web 20 five years on 15 chief among our insights was that the network as platform means far more than just offering old applications via the network it means building applications that literally get better the more people use them harnessing network effects not only to acquire users but also to learn from them and build on their contributions from google and amazon to wikipedia ebay and craigslist we saw that the value was facilitated by the software but was cocreated by and for the community of connected users since then powerful new platforms like youtube facebook and twitter have demonstrated that same insight in new ways web 20 is all about harnessing collective intelligence collective intelligence applications depend on managing understanding and responding to massive amounts of usergenerated data in real time chen and schulz 16 presented review study focused on utilization of social media in the connection with social isolation among elderly people evidence indicates that contemporary information and communication technologies have the potential to prevent or reduce the social isolation of elderly people via various mechanisms ict was found to alleviate the elderlys social isolation through four mechanisms connecting to the outside world gaining social support engaging in activities of interests and boosting selfconfidence gonzalez 17 et al focused on the analysis of the main habits of use and consumption of new technologies by older people in particular the level of knowledge and their level of education methodology and goals elderly people as a term doesn´t have a single definition there is no general agreement when the person is considered old most developed world countries have accepted the chronological age of 65 years as a definition of elderly or older person at the moment there is no united nations standard numerical criterion but the un agreed cut off is 60 years to refer to the older population 6 casadomunoz et al presented in their paper 7 elderly people from 55 years in our paper will be presented data from 55 when data is known montaa et al 8 classify in the research young olds from 6170 years and middle olds the goal of the article is to analyse the situation in the field of utilization of social software applications by elderly people in the czech republic and to compare the use of social networks in the czech republic with other countries v4 visegrad group is the association composed of the czech republic the slovak republic poland and hungary it focuses on foreign policy activities and the group aims to promote cooperation and stability in the broader region of central europe the following scientific questions will be solved in the article  at least 5 of elderly people in the czech republic were using social networks in 2015  the percentage of users of social networks by elderly people is increasing every year in the last three years  at least ½ of elderly people who use social networks attend them regularly while composing this article especially secondary sources from the various authors but also official statistics by the eurostat and czech statistical office were used information was also obtained from expert press conferences seminars and other sources the obtained data were further sorted processed in custom tables clearly setout diagrams and further analysed to provide a basic overview of the relevant problem area data that were gained from eurostat 18 refer to the last 3 months before the survey for private purposes participating in social networks creating user profile posting messages or other contributions to facebook twitter etc data given in this domain 18 are collected annually by the national statistical institutes and are based on eurostats annual model questionnaires on ict usage in households and by individuals the aim of the european ict surveys is the timely provision of statistics on individuals and households on the use of information and communication technologies at european level data for this collection are supplied directly from the surveys with no separate treatment the survey is a general population household survey the detailed description of methodology and data are discussed directly by tables and graphs results international comparison statistics were obtained from eurostat sources data are always stated for years that were statistically processed always refer to all all individuals data only for 65 are not available at the moment selected data for the eu 28 and the czech republic together with the countries of the visegrad group were chosen for comparison because those countries are close to the czech republic data 18 are always given in tables are completed with graphs which will help in fasterafter straightening even though the use of social networking is still growing data shows that the czech republic was in a comprehensive comparison almost always in the last position social networks are being used the most over the evaluated period in hungary followed by slovakia eu 28 and similar results as the czech republic reached polandif we additionally add into comparison professional networks percentages are slightly raised there are not significant changes in the comparison of the trend see figure 2 only 05 of pensioners in the czech republic use professional networks see fig 2 fig 2 participating in social or professional networks source own elaboration based on 18 posting messages to social media sites or instant messaging is the next researched topic see fig 3 at first glance is it is evident from the graph and table in figure 3 that the czech republic is again on the last place and lags behind other countries despite the fact that from 2009 to 2012 posting messages increased by 3 other countries grew much more the highest increase was 12 in the eu 28 but the eu 28 reached in the 2012 the second lowest percentage in the reference sample about 18 to 47 increased messaging in slovakia 9 to 43 in hungary and increase by 7 to 42 in poland the connection of social networks with elderly people will be solved in the next part of the article czech republic the table 2 shows the reasons for utilization of the internet with focus on the use of social networks presented results are divided for citizens over 16 years furthermore according to gender over 16 years and then by age and according to economic activity status two age groups from 55 to 64 years and 65 years were chosen for comparison furthermore statistics are given for employed unemployed and pensioners both age groups in all economic activity statuses can be represented in the czech republic it can also for example happen that pensioner is employed in detailed table at czech statistical office is at the first glance evident that young adults are still the most likely to use social media 374 of the population over 16 years uses social networks according to the czech statistical office 407 individuals aged 16 to 74 years uses social networks according to the eurostat in the event that we focus on the individuals who use the internet the percentage will rise 495 of the population that uses the internet uses social networks according to the czech statistical office for gender there were no significant differences data shows that women and men use social networking sites at comparable rates the similar results were gained also in the pew research center 20 a slightly higher percentage of men 376 use social networks womens use is smaller by 03 in case that we focus again on the group using the internet the percentage will rise again 482 of men using the internet are also using social networks representation of women stand higher by 508 2009 as a of total number of individuals in a given sociodemographic group 2 as a of total number of internet users in a given sociodemographic group 3 as a of total number of social network users the data presented by eurostat for the czech republic covers only individuals aged 16 to 74 years the age groups shows that with increasing age is a declining trend for the use of social networks while 887 of the population from 16 to 24 years benefited in 2015 from utilization of social networks in the age group 1534 it was 723 from 3544 it was 239 101 of the population from 55 to 64 years and 33 of the population over 65 use social networks other statistics show that nearly 68 of users who use social networks attend these application every day or almost every day for older population this percentage decreases by almost a third to 454 a similar percentage 457 are also listed among pensioners from the data it is evident that almost half of the elderly people that use social networks are connected each or almost every day in the case that we will focus on the development in time it is from table 3 evident that in almost all of the analysed groups in the article increased using the social networks the exception is the last year when in the last two age groups has slightly decreased using of social networks as well as a decline among pensioners the available statistical data from the czech statistical office from 2011 used social networks 6 of people 55 to 64 years and only 1 of the population over 65 years another interesting statistics shows that a small percentage of the population uses professional networks see tab 4 only 41 of the population over 16 years use professional networks by the czech statistical office men outnumber women from 51 to 19 in the case that we focus on elderly people only 04 over 65 use professional social networks and 19 from 55 to 64 years in the event that we will focus on economic activity status 05 of pensioners use social networks the table also shows the data for employed and unemployed results are surprising 24 unemployed uses social networks participating in social networks was in the compared years in the czech republic and in poland on the lowest levels in visegrad 4 and in eu 28 in the czech republic and in poland participate on social networks more than 35 in eu28 it was 50 in slovakia 54 and the highest use presented hungary with 61 the development was in all countries similar instead poland due to the above mentioned facts it is not possible to confirm scientific questions which were stated in the second chapter of the article in the czech republic is also rising the percentage of the individuals aged 65 to 74 old people that have to use internet the next researched topic was the utilization of social networks in the czech republic and in other countries of visegrad group and the eu28 average it was found out that social networks were used in the followed period less often in the czech republic than in other countries involved into the comparison the question can be why do pensioners have digital literacy or necessary equipment are there the courses for seniors in the large cities like hradec králové also for these reasons we recommended to promote information and digital literacy to citizens and to invest in further education in this field information on the courses that are focused on the elderly people and computer literacy in hradec králové are presented in 26 most elderly people watch tv and read newspapers and for that reason promotion could focus on those channels but also on other sources this topic is also interesting due the smart cities the question in the discussion is whether the increasing number of pensioners in the czech republic will increase the number of internet users and social networking for 65 or will be still personal communication significantly more used it is expected that the increase in percentage of elderly people who will use advanced technologies will continue therefore the next question might be whether growing population in 5564 group which currently uses advanced technologies by 20 more than the 65 group will keep this trend the influence of family and health status on the utilization of social networks to communicate with other people or more detailed mentioned benefits gained from utilization of advanced technologies by elderly people may be other areas of research next important topic can be social networks and clustering 21

in the article we will focus on the elderly people in the connection with the utilization of social networks in the czech republic countries of visegrad group and the eu 28 individuals use social networks for sharing materials photos or videos communication or posting messages very important is also a topic of social isolation that will be discussed in the article the results of the statistics show that the share of seniors in the czech republic has an increasing trend the utilization of social networks by elderly people has in the czech republic also increasing trend except for the second quarter of the 2015 year when a slight decrease was recorded in comparison with other countries from visegrad group and the eu 28 the czech republic reached lower results in the utilization of social networks in two evaluated criteria from three the czech republic was comparable to poland the age groups show that with increasing age there is a declining trend for the use of social networks 101 of the population from 55 to 64 years and 33 of the population over 65 use social networks in the second quarter of 2015 data show that almost half of the elderly people that use social networks get connected almost every day

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background despite escalating poverty and communicable diseases the number of people surviving into old age is increasing and statistics show that the number of people with dementia is also increasing 12 according to the who 3 worldwide nearly 356 million people live with dementia by 2030 this number is expected to double and more than triple by 2050 as populations continue to age in 2009 the united nations estimated that between 2009 and 2050 africa would witness a 68 increase in people living to be 60 years or older statistics show that more than half of pwd live in lowand middleincome countries and an increase to more than 70 by 2050 has been projected similar estimates were also presented by prince in africa population aging is occurring at a faster rate 45 the prevalence of pwd in developing countries is estimated to be 5 in those over the age of 65 years 2 in 2003 in tanzania people aged above 60 years old were estimated to be 4 of the population and this figure is expected to increase to 10 by 2050 6 in 1998 the prevalence of pwd in egypt was 59 a recent review reported that the prevalence of dementia increase with age from 2 at 60 to nearly 13 at the age of 90 4 trends show that the prevalence rate increases with age and more women than men are affected 47 although the fundamental cause of dementia is not known available literature demonstrates the most important risk factors for dementia are stroke increasing age female gender low education low socioeconomic status cardiovascular disease and certain genetic markers 7 other risk factors include alcohol consumption and living in rural areas 89 in subsaharan africa authors have found that stigma exists around neurological and psychiatric diseases family members hide or do not report dementia cases and this could be linked to lower prevalence rates reported from developing countries 10 health care and social support it has been well documented that health care systems and services in less developed countries do not have adequate capacity to address the increasing demand of chronic diseases 1 unlike western countries where there are special programs for pwd such as memory clinics geriatric services social work and carer support programs the majority of pwd in the developing world are poor and do not have access to even basic care they are usually undiagnosed 11 and receive inadequate support from informal carers such as family members caring for pwd is one of the burdens that the family or caregivers face as part of cultural practice older people in africa are exempted or discouraged from carrying out complex functional tasks 11 this practice makes elders more dependent and might have consequences on cognitive function on the other hand due to ruralurban migration and the impact of hivaids on the younger population elderly pwd have additional responsibility to care for themselves as well as grandchildren the burden for women with dementia is even bigger because they have other domestic responsibilities although chronic diseases such as dementia require long term care and treatment there are no effective health policies for old age and the majority of old people do not have a pension and are not covered by any health insurance despite its socioeconomic and health effects dementia is not a public health priority in tanzania in tanzania for example the 2003 policy for old people 6 admitted that the majority of old people live in poverty and uncertainty most studies have approached dementia from a biomedical perspective in this study we adopted a social model 12 to explore the sociocultural beliefs surrounding dementia and the life experience of pwd and their caregivers in the hai district of tanzania in the current study dementia was defined as a syndrome caused by disease of the brain usually of a chronic or progressive nature in which there is disturbance of multiple higher cortical functions including memory thinking orientation comprehension calculation learning capacity language and judgment 13 the term dementia is used to describe the symptoms that occur when the brain is affected by specific diseases and conditions symptoms of dementia include loss of memory confusion and problems with speech and understanding 13 methods design and methodology this was a crosssectional communitybased study which employed qualitative methods study area hai district is in east part of kilimanjaro region the district has 14 health facilities including machame district referral hospital hai district has a population of 210533 and the proportion of people aged 70 years and above is about 2 however the hai demographic surveillance site where the research was based had a population of 160000 at the time of the 2009 census on which the prevalence study was based of whom 5 were aged 70 and over 11 the majority of the population lives within 5 km from a health facility the national referral hospital kilimanjaro christian medical center and mawenzi regional referral hospitals are just 25 km away the population of hai is mostly involved in both food and cash crop production and animal keeping literacy level in the district is over 90 most families have access to a smallholding and daily activities consist of agricultural work including cultivating and animal husbandry alongside running the household and taking care of family members sampling procedures the study was part of a larger study of the prevalence and treatment gap for dementia in hai district hai district is an established demographic surveillance site we purposively sampled 41 pwd identified by the prevalence study for recruitment of pwd we considered their ability to express clearly age 70 years and above gender village and marital status data collection methods two experienced social scientists performed the interviews indepth interviews were performed in nine villages namely mudio bomangombe mbweera nshara sawe kwasadala kware kyuu and urori data collection took place between february and april 2011 using kleinmans explanatory model data collection tools were developed to examine perception of dementia meaning attached to and experiences of pwd and their carers and their health seeking behaviors 12 we conducted 25 paired interviews which involved both pwd and their carers and 16 interviews which involved carers alone paired interviewed was adapted during the data collection after noting that some of the pwd had difficulties in expressing themselves or remembering things in this case most of the information was given by carers the majority of carers are family members who have lived with patients for more than 20 years interviews were conducted in kiswahili at home and were recorded using a digital device each interview lasted for about 45 minutes the key questions asked were 1 in your opinion what is dementia 2 could you please tell me your experience with dementiacaring for a person with dementia source of social support etc ethical approval was obtained from the national institute of medical research and locally from kcmu college research and ethics committee the objectives of the study were explained to study participants and written consent was obtained from pwd and their carers in advance permission to record interviews was sought from study participants prior to commencing interviews confidentiality and anonymity were strictly observed data analysis recordings were transcribed verbatim and translated into english by three researchers data were checked and cleaned and then stored as microsoft word files data were manually analyzed using a content analysis approach 14 which included identification of recurring themes categorization and interpretation analysis was undertaken and discussed by the two social scientists involved in the study results forty one participants were purposively recruited these included 25 pwd and 16 caregivers males were 15 and females 26 the age of patients was 70 and above with median age of 84 and 26 aged between 80 and 100 the majorities were widows 22 widower in 6 and married in 13 nearly all patients were from the chagga ethnic group while 35 were christian and 6 were muslim all patients were farmers and 33 had no primary education seven had some primary education while one was educated beyond primary no one had a pension and only one patient had health insurance a total of 16 caregivers participated in the study half were married 5 were single and 3 were divorced the age of caregivers ranged between 19 and 58 years old only 6 of the caregivers had formal employment most of the caregivers were the regular carers of pwd and had lived with patients for more than 10 years knowledge and perception of dementia from our findings no participants knew the term dementia out of those interviewed 14 pwd and 21 carers saw the disease as uncommon but referred to it as a normal disease of old people ugonjwa wa wazee or ugonjwa wa kusahau across the interviews the phrase hii ni kawaida kwa wazee was mentioned several times by both patients and caregivers ten pwd and 17 caregivers could not describe the disease the common response was i dont know what the problem is during interviews six pwd and 18 caregivers associated dementia with other diseases like high blood pressure stroke diabetes and malaria dementia was reported to be a result of old age life stress thinking deeply death of dear ones in pwd and 9 caregivers four pwd and five caregivers related dementia to curses or witchcraft seven of pwd and six caregivers said they didnt know the cause of disease most responded mungu anajua no participants mentioned that dementia could be inherited symptoms of dementia participants were asked to describe any symptoms of dementia which they knew their responses are summarized in the table below in more than half of the interviews participants said that people in the community have little knowledge about this problem when asked how and when they noticed the problem about half of the caregivers said after a sudden fall and others said it started slowly and the major sign was memory loss stigma against dementia although no strong stigma was attached to it dementia is accepted as an old age problem and people believe nothing much can be done about it one female caregiver said that people do feel bad to have patients with dementia another respondent said majority of pwd do not have interaction family members feel shy to disclose their status health seeking behaviour of 41 pwd 22 had attended modern care 13 had sought help from prayers in the church and 6 had been to traditional healersherbalists the majority 30 of interviewees reported pluralistic behavior in seeking care and had sought help from modern care and from prayers or traditional healers we noted that participants were free to say that they had visited modern care had spiritual help or seen the traditional healers further probing revealed that caregivers reported that most of the time when they took patients for modern care it was due to other health conditions and not necessarily for dementia treatment a 35 year old male carer said because we know there is no treatment for dementia in our area people take pwd to hospital for other treatment when asked why they took pwd to alternative care the common response was that we think the problem is beyond human control only god knows the solution a female patient complained that modern treatment is not helping and the situation is getting worse as days go on on the question of effectiveness of different forms of treatment there were mixed feelings the majority of pwd and caregivers who had been to seek modern care or prayers confessed that they didnt see much improvement however 1225 of pwd and 6 16 of caregivers had a positive attitude towards modern care the common phrase was that the modern treatment is better because health workers are knowledgeable seven caregivers believed that prayers are more effective a female patient aged 71 years old said prayers are very helpful because you get encouragement no one commented positively on the effect of traditional healing almost all those who had been to traditional healers said they didnt see an improvement a female caregiver aged 47 years old said the only solution is to attend hospitals and to trust god source of social support nearly all pwd receive social and economic support from close family members such as spouses children grand children relatives or neighbors and only 8 caregivers said their pwd could manage their life without close supervision from caregivers majority of caregivers were females followed by grand children as shown in table 2 caring for pwd pose great challenge to caregivers because they cant fully engage in other productive activities and sometimes it can cause conflicts participants were asked to what extent the disease has impacted on their life their responses are presented in table 2 views on how to address the problem pwd and caregivers had expressed different views regarding what should be done to help pwd and their families doctor should educate us more because we dont know much about this problem table 1 summary of symptoms of dementia as reported by participants pwd caregivers memory loss forget the road or people including their own children forget things or places forget to eat or to change clothes forgetting people lost in conversation repeating same stories talking stories of the past difficult in keeping change during businessreturning more or less change sitting in one place for a very long time doingrepeating the same things twice or more shouting during the night difficulty in eating the quotations above shows that pwd have different needs which could be met by involving health care providers ngos religious institutions and the government discussion in this study we aimed to explore the sociocultural beliefs surrounding dementia and the life experience of pwd and their caregivers in the hai district of tanzania the study shed light on the facts that knowledge about dementia and its causes is low in this area and dementia is accepted as an old age problem in addition pwd and their carers have pluralistic behavior in seeking care and dementia has a huge impact on the social and economic life of families of pwd the findings from this study are generally similar to previous studies 31516 however more insights on what issues to consider in designing communitybased interventions in resource poor settings are discussed social demographic characteristics and social support in this study females with dementia constituted a larger proportion nearly three quarters of pwd were single meaning that they depend from family members for social support the majority of pwd are poor and economically inactive which pose a great challenge to people who are demented and old we further noted that all had no pension or health insurance meaning that they pay their health bills from out of pocket pwd heavily depends from their children grandchildren and close relatives for support we also noted the interdependence between some of the pwd and their grandchildren pwd provide support to their grandchildren and they also receive support and help from their grandchildren however challenges posed with this kind of interdependence in tanzania context and particularly among elderly with cognitive difficulties need to be studied further knowledge causes symptoms treatment and care knowledge of how people understand dementia and its impact is fundamental to designing clinical care and awareness raising programs knowledge about the causes of dementia was described using both a biomedical and a social model the majority of the patients fell under a biomedical explanation as they associated dementia with diseases old age and life experience interestingly no one mentioned that people could inherit dementia under the social model only a few participants associated dementia with curses or witchcraft recent studies have shown similar findings 17 nearly half of participants could not describe the dementia they kept saying i dont know what is the problem and that god knows in their context this means that it is the will of god normally chronic diseases which people believe cannot be cured with medicine are often seen as gods will or punishment 18 connel et al 19 commented that relating illness as gods will reflect high value placed on religion in the african american community such beliefs usually mean some degree of disease acceptance and that nothing can be done about it in line with other studies elsewhere the majority of participants described and accepted dementia as a normal old age problem 319 this may explain why most participants described the disease using a biomedical model although knowledge on symptoms was sufficient knowledge of dementia causes and treatment was found to be inadequate only two medically confirmed risk factors were known to the study participants limited knowledge about dementia could be associated with health service factors and the nature of the disease at health facility level the system doesnt have special programs for pwd and maybe doctors or health professionals dont explain the problem to the pwd or caregivers with regard to the nature of disease dementia is currently relatively rare 20 and this could explain why nearly a quarter of participants didnt know about it we also noted that unlike other chronic diseases such as epilepsy and parkinsons disease 21 dementia was less associated with witch craft or curses and little stigma is attached to it in hai 1022 health seeking behaviour this study found that the majority of pwd seek health care in more than one health sector including modern care traditional sectors and prayer sessions the biomedical sector seems to be favoured more when other options fail over half of pwd had visited modern care however it was not clear if they did so specifically for dementia or due to other health conditions people have the perception that nothing can be done and so they also seek care from other sources particularly if people relate the problem with supernatural powers religious services such as counseling and prayer are part and parcel of peoples life in hai a substantial number of pwd had sought help from prayers in the church this implies that if religious leaders are targeted and involved they could help in offering advice and support to community members they could also offer a venue for training and a meeting point for pwd and their carers based on these findings intervention for dementia requires effective coordination between modern care and informal health care experience and coping with dementia as has been found elsewhere pwd in hai district suffer from multiple problems such as poverty ageing challenges other diseases stigma inadequate health care and lack of health insurance pwd are cared for by informal unpaid relatives or children who do not have knowledge and support skills 3 brodaty and luscombe correctly argued that caregivers are at risk of becoming socially isolated because of the demanding nature of their role 23 older people in africa are exempted or discouraged from carrying out complex functional tasks this makes elders more dependent and might have consequences for their cognitive function 11 although people believe nothing can be done about dementia participants expressed views about the burden of care for pwd and the need for improved care and support of pwd and their families participants expressed that support such as food money appropriate information and care centres could help reduce the burden of care providing support to carers on the caring process and development of relevant skills should be the focus of any intervention at a community level interventions such as support groups have proved to be effective in reducing the burden on the family 24 in the study area there is no governmental organization or programme addressing the problem of dementia unlike in the west where there are special programs for pwd such as memory clinics and cognitive stimulation therapy previous studies in the hai district have reported that there are no health facilities which meet the needs of people with cognitive impairment 2225 participants had the view that churches could play an important role in this area through the establishment of day centres for older people in churches where relatives could leave their pwd this could allow family members or other caregivers to engage in more productive work 26 it is worth noting that in the hai district churches are very active in health care provision and in each parish there are two committees which deal with various social problems in the community regardless of peoples religious background in designing community based interventions for people with dementia planners could exploit their potential according to who 3 only eight countries worldwide currently have national programs in place to address dementia a recent report by who and alzheimers disease international 3 recommends that programs should focus on improving early diagnosis raising public awareness about the disease and reducing stigma and providing better care and more support to caregivers the same report recommends that caregivers should be involved in designing programs to provide better support for people with dementia and those looking after them moreover in resource limited countries like tanzania deliberate efforts are needed at a national level as the elderly population is expected to increase by more than 10 by 2050 6 who promote preventive programs both in high and low income countries because they could delay the need for people to enter highcost care 3 study limitation this study had two major limitations first biases might have been introduced by individuals who might have given socially desirable answers particularly when probing about the challenges facing carers secondly the fact that we conducted paired interviews the views of care givers might have been more dominant in some aspects than those of pwd conclusion this study sheds light on the fact that knowledge about dementia and its causes in this area of tanzania is in adequate and it is generally accepted as an old age problem pwd and their carers have pluralistic behaviour in seeking care from modern care prayers and traditional healers since dementia is considered to be part of normal ageing and since there is little or no awareness of risk factors for dementia medical intervention is rarely sought based on our findings intervention for dementia requires effective coordination between modern care and informal health care despite the social and economic impact of dementia the majority of the carers and family members lack basic skills on how to care for people with dementia family and caregivers need more education on causes early recognition of symptoms and cost effective management of dementia at a family level faithbased organizations could play an important role in communitybased dementia interventions at national level effective policy and improvement of the health care system to address the needs of pwd and their families are imperative more research should be carried to develop culturally appropriate family based interventions to support pwd and their caregivers in poor resource settings competing interests the authors declare that they have no competing interests authors contributions dm designed the study collected and analyzed data and prepared the manuscript for publication ar and cm completed data collection and conducted initial data analysis smp was involved in the identification of patients and in preparation of the article rw and cd provided scientific advice and input during study design and writing up all authors read and approved the final paper

background with the increasing number of people surviving into old age in africa dementia is becoming an important public health problem understanding the social dynamics of dementia in resourcepoor settings is critical for developing effective interventions we explored the sociocultural beliefs surrounding dementia and the life experience of people with dementia pwd and their caregivers in the hai district of kilimanjaro tanzania methods crosssectional qualitative design forty one pwd were purposively sampled from the hai district of kilimanjaro twenty five paired interviews with pwd and with caregivers and 16 with caregivers alone were conducted interviews were tape recorded transcribed verbatim and analyzed using content analysis approach results forty one pwd 26 females aged 70 years and older were recruited but due to speech difficulties only 25 participated in the interviews married were 13 widow in 22 and widower 6 the majority 3341 were illiterate pwd and carers perceived memory problems as a normal part of ageing dementia was commonly referred as ugonjwa wa uzeeni disease of old people or memory loss disease the majority of pwd 1312 and carers 716 did not know what dementia is or what causes it dementia was felt to be associated with stroke high blood pressure diabetes old age cursewitchcraft and life stress half of the participants had used modern care and alternative care such as herbs prayers or traditional healers caregivers complained about the burden of caring for pwd and suggested that community organizations should be involved in addressing the problem conclusions knowledge about dementia is low and the symptoms are accepted as a problem of old age pwd and carers demonstrate pluralistic behaviour in seeking help from modern care prayers and traditional healers the disease adds significant burden to family members family and caregivers need more education on early recognition of symptoms and cost effective management of dementia at family level faithbased organizations could play an important role in dementia interventions at a national level effective policy and improvement of the health care system to address the needs of pwd and their families are imperative

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introduction the term long covid is now widely used to describe the ongoing illhealth experienced by a significant minority of people who have had sarscov2 infection 1 some organisations use different terms including postcovid condition and postacute covid syndrome but long covid is the preferred term of patient groups the term was coined by those with lived experience of persistent symptoms in the first months of the pandemic 2 in the first half of 2020 little attention was paid to the emergence of longerterm symptoms with surveillance focused on numbers of cases hospital admissions and deaths much of the political and clinical focus was on reducing transmission and the impact of acute covid19 through public health measures including lockdowns however the messaging at the time of a dichotomous disease profile of mild or severe did not match the experience of many people who came together in online groups to share their stories 3 group members reported a range of symptoms and lack of recovery months later even in those who experienced minimal symptoms at the initial stage of infection the challenges faced by this growing community were compounded by the lack of covid19 testing to confirm and validate symptoms and the focus of most research on people who were hospitalised with covid19 the lack of recognition was the catalyst for and focus of many long covid support groups led by patients these included people with professionally validated forms of authority such as clinicians academics and public representatives suffering from long covid themselves who sought to raise awareness and prompt the call for recognition research and rehabilitation 3 4 5 one early group was body politic on slack which had an international reach and provided distinct spaces for specific demographic groups or people with particular types of symptoms 6 the patientled research collaborative was formed by members of the body politic group and produced the first survey of prolonged symptoms following covid19 infection in may 2020 7 in the uk groups such as the long covid support group on facebook or the long covid sos website emerged to provide more local support 89 many long covid studies have recruited participants from these online support groups social media or through specific clinical services for people with long covid 10 while the support groups have been open to all there will be many people and groups who are not included research into other chronic condition support groups has shown that taking the step to join can be difficult with some feeling a diagnosis is needed to legitimise membership 1112 people who are experiencing new or persistent symptoms following covid19 infection • the agreements and procedures governing usage and sharing of the collected dataset established by the study sponsors present a study proposal that has received approval from an independent research committee or research ethics board 2 provide a data request for review by the study principal investigators and coinvestigators 3 following approval of the request execute a datasharing agreement between the investigators and the study pis study proposals and data access requests for elements of raw data may be sent to the react data access committee may have limited awareness of long covid and this may reduce the likelihood that they seek out support groups or clinical assessment furthermore the demographics of these support groups and social media communities appear to be skewed in terms of gender ethnicity and age for example in their study of persistent covid19 symptoms davis et al distributed a survey via patient support groups and social media and found that the majority of respondents were white women aged between 3059 they acknowledge that their findings may not be representative of the entire long covid population or their experiences 1 further research drawing on more representative samples is essential to get a broader picture of who is being affected by long covid and how this impacts their lives the react study involves repeated random crosssectional samples of the population in england to quantify prevalence of virus in the community by rtpcr and to estimate the prevalence of igg antisarscov2 antibody positivity based on a selfadministered lateral flow immunoassay test 13 taking this nationally representative sample as a framework for recruitment the reactlong covid study aims to identify the genetic biological social and environmental pathways that underpin progression to long covid following covid19 one component is a qualitative interview study to explore variations in experiences of people with new and persistent symptoms after infection with sarscov2 who were not hospitalised we undertook a pilot study to inform the design of the larger qualitative study and to identify preliminary insights into the experience of new and persistent symptoms after covid19 and explore awareness and perceptions of the term long covid methods sample and recruitment the pilot took place in the reactlc assessment centres between may and july 2021 people were invited to one of these assessment clinics across england if they had taken part in react and had a documented history of sarscov2 infection were not hospitalised and who may or may not have reported persistent symptoms a total of 10525 people attended these reactlc assessment centres where they underwent clinical tests and had samples taken for multiple biological investigation the aim of these studies is to characterise genetic and downstream biological pathways responsible for individual differences in response to sarscov2 infection participants were eligible to take part in the pilot study if they were attending the reactlc clinical assessment centre in west london where the research team is based and reported persistent or new symptoms following covid19 this was a convenience sampling approach we undertook the pilot study at a time when the assessment centres were prioritising recruitment of people aged 1834 years old allowing us to reach a younger cohort than those often included in long covid studies ec attended an assessment centre in west london and with the help of the clinic research nurses and reception staff offered those who had persistent symptoms the opportunity to take part in a research interview immediately after their clinical assessment initial uptake was slow due to limited interviewer availability a minority of people reporting persistent symptoms participants being unable to stay for an interview and the challenges of social distancing within the clinical setting the exact number of people who declined to participate are unknown as only those who opted in were introduced to the researchers the recruitment approach was subsequently altered to allow centre staff to consent eligible participants to be contacted by ec and al for remote interviews at a time convenient to them we undertook a total of 13 interviews with nine participants aged 18 to 34 years and four aged 35 to 44 years old topic guide the topic guide was designed in collaboration with the reactlc public advisory group an initial outline was developed by ec guided by the research questions and informed by current literature on long covid this outline was then shared with and edited by pag members individually as well as during a series of group video calls the pilot guide aimed to follow the patient journey from precovid19 health through initial covid19 symptom experiences to then discuss any symptoms that persisted or new symptoms that appeared after 12 weeks the guide also covered access to and availability of long covid support and views on long covid as a term the advisory group suggested key areas of focus such as symptom fluctuation and factors that promoted or prevented recovery the semistructured style of the guide provided broad topics for discussion using prompts and probes to be used at the interviewers discretion the topic guide can be found in s1 appendix interviews semistructured interviews were carried out by ec and al either face to face in the assessment centre or remotely by telephone or using video conferencing software teams depending on participant preference interviews lasted between 19 and 70 minutes with participant consent interviews were recorded using a digital recorder or using the builtin recording function on zoomms teams after the interview was completed the audio recording was saved to a secure folder at imperial college london and deleted from all devices the audio recordings were sent for transcription to an external provider the transcripts were then downloaded back to the secure folder the researchers kept field notes following interviews to support analysis analysis an initial thematic analysis of the pilot interviews was carried out in nvivo transcripts were inductively coded by ec and al and a consensus on the final codes was made through a process of comparison of the researchers codebooks 14 the content of the codes were then reviewed by the researchers and descriptive topic summaries were developed through a process of detection 15 preliminary findings were not discussed with participants but were instead reviewed by the public advisory group for this pilot study we drew on the experiences on a limited number of participants and undertook an initial thematic analysis to produce our current findings these findings are descriptive and therefor are not presented as major or minor themes while this study provides insights into experiences of living with persistent symptoms following covid we do not claim to have reached data saturation and will endeavour to explore a more diverse range of voices in our main study patient and public involvement the reactlc pag is made up of nine members with experience of living with or caring for someone with long covid initial contributions included the development of the recruitment material and topic guide a detailed summary of our pilot findings and planned approach to sampling for the main qualitative study were presented to the pag for feedback one pag member undertook a review of this paper and is listed as a coauthor reflexivity statement ec is a white female research assistant with a background in qualitative research and anthropology al is white male research physiotherapist with a background in clinical practice specialising in respiratory medicine ec and al both have experience and training in qualitative methods no relationship was established between researchers and participants prior to study commencement participants were given a brief explanation of ec and als role as qualitative researchers within the reactlc study and the overall goals of the project the authors were aware of how their own position may affect the study design analysis and interpretation of the findings both researchers were aware of the current literature and social media discussions regarding long covid but neither had lived experience of the condition we anticipated that participants would share a wide range of experiences in terms of symptom type severity and impact but did not have preconceived ideas regarding potential findings or interpretations the researchers worked closely with the reactlc pag to support the analysis and reporting of our findings governance this study received ethical approval from the southcentral berkshire b research ethics committee and all participants provided informed consent to be interviewed this manuscript is written in accordance with the standards for reporting qualitative research which can be viewed in s1 checklist results thirteen people were interviewed between may and july 2021 the sample included 6 women and 7 men aged between 18 and 44 years participants were from a range of ethnic groups with 8 being of white ethnicity all had experienced persistent symptoms of covid19 for more than 12 weeks three had received a positive rtpcr test and ten had a positive antibody test below we report on our preliminary findings related to how participants experienced persistent symptoms and their perception of the cause of these symptoms we also present findings related to their understanding awareness and views on the term long covid symptom experience participants reported a wide range of ongoing symptoms following the acute phase of covid19 with some reporting symptoms persisting well beyond the initial illness others reported the development of new symptoms in the weeks and months following infection the symptoms that persisted tended to appear at some point during the initial illness and continued even after the individual felt they had largely recovered from the worst of the acute phase these persistent symptoms included breathlessness fatigue headaches loss of taste and smell a lack of energy and for one participant a continued temperature i had a temperature for like i would say probably three weeks it wasnt as intense as the first four days then i would still get days where my temperature would go really high and that was quite debilitating the trajectory of symptoms varied and often fluctuated were sometimes unpredictable one participant told a story of initial recovery and tentatively restarting work social and physical activity only to experience a significant relapse in symptoms i was feeling more or less fine there and then i started to push so i started to run a bit because i was feeling better but you know like having pizza more like a normal life like its the weekend its sunny you have a beer you order pizza and i started to run and that was the worst mistake ever that gave me a super big relapse and then in october i went basically downhill again so my symptoms came back with revenge new symptoms experienced once the acute illness had passed were diverse in presentation with little consistency between individuals some of these new symptoms seemed similar to those experienced with the initial illness such as a sore throat temperature weakness or headache but they had appeared at a later point for some participants for others new symptoms were more distinct and included a variety of things such as loss of coordination weight change pins and needles vision changes and chest pain among others sometimes the onset of such symptoms could be months after the initial infection then on one particular day it could have been a month it might have been two after but a long time after all the severe things i remember just having the thing that everyone describes as like the rocks pressing down on your chest just one day of having that the most severe if it happened again i probably would have taken myself to the hospital but it did only happen once really bad for some these new symptoms included flaring up of preexisting conditions or were similar to symptoms they had experienced before covid19 making attribution uncertain menstrual changes were reported by a number of participants one reported having periods which were really really painful and another described her symptoms getting worse during her period so by end of april i was feeling more or less good then my period came and it was like all my symptoms started to be really really bad i woke up with my heart beating really really fast so i called my gp and he referred me to go to the hospital breathlessness and fatigue featured in participant descriptions of both persistent and new symptoms the severity of breathlessness varied with one participant needing to use his asthma inhaler more frequently after running and another participant was so breathless they could no longer use the shower fatigue was a major concern with one person describing waking up more tired than i went to bed and another highlighting the compromises that are needed to manage fatigue so i guess the big things were fatigue my partner has actually banned the t wordwe call itin my house me saying im tired because hes like you say it all the time so yes im really tired normal activities that i would have done before that would be simple are exhausting i have to put all my energy into work rather than anything else anything social working out exercise and things like that have really fallen by the wayside participants were asked to describe a good day and a bad day to explore the extent of the fluctuation and the varying impact on their day to day lives a good day i can smell my coffee my toast and i wake up before my alarm i can have a full day on my feet and at the end of the day ive got energy to meet with a friend so thats a good day like what it used to be full of energy a bad day everything just takes a little bit extra energy so mentally as well and emotionally everything is just quite difficult to engage or i feel a little bit distracted i struggle at work being on my feet the whole day perception of symptom cause during the interviews participants were asked to describe their thoughts and feelings about their new or persistent symptoms some questioned whether these symptoms were related to covid at all instead suggesting other social or environmental determinants including lockdown and related changes could be responsible well no yes yes well i have constant headaches that is true but i dont know if that is because of covid or just because im stressed it is psychological but it is very weird and sometimes it appears in the righthand side of my head and then goes up and then to the left some days i lose entire days because i cant focus but i dont know if that is covid one participant reported how he was struggling to exercise since having covid earlier in the year but that this was perhaps related to a lack of routine i think that because on my days off i would have enough energy to go to the gym and just feel more motivated but i dont have that at the moment im just doing what i need to do and then just rest yes i dont know if its because i need to get back into a routine i dont know if lockdown messed that routine up and i just need to get back into a routine when i just need to get into things moving again i dont know the effects of the pandemic and lockdowns over the past year were cited as a potential cause of symptoms one participant highlighted how their mental health had been affected leaving them feeling emotional due to a lack of control another suggested that she initially suspected her coordination and dizziness symptoms were due to being stuck indoors during lockdown those participants who described more certainty that their new or persistent symptoms were covid related had views on possible mechanisms driving their symptoms participants understanding of the cause was determined by how the symptoms manifested what information they were able to glean from their own research or medical investigations and what treatments they felt worked for them for example a participant experienced onesided muscle weakness along with brain fog blurred vision and loss of smell which made her think of a neurological cause however she later explained that she was trying treatments related to a broad range of body systems and found some particularly helpful despite not having been prescribed them and i have found that the vitamin b12 is really making something i dont know if maybe my blood tests show that i was not deficient but i have a feeling that maybe that was not totally right because when i have it i feel basically normal i even forget about covid a participant who was suffering from nonspecific chest pains expressed confusion about the cause of his pain he could not tell whether it was his heart or his lungs due to the side of the body the pain was radiating from and he was uncertain if there were in fact two separate kinds of pain with different causes on one occasion it appeared as a sharp intense pain then other times as gradual and less severe he reported having multiple investigations including a chest xray in which clinicians reported they didnt see anything leaving him with no further insight into the cause of his pain understanding and awareness and relevance of the term long covid in the interviews we asked participants about covid19 including whether they were experiencing any persistent symptoms we tried to avoid using the term long covid in the interview at this point although they were likely to be aware that the main study was called reactlong covid however later in the interview we asked specifically about their knowledge and awareness of long covid although some had already referenced it when speaking about their symptom experience those who didnt know much about long covid suggested it hadnt crossed their mind as a possible diagnosis despite their persistent symptoms some did not view long covid as a distinct illness for example seeing these persistent symptoms resulting from the body still dealing with the consequences of the acute phase others described the ongoing symptoms as a natural part of the recovery process which they saw as taking more time compared to other conditions such as the flu patients who are still not recovering theyre still dealing with a lot of the symptoms their body is still taking a toll from what theyve been through and its just affecting their daytoday activities some reported that they only found out about long covid through a clinicians suggestion which led them to read more about the condition but with the amount people reported carrying out their own research varying between participants receiving a potential diagnosis gave some participants a sense of vindication confirming what they were experiencing was real and giving them a sense of control for one participant however the diagnosis was devastating because there was no information about recovery or a cure a number of participants mentioned being made aware of long covid in the media and seeing the similarities to their own symptoms however for one person this meant seeing only the worst cases of long covid which were much more severe than anything they had experienced witnessing severe cases of long covid such as those depicted in the media or experienced by family members led some participants to feel that their own persistent symptoms were not severe enough to count one participant reflected on whether the term long covid applied to them so i feel like it probably doesnt apply to me because i feel like my symptoms or whatever i have left is not as severe as what other people are going through confusion about what should be classed as long covid was widespread some felt that they were not sure if their symptoms fit with the normal long covid symptoms because they were too niche or that they were different to the more widely discussed symptoms like fatigue or breathlessness one participant felt that the current definition was too wishy washy to understand yes so its a bit wishywashy to me anyway but also i think everyone is feeling that theyve got slightly different as well its not all a b and c and thats what everybody is feeling my kind of understanding is oh some people are getting headaches some people still cant taste anything and some people you know so its one of those things its a bit of a broad term isnt it some shared a view that their experience did not fit with what would be commonly defined as long covid however they also reported that they did not know the medical definition it is important to acknowledge the interview effect on whether a person thinks they have long covid one participant stated they had not thought of their symptoms as being long covid until they had been asked the questions for the interview after talking to you actually yes i was like hold on really i could have had it at that whole time i didnt really think about it in a way views on the term long covid opinions on the term long covid were mixed some liked the term and felt that it was sensible and perfectly appropriate for example using the term talking to a person in the street they felt people would understand what it meant others had no strong feelings stating they had no objection or werent really concerned by the specific name or label probably i would say tell it to anyone in the street and they would be like yes i get what long covid is i would rather that term than say chronic covid that would be a lot more worrying we would be like oh god do i have a disease in me or something like that one participant stated that the connotations of covid as being chronic would create a stress that could hinder her potential recovery for her it was important to believe that she will eventually recover those who disliked the term long covid felt it sounded as if they still had covid this was seen to be confusing for the public and that it could create fear particularly in those who were shielding one participant felt that the initial debates about long covid in the media had tarnished the term to some extent leading some people to believe it was not a real thing creating a new name for the condition rather than using a term developed out of necessity was put forward as a potential solution some of those who disliked the term long covid suggested the alternative label of postcovid which they felt emphasised that it is experienced after the initial infection yes the long covid name to me feels like youve still got covid its like a long version of it like youre still suffering from covid thats how it comes across to me i always say post covid personally just because usually when talking about things like postop you would say not longop discussion summary and implications of our findings in this pilot study we sought to gain preliminary insights into the experiences of those with new or persistent symptoms following covid19 infection participants experienced a diverse range of symptoms that either persisted or developed some time after their initial sarscov2 infection it was reported that multiple body systems were affected and severity varied widely with some participants reporting that persistent symptoms were significantly more debilitating than the early infection itself a key challenge reported by participants was the unpredictable or fluctuating nature of their symptoms our findings on symptom experience echo the voices of those living with persistent symptoms 689 and concurrent research 1617 our pilot findings offer new insights into perspectives of those living with persistent symptoms which have been underexplored we uncovered differing explanations of symptom cause and attribution some participants were confident there was a causal link between their current symptoms and covid19 based on an awareness of others with shared experiences their own interpretation of existing scientific research or confirmation by a medical professional others expressed doubt about whether covid19 was the actual cause of their symptoms alternative explanations offered by participants related to the physical and emotional impact of the pandemic we also found that not all participants were familiar with the term long covid and some did not feel it applied to them or their symptoms some participants suggested their symptoms were related to a prolonged yet typical recovery from covid19 infection rather than a distinct illness others were aware of long covid but felt that their symptoms did not fit the diagnosis or were not severe enough to count this variation in symptom attribution and understanding of the term long covid has implications for recruitment approaches and warrants deeper exploration in future research we did not directly recruit from support groups or social media which have been used as a key source of participants for long covid symptom and qualitative studies 18 those we interviewed were part of the react study experienced persistent symptoms and had chosen to participate in the clinical strand of the long covid study however they were not recruited based on being diagnosed with or believing themselves to have long covid our naïve assumption was that participants would associate what they were experiencing with the term long covid but through conducting the interviews it quickly became apparent that participants interpreted their symptoms in several different ways by including only those who identify as having long covid in studies we might fail to gain an insight into the perspectives and experiences of those who have new unexplained or persistent symptoms but who do not recognise their condition as being included within the long covid category these findings may also have impact beyond research those who do not recognise or identify with the term long covid may not access healthcare services for investigation and management of their persistent symptoms or may not seek peer support through long covid groups in the absence of certainty around the biomedical facts of this emerging illness there is potential for conflict around how long covid is understood framed and categorised callard and perego suggest the term is unstable and highlight that it is crucial that long covid patients with different disease experiences and pathways are included in deliberations over terminologies used for longterm symptomsillness 3 in our main qualitative study we will further explore the insights raised in the preliminary findings of this pilot planned changes to our main qualitative study the primary aim of this study was to inform the design and conduct of our main qualitative study undertaking this pilot has helped us identify key areas for improvement particularly in terms of sampling and recruitment strategies the topic guide and analytic approach a full overview of how this pilot has informed our main qualitative study design can be found in s2 appendix sampling and recruitment strategies the study sample was drawn from wider react cohort which was itself a representative sample of the population of england however the limitations of our sampling approach and the smallscale nature of this pilot meant we were not able to reflect the full diversity of age and ethnicity in the current study furthermore recruitment took place in a single geographic location and participants needed to be well enough to physically attend a reactlc assessment clinic so we are likely to have not captured those experiencing more debilitating long covid symptoms in the main study we aim to recruit a larger and more representative sample we will broaden our recruitment approach to include those who have attended reactlc assessment centres across the country and additionally draw on respondents to a reactlc questionnaire which will be sent to more than 200000 react participants we will purposively sample for diversity of experience and demographic background this will be particularly important for ensuring the ethnic diversity of the sample the lack of ethnic diversity in health research participation and the existing barriers has been widely documented 19 a recent rapid review highlighted a lack of diversity in long covid qualitative studies and encouraged researchers to prioritise recruitment of patients from diverse social and ethnic backgrounds to better represent the demographics of wider society 17 topic guide and analytic approach undertaking pilot interviews provided insights into how the topic guide in the main study could be improved we identified a number of gaps and found that the structure of the guide did not fit with the natural trajectory of the narratives shared by participants one significant improvement will be the mapping of change relative to participant baseline in 2019 we will use their prepandemic experience as an anchor to prompt and probe participants on what has changed and how their symptoms have impacted these elements of their lifestyle the topic guide will be adjusted to allow for more indepth exploration into the lived experience of new and persistent symptoms including treatment and recovery as well as new topics such as changes to menstrual cycles sex and intimacy we will conduct more indepth and explanatory analysis of the data using reflexive thematic analysis in the main qualitative study to provide insights beyond basic descriptions of different experiences 20 we anticipate that our approach will be informed by social science literature to allow us to draw on theory related to how illness is constructed contested and stigmatized when examining the evolving meaning of the term long covid 21 22 23 conclusion we undertook a pilot to inform the design of our main reactlc qualitative study this pilot provided preliminary insights into the experiences of new and persistent symptoms following covid19 infection even within this small sample we identified significant variation in symptom type and severity as well as differences in awareness or perceived applicability of the term long covid the findings also show a variation in participants attribution of ongoing symptoms these insights highlight the value of including a range of people in long covid studies not just those already accessing services and support groups by recruiting beyond these groups research might reach those who do not seek or are not offered support and treatment for their persistent symptoms this pilot study along with feedback from our advisors with lived experience of long covid has shaped the development of the main qualitative study we have broadened our recruitment approach and will undertake purposive sampling based on variations in experience and demographics additional improvements include restructuring the topic guide and taking a more indepth and reflexive approach to analysis we hope other social science researchers may find our insights helpful in designing their own long covid studies there are ethical or legal restrictions on sharing a deidentified data set the full study data cannot be made publicly available due to • the sensitive nature of this data competing interests the authors have declared that no competing interests exist supporting information

long covid is a patientmade term describing new or persistent symptoms experienced following sarscov2 infection the realtime assessment of community transmissionlong covid reactlc study aims to understand variation in experiences following infection and to identify biological social and environmental factors associated with long covid we undertook a pilot interview study to inform the design recruitment approach and topic guide for the reactlc qualitative study we sought to gain initial insights into the experience and attribution of new or persistent symptoms and the awareness or perceived applicability of the term long covidpeople were invited to reactlc assessment centres if they had taken part in react a random communitybased prevalence study and had a documented history of sarscov2 infection we invited people from reactlc assessment centres who had reported experiencing persistent symptoms for more than 12 weeks to take part in an interview we conducted face to face and online semistructured interviews which were transcribed and analysed using thematic analysiswe interviewed 13 participants 6 female 7 male median age 31 participants reported a wide variation in both new and persistent symptoms which were often fluctuating or unpredictable in nature some participants were confident about the link between their persistent

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the covid19 pandemic has resulted in a worldwide increase in the number of adults who are socially isolated and experiencing high levels of loneliness although research has focused on social isolation and loneliness few longitudinal studies have examined isolation and loneliness together in the context of the covid19 pandemic we introduce a novel index of resilience to loneliness which captures the degree of congruence or discordance between subjective feelings of loneliness and objective social contact using seven longitudinal samples across three continents we examined trajectories of social asymmetry across the onset of the pandemic using bayesian multilevel discontinuous growth models these allowed us to demonstrate differences in level and change of social asymmetry across the onset of the pandemic levels and change tended toward resilience over time but did not show significant changes across the onset of the pandemic however these results were not consistent across samples indicating heterogeneity across countries age groups and more we discuss how examining covidrelated changes in social asymmetry advances our understanding of the extent to which broad societal challenges can induce shortand longterm impacts on trajectories of resilience and what factors account for heterogeneity in adaptive responses to adversity session 1260 technology research and applications abstract citation id igad1040265 a gold mine of text text mining versus manual coding methods regarding quality of care in longterm care for older adults coen hacking 1 hilde verbeek 1 jan hamers 2 and sil aarts 1 1 maastricht universitymaastrichtlimburgnetherlands2 caphrimaastricht universitymaastrichtlimburgnetherlands in longterm care for older adults large amounts of text are collected that cover the quality of care such as transcribed interviews medical records and text in electronic health records researchers currently analyze textual data manually to gain insights which is a timeconsuming process text mining could provide a solution as this methodology can analyze large amounts of text automatically therefore this study aims to compare tm to the gold standard of manual coding regarding sentiment analysis and thematic content analysis data was collected from interviews with residents family and care professionals tm models were developed and compared to the manual approach the results of the manual and tm approach were evaluated in three ways accuracy consistency and expert feedback accuracy showed how similar the approaches are consistency showed if an individual approach finds the same themes in similar text segments expert feedback was used to show the perceived correctness of the tm approach the accuracy analysis showed that 818 of text segments receive the same sentiment code in both approaches and 837 of text segments receive the

individuals with functional limitations who lived alone had higher levels of loneliness than those with functional limitations who lived with others the findings emphasize the vulnerability in social isolation of older adults with functional limitations especially those who live alone yet this vulnerable group may also benefit more from adequate daily social contacts

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introduction the concept of sustainable tourism has been introduced since the 1980s in relation to tourism that takes full account of its current and future economic social and environmental impacts addressing the needs of visitors the industry the environment and host communities indeed sustainable tourism development requires a joint effort with all tourism stakeholders in balancing three dimensions to guarantee the longterm sustainability of destinations sustainability in action or responsible tourism has been enhanced as the implementation of sustainability focusing on minimization of interference in the natural environment respect for cultural diversity generating economic benefits for host communities maximization of participation of local people and providing meaningful connections between tourists and local people increases customer satisfaction responsible tourism is regarded as one of the pathways for meeting the 2030 sustainable development goals of the united nations and is seen as an alternative tourism practice particularly goal 12to ensure sustainable consumption and production patterns as one of the most famous destinations in the world for its variety of cultural uniqueness its designation as the land of smiles and over 50 years of development tourism has become an essential component of thailands economy the number of domestic and international tourist arrivals grew continuously until the covid19 pandemic during 19952019 the number of tourist arrivals grew drastically from 695 million to 3992 million resulting in a significant financial contribution with the increasing amount of tourism revenue rising from 926 billion usd to 6437 billion usd however there were also several negative impacts resulting from the long term practice of mass tourism including overcrowding pollution solid waste and littering and traffic sustainable development depends largely on tourist attractions and their behavior onsite consequently understanding from the demandside perspective is critical to the success of sustainable development and is widely discussed subsequently the tourism authority of thailand has enhanced the practice of sustainable and responsible tourism among all stakeholders involved from tourists communities entrepreneurs and suppliers as mentioned by tat deputy governor responsible tourism and sustainability in tourism will be the main direction in the future tourists as the main consumers of tourism resources are one key driver of responsible tourism measuring and monitoring tourists responsible behavior is vital however since the covid19 pandemic the number of international tourist arrivals visiting thailand has declined significantly with domestic tourism becoming a main source of income ttb analytic anticipated that the number of thai visitors traveling domestically in 2023 will reach 226 millionvisits generating approximately 820 billion baht in tourism revenue with the domestic tourist market still the main driver of the thai tourism industry hence this study places emphasis on the behavior of thai domestic tourists toward responsibility previous studies reveal a limited view of sustainability most dominated by the effect of tourist behavior on the environmental dimension rather than social and economic issues to fill these gaps this study highlights dimensions of sustainability in practice from a demandside perspective and examines the factors influencing tourists responsible behavior application of the theory of planned behavior was employed to understand responsible behavior as it is widely used in the management and tourism context the tpb postulates that human behavior is based on behavioral intentions which are driven by attitude subjective norms and perceived behavioral control apart from attitude toward behavior subjective norms and perceived behavioral control are predictors of behavioral intentions ajzen suggested the inclusion of additional predictors that could explain intentions or behavior thus rather than assuming the three main tpb predictors it is useful to the tourism research community to investigate variables perceived to have an impact on tourists responsible behavior several studies have investigated the environmental and social concerns affecting behavioral intentions additionally the studies by xu et al and macinnes et al pointed out the effects of proenvironmental behavior in everyday life toward behavioral intentions hence this research underlines the academic contribution for the extended theory of planned behavior as it has been suggested by several academics a structural equation model was developed to examine the relationships of the tpb proenvironmental behavior in everyday life environmental and social concerns behavioral intentions and the responsible tourist behavior of thai tourists this study addresses understanding regarding responsible behavior as well as supporting the theoretical foundation on the significance and usefulness of the theory of planed behavior and the development of an extended theory of planned behavior in the tourism context the results of this research can support the decisions of destination management organizations in modifying tourism activities and services that are suitable for responsible tourist behavior the government and related organizations may use these new results for policy adjustment literature review sustainable and responsible tourism the concept of sustainable development has been introduced and widely accepted within the tourism industry worldwide with a balanced approach to the three pillars of sustainability including environment sociocultural and economic aspects the sustainability paradigm is a longterm perspective which addresses the future of the planet based on the responsible actions of all stakeholders to all forms of tourism as mentioned by mihalic et al and goodwin sustainability is a complex issue whereby there is difficulty in determining whether ideas are operative or inoperative in a way that secures the attainment of sustainability in the longterm a new aspect of sustainability in action has been presented as responsible tourism headed for implementation and effectiveness placing the emphasis on what people businesses and governments do to make tourism more sustainable responsible tourism is regarded as one of the pathways for meeting the 2030 sustainable development goals as an alternative tourism practice several of the targets associated with sdg goal 12 specifically link to responsible tourism for example 122 by 2030 achieve the sustainable management and efficient use of natural resources 125 by 2030 substantially reduce waste generation through prevention reduction recycling and reuse and 126 encourage companies especially large and transnational companies to adopt sustainable practices and to integrate sustainability information into their reporting cycle according to goodwin in 2007 the world travel market adopted the cape town declaration definition of responsible tourism which requires operators hoteliers governments local people and tourists to take responsibile actions for making better places for people to live and better places for people to visit including minimizing negative impacts generating greater economic benefits for local people making positive contributions to the conservation of nature and cultural heritage providing more enjoyable experiences and access for people with the disadvantages engender respect between tourists and hosts and build local pride confidence and participatory decision making the importance of responsible tourism has been acknowledged worldwide such as world tourism organization has considered the promotion of equitable responsible and sustainable world tourism and validated the guideline for tourists on how to travel responsibly in 2020 the world committee on tourism ethics developed the tips for responsible travelers including honor your hosts and common heritage protect the planet support the local economy travel safely be an informed traveler use digital platforms wisely make tourism a force for good and set a good example for other travelers various countries around the globe including thailand are also committed to promoting responsible tourism and sustainable tourism as the main direction in the future understanding tourist behavior particularly responsible tourist behavior is critical in the pursuit of sustainability and has become increasingly popular and recognized as one of the key success factors for product development and destination management strategies the study of dias et al explained that responsible tourists are willing to invest adequate time and resources and seek information before traveling to destinations to live local experiences consciously and ethically the three pillars of sustainability were applied to measure and monitor tourist responsibility however most studies revealed a limited view of responsible behavior mostly dominated by the environmental dimension ignoring social and economic aspects previous studies have suggested several practices of responsible tourist behavior including buying local products compliance with regulations and legislation of the country being visited social interaction with local residents appreciating local products and activities saving resources and recycling and engaging in natural and cultural activities among others theory of planned behavior explaining human social behavior is a difficult task due to the differences in individuals physiological and behavioral dispositions and social psychology and personality as well as the effects of biological and environmental factors on behavior the framework of the theory of planned behavior was designed to predict and explain human behavior in specific contexts and is one of the most established and widely used theories the tpb postulates that human behavior is based on behavioral intentions which are driven by attitudes subjective norms and perceived behavioral control as general rule the stronger the intention to engage in a behavior the more likely it is to be performed the theory suggests three main antecedent variables that predict responsible behavioral intentions firstly attitudes toward behavior refers to the degree of positivity in an individuals opinions and feelings toward the responsible behavior subjective norms refer to the social factors that an individual perceives as the social pressure to perform or not perform the responsible behavior the last predictor is perceived behavioral control which refers to an individuals ability to perform the responsible behavior in turn these responsible behavioral intentions can account for a considerable proportion of variance in responsible behavior additional distinctions among additional kinds of beliefs and related dispositions have been suggested for expanding the original theory of planned behavior such as environmental concern environmental background and proenvironmental behavior environmental and social concern with the increasing seriousness of environmental problems such as climate change and pollution and the continued irresponsible actions of people toward the environment there is increasing public concern regarding environment issues the study of tam chan revealed that most of the worlds population is aware of environmental problems and supports environmental protection however there is variation in the extent of environment concern in different cultural contexts environmental concern broadly refers to the degree of individual care for environmental issues and the environment previous studies have posited that environmental concern can have a direct effect on behavioral intentions implying that individuals with a higher degree of environmental concern are more willing to take responsible actions in environmental and social dimensions social concern appears to have been less researched especially in the tourism context which is generally specified as a set of propensities that sometimes lead an individual to give more consideration to others limited tourism research has applied social concern as one of the variables influencing behavioral intentions in this study social concern refers to a tourists concern for negative social impacts including unemployment labor rights and the irresponsible actions of other people thus an individual with high social concern is willing to sacrifice hisher desire to behave responsibly when heshe thinks that such an act will harm others considering the importance of environmental and social concerns to responsible behavioral intentions this study additionally addresses environmental and social concern as proposed antecedent variables pro environmental behavior in everyday life proenvironmental behavior refers to purposeful green sustainable or environmentally friendly actions that can minimize the negative impacts of human behavior on the environment individuals with proenvironmental behavior engage within various contexts ranging from outdoor workplace daily life and on holiday several studies have explored peb at home including resource efficiency behavior recycling household resources selecting environmentally friendly transportation while xu et al considered the associations of peb with various aspects in the holiday context the study of whitmarsh et al compared peb across contexts finding evidence that waste reduction behavior was significantly correlated with behavior both at home and on holiday additionally macinnes et al supported the spillover effects of proenvironmental behavior in the everyday life context with 72 of the variance of stated peb being explained by habit on holiday the current study explored potential spillover of peb between everyday life on the holiday context the collected literature leads to the conclusion that attitudes toward behavior subjective norms perceived behavioral control environmental and social concerns proenvironmental behavior in everyday life and responsible behavioral intentions will have an impact on tourists responsible behavior a proposed theoretical framework and hypotheses for the study were devised accordingly as follows h1 attitudes toward behavior have a positive effect on the responsible behavioral intentions of thai tourists h2 subjective norms have a positive effect on the responsible behavioral intentions of thai tourists h5 h4 h3 perceived behavioral control has a positive effect on the responsible behavioral intentions of thai tourists h4 environmental and social concerns have a positive effect on the responsible behavioral intentions of thai tourists h5 proenvironmental behavior in everyday life has a positive effect on the responsible behavioral intentions of thai tourists h6 responsible behavioral intentions have a positive effect on the responsible behavior of thai tourists methodology since the majority of research in the field of tourism and hospitality is based on data collected from surveys using structural questionnaires to gather opinions perceptions attitudes and behaviors of individuals this study employed a quantitative method to measure the tourists responsible behavior and examine the relationship of the constructs used in the study sample and data collection the population of the study was thai domestic tourists who had travelled nationally at least twice from last year and who practice responsible behavior at home and during their trips the sample size was determined by the 10times rule of thumb introduced by hair et al fortysix parameters were included in the study with a suggested sample size of 460 a purposive sampling method was used to collect responses with screening questions used to identify the respondents responsible behavior such as avoiding activities that may affect the environment properly disposing of litter and valuing local traditions and customs data were collected in septembernovember 2022 with an online selfadministrated questionnaire of the 526 questionnaires that were collected a total of 503 valid questionnaires were used for data analysis the study was approved by kasetsart university research ethics committee survey development the survey questionnaire consisted of five major sections the first section measured factors affecting tourists intentions to behave responsibly including attitudes toward behavior subjective norms perceived behavioral control the theory of planned behavior was applied in this study including att sn and pbc with a 10item scale being developed based on previous study environmental and social concern was adapted from the scales of hosta zabkar with a 4item scale to evaluate individual worriedness about harmful effects to environment and society at large proenvironmental behavior in everyday life utilized a 6item scale regarding environmental conservation in daily life as developed by dowruang akkawanitcha the second section of the questionnaire measured responsible behavioral intentions with 4 items adopted from previous studies the following section focused on measuring tourists responsible behavior with a 22item scale adapted from the guidelines for responsible tourism by the tourism authority of thailand goodwin andsuwachat lastly information regarding the respondents demographics and behavior was collected some measurement items in the questionnaire originally written in english were translated into the thai language and adapted to the thai cultural context to minimize translation bias and the effects of language nuance three scholars fluent in the english language scrutinized the translation to thai a five pointlikert scale was employed to measure each respondents opinions attitude and responsible behavior data analysis data analysis consisted of several phases through the descriptive and multivariate analysis including correlation exploratory factor analysis confirm factor analysis and the structural equation model firstly sociodemographics and behavior were examined with percentage scores regarding the respondent profile this was followed by analysis of the basic assumptions in structural equation modelling with tests of correlation and multicollinearity principal component factor analyses with varimax rotation was then used to analyze and categorize tourists responsible behavior with eigenvalues greater than 1 which comprised of items with factor loading greater than 06 to perform the structural equation model a twostage approach was applied consisting of the measurement model and structural model the measurement model assessed patterns of interrelationships among constructs through confirmatory factor analysis with a maximum likelihood estimation method using the goodness of fit analysis convergent and discriminant validity analysis in the final stage the sem was tested to determine the consistency of the developed model with empirical data a series of goodness of fit indices was reported based on the criteria recommended by gefen et al including absolute fit indices and incremental fit indices four criteria were chosen namely cmindf rmsea cfi and tli the acceptable threshold levels of the model fit criteria were proposed as follows cmindf below 3 rmsea below 005 and cfi and tli above 090 the hypothesized relationship among constructs was analyzed at a 5 level of significance coefficient of determination and significance levels of the path coefficients were tested in this study as the main criteria to evaluate the structural model results the descriptive statistical analysis was scrutinized to analyze the respondent profile most of the respondents were female in generation y or z aged between 1941 years old and held a bachelors degree the majority of respondents travelled during the weekend period and the main purpose of travel was for relaxation with transportation via private vehicle the respondents chose the beach as a main destination choice and preferred to stay in the hotelresort the source of their traveling information frequently came from the internet a multivariate analysis was conducted with preliminary analysis including testing of correlations and multicollinearity analysis was performed on all 46 items to illustrate the relationship between constructs with a correlation matrix resulting in 12 items with low correlation which were eliminated from the study based on the study of yong pearch who mentioned that a large number of low correlation coefficients should be removed as they indicate a lack of patterned relationships the two remaining items of peb and fourteen items of tourist responsible behavior were then used for further study moreover the vif value and tolerance value of each construct indicated no evidence of multicollinearity with a tolerance value less than 010 and a vif value above 10 hence the multicollinearity assumption was not violated and the data were suitable for factor analysis to measure tourists responsible behavior efa was examined to reduce the number of items and generate dimensions of thai tourists responsible behavior the test of bartlett sphericity test and the kaisermeyerolkin indicated that the sample was acceptable for efa with a kmo of 0926 and significant bartletts test of sphericity two underlying factors emerged with eigenvalues greater than 1 and factor loadings greater than 060 namely impact consideration and local connections the total sum of the explained variance was estimated at 50 confirming the validity of the extraction factor 1impact consideration responsible behavior regarding to the tourists assessment of their behavior in reducing the environmental and social impacts on the destination site by reducing waste complying with rules and regulations avoiding activities that could affect the environment and being aware of the impacts that may be caused by their tourism activities factor 2 local connections behavior that permits contact with and appreciates the local ways of life and culture and establishing interactions relationships between hosts guest and travel companions after identification of these factors a twostage approach was applied to construct the structural equation model for the responsible behavior of thai tourists as indicated in the following measurement model and structural model measurement model according to weston gore sem describes the relationship between observed variables and the construct or constructs those variables are hypothesized to measure confirmatory factor analysis is used in testing the measurement model in this study eight latent variables and twentynine observed variables were analyzed the cronbachs alpha value was demonstrated to range from 079 to 091 which is higher than the acceptable cutoff value of 070 as suggested by hair et al moreover the factor loading values of the items were above 060 indicating high convergent validity excluding item int3 which was revealed to have a lower factor loading value from the recommended range convergent validity was investigated including cronbachs alpha factor loading the average variance extracted and construct reliability according to hair et al convergent validity is observed when the cr is higher than 06 and ave is higher than 05 table 1 shows the results of the measurement model assessment which revealed that the convergent validity was established for all constructs with cr values of 087095 and ave values of 048076 following previous study by hosta zabkar even though the ave value for the construct of environmental and social concern and responsible behavioral intentions were below the 050 recommended criterion the composite reliabilities were greater than the threshold the convergent validity of these constricts is still adequate the evaluation of discriminant validity is also specified in table 2 which shows the interfactor correlation values of the constructs were between 0173 and 0757 cicfa inspected 95 cis of the estimated factor correlations the results of the upperlower bound values were lower than 80 providing evidence for the models discriminant validity it can be concluded that each construct assessed distinct and different concepts thus the discriminant validity was considered satisfactory furthermore the model was tested with a goodness of fit statistic the result exhibited that the model has a good fit with the empirical data with cmindf 245 rmsea 0054 cfi 094 tli 093 thus it can be concluded that the measurement model of the latent variables revealed internal consistency reliability convergent validity and discriminant validity and can be assembled for sem analysis structural model the structural model was assessed toillustrate the causal relationship among the constructs the goodness of fit statistic indicated the consistency of responsible tourist behavior model with the empirical data in which all four criteria were found to meet the acceptable threshold levels recommended by gefen et al the hypotheses testing was then continued with the test of the coefficient of determination and significance levels of the path coefficients figure 2 indicates the standardized path coefficients the results specified that att sn pbc peb and concern had a significant positive influence on int thus h1 h2 h3 h4 h5 were all supported as such tourists pbc is the strongest predictor of responsible behavioral intentions meaning that when tourists believe that they can perform responsible behavior they are likely to do so the feeling of confidence to do something to protect tourist sites represented the highest main contributor of pbc 405 425385 1 453 483423 489 509469 64 6860 1 488 528448 551 531531 509 539479 581 611551 1 492 532452 588 608568 559 599519 757 797717 579 609549 1 502 532472 541 551531 567 597537 746 776716 597 617577 744 774714 1 358 408308 173 193153 558 608508 588 638538 449 489409 517 567467 694 734654 1 pbc concern int imp loc note values below the diagonal represent the correlations between the latent constructs and represent the correlation values of the latent constructs at the 5 lower upper bound concern was the second main predictor of responsible behavior with the item of preserve natural resources and protect worker rights as the main contributor the third predictor of responsible behavior is peb which indicates the extent of proenvironmental habits in everyday life specifically purchasing energy saving appliances acts as the main influence in this construct while sn is presented as the fourth predictor exhibiting that key reference people could put pressure on the tourists responsible behavior intentions especially people that hold ones respect nevertheless att is presented as the weakest predictor it can still explain tourists positive attitude toward responsible behavioral intentions and show their willingness to perform as it is seen as worthwhile to protect the tourist sites regarding h6 responsible behavioral intentions were found to have a positive effect on responsible behavior in both dimensions impact consideration and local connection the results identified that int has a significant positive effect on imp and loc statistical analysis of the cmindf 262 rmsea 006 cfi 094 tli 092 figure 2 structural model data revealed that tourists awareness about the impacts from tourism activities and waste reduction during a trip were the main contributors to responsible behavior and the impact consideration dimension meanwhile interacting with local communities had the main effect in building up tourists responsible behavior in the local connection dimension the analysis revealed support for all hypotheses moreover the rsquare values which indicate the amount of variance of the dependent variables that is explained by their predictor variables were calculated henseler et al provided the following rule of thumb for acceptable r 2 values whereby values of 75 50 and 25 for constructs in the structural model refer to substantial moderate or weak influence respectively in this study the ability of model to predict responsible behavioral intentions is 70 the model was also able to explain the variance in responsible behavior in impact consideration behavior by 734 and in local connection behavior by 44 which substantially and moderately accounted for responsible behavioral intentions respectively this is better than traditional models which on average explain around 50 of variance and 30 of behavior discussion and conclusion sustainability in action via responsible tourism has been enhanced as one means to the implementation of sustainability and the pathways for meeting the 2030 sustainable development goals of the united nations measuring and monitoring tourists responsible behavior is critical this study revealed the responsible behavior of thai tourists to have two underlying dimensions impact consideration and local connection one of the key results of the study is that tourists responsible behavior reflects the social and environmental pillars of sustainability and is in line with the tips for responsible travelers by the world committee on tourism ethics and the cape town declaration these two dimensions confirm the theory of responsible tourism as it minimizes negative impacts makes positive contributions to the conservation of nature and cultural heritage and engenders respect between tourist and their hosts the first dimension impact consideration refers to the tourists assessment of their behavior in avoiding negative impacts on the tourist site items such as avoiding activities that impact the environment being aware of the impacts that may be caused by tourism activities reducing waste during travel and undertaking activities which have the least impact on the tourist site are related to the fundamental frame of reference for responsible and sustainable tourism within the global code of ethics for tourism as detailed in the article three states that all stakeholders in tourism development should ensure are safeguarding the natural environment that all forms of tourism development are conducive to saving rare and precious resources in particular water and energy and avoiding so far as possible waste production these three states should be given priority and encouraged by national regional and local public authorities the second dimension local connection refers to the tourists responsible behavior in that they are open to local experiences with meaningful connection and understanding of local cultural social and environmental issues appreciating the local way of life and culture and establishing interactionsrelationships between hosts guests and travel companions consistent with the cape town declaration and dias et al the responsible tourist profile indicates that most respondents from the generation y and z cohorts travel for relaxation purposes to beach destinations and frequently access internet as the main source of their travel information these findings are consistent with previous studies that millennials or gen y and gen z are empowered by technology and are important and effective stakeholders who can make valuable contributions towards any sustainable environmental development these young travelers seek adventure fun and escape from their daily routine and look for authentic local experiences and socialization another important result of the study confirms the theoretical dimensions of tpb att sn and pbc that affect the tourists responsible behavioral intentions the path coefficients specify pbc as the most positive and significant influence on tourists responsible behavioral intentions in line with previous studies that remarked on pbc as the most important part of the tpb theory where tourists responsible behavior is strongly influenced by their confidence in their ability to perform consequently interventions to increase tourists pbc could lead to more responsible actions to enrich and provide further justification the most interesting insight derived from the study is that the feeling of confidence in what one can do to protect the tourist sites acts as the main contributor to pbc as suggested by kidwell jewell both internal and external controls affect successful behavioral performance and are distinct constructs of pbc strengthening tourists perception of the ease of the responsible actions may influence confidence in the ability to perform responsible behavior with the expectancy of success subjective norms were also presented as a predictor of responsible behavioral intentions indicating that tourists responsible behavior can be guided by key reference people in their life previous studies had suggested important key persons with social bounds and interpersonal bonds including friends family colleagues travel companions famous people celebrities and influencers all of whom could affect responsible behavior setting up good examples of sustainability practices and guidelines from these people could enable the willingness to perform responsible behavior as a tourist the last component of tpb attitudes toward behavior was found to have a significant and positive impact on tourists responsible behavioral intentions even though it was presented as the weakest predictor among the three variables the positive feeling toward protecting the tourist site can still drive tourists responsible behavioral intentions these findings are consistent with the results of studies conducted by gautam and panwanitdumrong chen which applied the theory of planned behavior in the context of environmentally friendly behavior and responsible behavior in the northern part of india and thailand the findings exhibited that attitudes toward behavior are the least important while perceived behavioral control was the main predictor followed by subjective norms this is in contrast with several studies that established attitudes toward behavior as the strongest predictor ajzen suggested that attitude subjective norms and perceived behavioral control in the prediction of intentions is expected to vary across behavioral characteristics sample groups and the situation of the study in the results of previous studies it was confirmed that crosscultural differences exist in the attitudes towards responsible tourist behavior which were constructed from values and reciprocal altruism additionally ajzen and han stoel suggested the inclusion of additional predictors that could explain intentions or behavior thus rather than assuming the three main tpb predictors it would be useful to the tourism research community to investigate variables perceived to have an impact on tourists responsible behavior few studies have considered the role of social and environmental concern influencing responsible behavioral intentions this study emphasized both environmental and social concerns as the second main predictor of responsible behavior as most of the respondents in this study were in the millennial and generation z who are described as green value consumers who have confidence in the possibility of creating a better future and have more concern about saving the planet they perceive value in preserving natural resources minimizing pollution as well as protecting workers rights and employability this study also linked the relationship between proenvironmental behavior in everyday life resource efficiency behavior and responsible behavioral intentions this is consistent with studies of sthapit bjork and xu et al which pointed out the association between domestic and tourism proenvironmental behavior the empirical evidence supports the extending body of knowledge on environmental spillover effect from habits at home into the tourism arena one of the reasons for the possible spillover is that the habit is of a repetitive nature of goaldirected behavior thus this behavior is retained while on vacation the theoretical achievement of this study is the establishment of an extended tpb model with two additional predictors including concern and peb which explain the formation of tourists responsible behavioral intentions by 70 despite various studies which have stated that people who are committed to the environment and have peb behave less sustainably on holiday the results of the current study are supported by empirical evidence that spillover effects of peb resulted in responsible behavior in the holiday context which is consistent with existing studies the new theoretical explanation defined that proenvironmental behavior in everyday life is one of the key driving factors of tourists responsible behavior at the same time concern has the second greatest influence on tourists responsible behavioral intentions implying that tourists are concerned about environmental issues focusing on preserving natural resources and pollution as well as the social concerns of workers rights irresponsible actions and unemployment the findings support the concept that concern for the environment and social interests can restrict the responsible behavior of thai tourists corresponding to the work of hosta zabkar the current study results reinforce claims about the extended framework of the theory of planned behavior as there are still many underlining beliefs regarding behavioral determinants research limitations these findings provided an introductory analysis of thai tourists responsible behavior however there are some limitations to the study due to the covid19 pandemic situation an online questionnaire was applied and was mainly completed by university students and alumni who had taken a sustainable tourism creative tourism or ecotourism course which could enable selection bias for those who might have avoided expressing their true opinions due to ethical pressure second the majority of the respondents were in the generation y and z cohorts aged between 1941 years old therefore the generalizability of the study findings does not have a wide scope improvement of the sampling method using a quota sampling technique with a comparative approach is recommended for future research in addition the conceptual model can be enhanced with other variables that might predict responsible behavior such as selfefficacy personality social engagement and place identity lastly the research was conducted in thailand with a sample of only thai tourists these challenges need to be solved in future studies with extended prediction variables for responsible behavior a more diverse sample including different age cohorts on site data collection and measuring tourists responsible behavior with inbound tourists from different nationalities in order to monitor and understand their behavior implications the practical value of this work lies in suggesting that tourists responsible behavior is directed toward impact consideration and local connection the results can provide several practical implications for tourism stakeholders to enhance destination sustainability destination managers and marketers can encourage tourists responsible behavior by implementing meaningful experiences with various lowimpact tourism activities for instance horseback riding scenic walks hiking cycling kayaking etc more activities that interact with local people and travel companions also need to be taken into consideration such as interpretive nature trails cookery courses art and craft workshops camping and volunteering activities it is beneficial to make tourists aware that responsible behavior is not something difficult to achieve building tourists confidence can be initiated by various stakeholders in creating simple activities with high impact on the ability to protect the tourist site destination managers should enhance the natural reserve policies such as collecting and returning the garbage generated during a visit reducing reusing and recycling solid waste during a trip providing efficient and ecofriendly transportation certification of tourist sites as sustainable destinations low carbon destinations green destinations or zero waste destinations could confirm that destination is committed to making a low impact regarding social cultural and environmental aspects which in turn could be a key magnet for not only thai responsible travelers but also for world travelers local communities and local guides can incorporate creative activities for engagement with locals by exchanging way of life experiences between hosts and guests locally made handcrafts and products should be developed with sustainable concepts representing the uniqueness of the destination such as recycled souvenirs and sustainable local products the findings will also be useful in providing insight to government agencies policy makers and tourism businesses to enhance destination sustainability this study highlights that perceived behavioral control subjective norms and environmental and social concern have highly significant effects on intentions to behave responsibly in practice these concepts can be executed by promoting responsible campaigns and events to improve tourists understanding of their role in responsible action integrated marketing communication including interactive ads through social media and short movie ads could enable tourists perception of the ease in being involved in responsible actions and be reflected in increased confidence and the feeling that it is worthwhile to perform responsible behavior in addition effective social media content of responsible practices with famous people celebrities and influencers can provide a stimulus for responsible behavior tourism business in the area could be a part of responsible practices by employing a green policy for reducing the consumption of water and electricity in their establishment moreover related government departments should enhance the publicity of education and knowledge about environment and social problems to increase tourists concern the empirical evidence suggests a possibility of proenvironmental behavior in everyday life predicting responsible behavior as a tourist using energy saving light bulbs and energy saving appliances as a proxy developing effective interventions to trigger more responsible behavior can be implemented such as promoting energy saving and other proenvironmental behavior nationwide finally the findings reveal that the internet is the main source of travel information for responsible tourists thus responsible digital platforms should be created to promote sustainable holidays for tourists as well as providing a code of conduct for responsible tourists pre during and posttrip information about green ecofriendly and responsible tourism destinations and tourism businesses should be provided along with responsible travel agents and tour operators who organize responsible travel trips effectively conflicts of interest there is no conflict of interest to declare

the study aims to measure tourists responsible behavior and to develop a structural equation model of responsible tourist behavior among thai tourists a questionnaire survey was conducted using an online questionnaire a total of 503 thai domestic tourists who practiced responsible behavior participated in the study the data were analyzed through structural equation modeling with a twostage approach the results of the analysis revealed a good fit with the empirical data cmindf 262 rmsea 006 cfi 094 tli 092 moreover the findings highlight two underlying factors which emerged for responsible behavior namely impact consideration and local connections the establishment of an extended theory of planned behavior tpb model with two additional predictors including environmental and social concern and proenvironmental behavior in everyday life explains the formation of tourists responsible behavior destination managers and marketers can encourage tourists responsible behavior by implementing meaningful experiences with various lowimpact tourism activities relevant government agencies and policy makers can promote responsible campaigns and events to enhance responsible behavior

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introduction globally an increasing number of individuals are providing unpaid assistance and support to family members or acquaintances with physical psychological or developmental needs 1 approximately 17 of americans have provided care to adults who are ill disabled or aged 2 in canada approximately 25 of canadians aged 15 years and above provide help or care to a family or friend with a chronic health problem 3 whereas in the united kingdom approximately 10 of the population are family caregivers 4 as families and households are getting smaller because of lower birth and marriage rates there are fewer family caregivers to meet the increasing care demands of the growing older population 5 this creates challenges in maintaining a workcaregiving balance assisting with daily living activities and managing services for the care recipient 26 as such caregiving remains a stressful experience and exerts a considerable burden on family caregivers 7 8 9 10 as a multidimensional response to the stressors associated with the caregiving experience caregiving burden can have devastating and longterm effects on family caregivers 1112 researchers have developed a range of technological interventions to assist in reducing the caregiving burden and overcoming the challenges faced by family caregivers 1314 these domains where technology can be leveraged include but are not limited to caregiver platforms caregiver support care coordination telehealth or diagnostics and digital care delivery alternative therapeutics transitions of care housing and operations and endoflife planning 1516 although technologies can reduce objective burden some of the physical responsibilities of caring and the subjective burden by providing carers access to support negotiation for emotional effort entailed in providing care 17 significant challenges and barriers still exist with respect to the use and adoption of technologies 18 19 20 21 for example technologies aimed at the caregivers of people living with dementia have been perceived as too complex and can create ethical issues such as reduced privacy data security and informed consent 18 19 20 21 in addition systemic shortcomings such as a lack of awareness and accessibility and insufficient integration with existing health care services have limited the rate of technology adoption among caregivers 22 given these gaps between technology development and adoption understanding technology perceptions among family caregivers is becoming increasingly important for identifying specific barriers and facilitators that can then be addressed during the technology development process for promoting the technology uptake recently researchers began to gather technology perceptions from family caregivers 23 24 25 26 these pioneering works have highlighted a variety of feature preferences relating to technology with all of them reporting a limited use of technologies because of barriers such as a lack of familiarity awareness and availability 23 24 25 26 although these studies set the groundwork by pioneering the examination of family caregivers perceptions of technology in general there has been limited exploration of how sex gender and diversity characteristics shape these perceptions or how the perceptions are considered during the technology development process the sex and gender gap in general technologies has been extensively studied 2728 however the lack of research on technology perception among informal caregivers still exists despite considerable sex and gender differences with respect to wellbeing as well as psychosocial and overall health 29 30 31 32 a recent systematic search of the literature on caregiving technology identified only a few studies that have assessed informal caregiver needs with respect to technology from the perspectives of sex and gender 23 33 34 35 in all of these studies there were more female caregivers ranging from 51 35 to 733 34 sex and gender differences were observed in terms of the perceived usefulness of technology 33 willingness to pay for technology 35 and overall attitudes toward technologies 2334 designed to assist with caregiving the systematic search found that the included studies highlighted important differences in the preferences and reception of technology among male and female caregivers but had methodological limitations including small sample sizes 3334 and a lack of qualitative studies moreover with the rapid pace of technology development including an increasing availability through webbased and mainstream shopping reduced cost of offtheshelf technologies and shifting caregiver demographics these results may no longer reflect the latest trends and opinions toward technology as such an uptodate indepth exploration of how sex and gender influence the perceptions of caregiving technology among family caregivers and how these perceptions are incorporated in the technology development process is timely this qualitative study aims to address these gaps by examining how family caregivers perceive the use of technology in assisting with their caregiving routines identifying any sex gender and diversity factors that shape these perceptions and how these perceptions and needs are reflected in the current technology development process we took a qualitative descriptive approach to allow for a detailed description and understanding of the who what and where of technology perceptions as it relates to caregiving and technology development 36 by drawing on the general tenets of naturalistic inquiry which involves the shift from tangible variables to focus on the social constructions of research participants this study also aims to explore these technology perceptions as a product of characteristics and behaviors that are socially and culturally contingent 3637 methods procedure ethics approval was obtained from the university of toronto and all participants provided verbal andor written informed consent for participation and the use of their information semistructured interviews were conducted in person or over the phone with family caregivers to explore their technology perceptions and technology researchers to examine how they incorporate caregivers perceptions within the technology development process before conducting the interviews gekr had no contact with the participants except for scheduling the time and place of their meeting interviews were conducted in a private room at the university of toronto ranged between 45 and 120 minutes and were recorded using an encrypted digital recorder before commencing the interviews gekr explained the purpose of the study and the detailed procedure of the interview to the participants openended questions were first asked to initiate discussion and probing questions followed to further enrich the conversation upon the conclusion of the interview gekr collected a demographics questionnaire from the participant remuneration was offered in the form of a can 40 gift card delivered via mail in person or via email field notes were taken by gekr during and after each interview which were used as a starting point during our analyses and discussion during each caregiver interview participants were asked about their knowledge of technology related to caregiving experiences with technology and how they perceived the influences of sex gender and diversity on their technology use for the interviews technology was communicated to participants as digital technologies such as but not limited to mobile apps medications and smart home technologies nonetheless participants were given the opportunity to explore other technologies that they were aware of or have used within their caregiving context during each technology researcher interview participants were asked about their current research knowledge of sex gender and diversity considerations in caregiving technology and the extent to which these considerations were incorporated in the technology development process full versions of the interview guides for caregivers and technology researchers are provided as multimedia appendices 1 and 2 verbatim transcriptions were outsourced to a data transcription service each transcript was reviewed by 2 members of the research team to ensure accuracy to ensure confidentiality all participants were assigned an alphanumeric code and any identifying information was removed from the data corpus during the review of the transcripts data analysis all data from the transcripts were coded and analyzed using the framework method 38 which is a form of thematic analysis designed to identify the patterns across a data corpus and describe participants experiences and perspectives 3940 in addition thematic analysis has the potential to yield complex and nuanced analyses 3940 the framework method comprises the following 7 stages transcription familiarization with the interview coding the development of a working analytical framework the charting of data into the framework matrix and data interpretation 41 by providing clear steps for following and producing a visually straightforward presentation of patterns and themes the framework method is helpful for projects with multiple groups of participants as in our study 41 nvivo was used to code and manage the coded data transcribed interviews were coded independently by cx and gekr who noted all caregivers perceptions and experiences relating to technology from the caregiver interviews during the preliminary coding of the initial interviews the authors uncovered additional significant influences on technology perceptions in addition to sex and gender furthermore with the advancement of sex and gender understandings a paradigm shift was observed in the interpretation of sex and gender within a more comprehensive framework that prioritizes diversity 42 as such the authors examined sex and gender in conjunction with other diversity factors that may shape technology perceptions including but not limited to age socioeconomic status personal relationships ethnicity and culture given the aim of examining how caregivers perceptions of technology are integrated within the technology development process the authors discussed their coding processes and created an analytical framework based on the collated codes gathered from the transcripts of both technology researchers and caregivers this allowed the charting of the data onto the developed framework during the final data interpretation stage the authors moved beyond collated codes by sorting them into categories and refining these categories into themes regular discussions between the authors were held during each step of the data analysis facilitating further exploration of participants responses discussion of deviant cases and agreement on recurring themes results overview tables 1 and2 describe the characteristics of the family caregivers and technology researchers included in this study respectively among family caregivers approximately 63 were females and 56 selfidentified as cisgender women the majority of caregivers were of european origin and were aged ≤55 years family caregivers within our sample have a diverse range of education levels length of care provision marital status and employment status care recipients have a wide range of medical condition types including but not limited to musculoskeletal cardiopulmonary and neurological conditions among the technology researchers approximately 63 were females and selfidentified as cisgender women most technology researchers work in a research lab and were aged ≤35 years technology researchers within our sample have a diverse range of education levels ethnicities and occupations three main themes with subthemes were developed to capture the benefits and challenges of using and adopting technologies for caregiving the first main theme is that caregivers see a need for technology in their lives and it comprises 3 subthemes caregiving is a challenging endeavor technology is multifaceted and caregiver preferences facilitate technology use the second main theme is that relationships play a vital role in mediating technology uptake and it comprises 2 subthemes the caregivercare recipient dynamic shapes technology perceptions and caregivers rely on external sources for technology information finally the third main theme is that barriers are present in the use and adoption of technology and it comprises 2 subthemes technology may not be compatible with personal values and abilities and technology not tailored toward caregivers lacks adoption finally the influences of sex gender and diversity will be discussed with respect to all 3 main themes theme 1 caregivers see a need for technology in their lives caregiving is a challenging endeavor caregivers describe several difficulties in fulfilling their caregiving duties specifically the need to provide care to their care recipient challenges their ability to meet the needs of both themselves and the care recipients caregivers report making significant adjustments to their daily routines to provide care for example one caregiver notes that he is no longer able to exercise and his life essentially revolves around caring for his mother as well as his own job by putting the care recipients needs above their own caregivers face difficulties in striking a balance and often find themselves neglecting their own health despite recognizing the importance of looking after their own wellbeing as one caregiver expresses everyone tells me oh you need to look after yourself if you look after yourself you can look after her yes its all well said and done caregiver 06 as a result of these changes entailed while providing care caregivers were both physically and emotionally burdened by the entire caregiving experience faced with the stress of having to take on a lot within a very short time caregivers experience a drop in their quality of life the health care system further exacerbates the caregivers physical burden and is called a rugged system that requires a lot of effort to receive assistance caregivers highlight a lack of clarity in the information provided and lengthy wait times for services such as home care support in addition to the physical difficulties that are experienced caregiving also puts an emotional drain on caregivers as cg02 shares i worry about her because she cannot its hard for her to defend herself because of the language issuethe memory issue because she has no power and no credibility so shes highly vulnerable so i feel stuck with that and i also feel i dont know scared for whats going to come caregiver 02 as cg02 takes on the caregiving role she is confronted with the uncertainties associated with the everchanging condition of her care recipient she expresses the fear of what the future holds a sentiment shared among several caregivers in the study for others the emotional drain takes the form of guilt toward the care recipient in particular caregivers develop the perception that they are not doing enough and that there is much more that they could do to help their care recipient technology is multifaceted technology plays a multifaceted role in mediating caregiving challenges caregivers describe a wide range of tasks for which they perceive technology to be the most useful specifically caregivers value the convenience of using technology to connect and communicate with loved ones on demand and remotely when the caregivers are away in a similar vein caregivers use technologies to obtain uptodate information and resources as cg18 shared see for megoogling stuff is my way of finding out information about my father so ill go on like webmd ill go on the mayo clinic like things like diabetes canada health canada caregiver 18 by using the internet caregivers are able to save time and effort in obtaining information and redirect this time and effort toward taking care of their care recipients this not only increases their caregiving efficiency but also opens opportunities for caregivers to engage in selfcare activities from browsing social media to using meditation apps caregivers see technology as a tool to allow them to relax and unwind amid their hectic schedules which can also be managed using technology as cg04 notes as part of google calendar which i use almost conclusively you can set up a variety of calendars there your personal your work but yeah there is one for my care recipient in there i mean she does not see it because she doesnt have a computer really she tells me about an appointment or whatnot i go right in then and just type that sucker and make sure to follow up caregiver 04 with these internetbased calendars caregivers can better plan their day and avoid running the risk of missing appointments or scheduling conflicting commitments given the need to balance both personal and care recipient needs these time management tools allow caregivers to appropriately apportion the time between themselves and the care recipient with regard to care provision technology has been used to support regular chores and provide a sense of security to caregivers by enabling caregivers to keep track of care recipients health status and whereabouts on a regular basis the use of technologies such as wearable devices and home monitoring cameras has been mentioned by the majority of caregivers as a means of alleviating caregiving burden and providing them with a piece of mind caregiver preferences facilitate technology use although technology has its rightful place in helping with caregiving not all technologies are created equally caregivers report looking for specific features and characteristics of the technologies that they are willing to use on a regular basis technologies that do not encapsulate these characteristics are not as wellreceived in line with the dominant expectations of technology acceptance and adoption between genders 4344 a greater proportion of males express a greater appreciation of and a desire to acquire the latest technologies as one caregiver notes i am like an early adopter of technology like i always try to be first among people to get technology i mean when i got my phone like it was just on the market for like three months before i like i went for it caregiver 18 in contrast female caregivers in our sample tend to gravitate toward technologies that resemble the items that they previously used as one female caregiver expresses i think however we can use make technology design a technology in a familiar way even if theres all kinds of fabulous things going on you know a little microchip put in a huge box just to make them feel like they are using something that they remember using in the past caregiver 01 female caregivers are uncomfortable in acquiring new technologies that are unfamiliar to them citing reasons such as an inability to unlock the technologys full potential in addition older caregivers expressed a desire to have technologies that are packaged in a way that is familiar to them accessibility • technology with features that meet specific needs • accessibility considerations include hearing visual or mobility impairments communication disorders and learning disabilities • products should include features that speak to these key areas such as screen readers speech recognition adaptive keyboards and simplified language and instructions • i think if there was like the ability to havethat personal one on one aspect in terms of the development of the products it might be beneficial just becauseeach persons spinal cord injury in my experiences has been very very different from the others so if there was like a customized element to it it would probably make it more attractive to me to want to even invest the money even if it was costly cg15 bang for the buck • caregivers consider cost effectiveness affordability and value for money while making decisions about purchasing technology • devices should be long lasting with a widespread availability of parts and software updates for older models • i know they got to make money to cover the development of the app but still its got to be a reasonable fee charging a hundred dollars a year two hundred dollars a year is going to make it impossible for some people in certain categories and youre going to end up with one sector of the population able to use it and another sector unable because they cant afford it cg12 blast from the past • caregivers feel more comfortable using products that look and operate in a way that is familiar to them or resemble something from their background • it has to be in language because youre dealing with people who are aging and have some problems with cognition or ability to adapt and to incorporate new technology into their life they have to be using something that looks or feels like something from their past cg01 ecofriendly • caregivers cited a preference toward technology that minimizes environmental impact including products that are recyclable or otherwise reduce carbon footprints • i think if something was ecofriendly it would make a huge difference i think people would be more inclined to actually get it because they dont want toincrease their carbon footprint so that that would be important to me at least cg15 latest and greatest • caregivers would like to be aware of the latest technology and be at the forefront of products that can assist with caregiving • a consideration for technology adoption includes the availability of consistent upgrades to the software and hardware caregivercare recipient dynamic shapes technology perceptions caregivers report frequently taking the opinions of the care recipient into account when faced with technology decisions the way technology fits within the caregivercare recipient space determines how it is being perceived and how likely it is to be adopted within the caregiving context caregivers are eager to convey the importance of including the care recipient within the discussion on technology use and uptake perceptions toward these devices have been reported by caregivers as being established through a 2way conversation between themselves and the care recipient one caregiver taking care of her mother describes the process of acquiring technology to help with caregiving saying i know with families you have different ability levels as it relates to technology so im thinking if i was sharing this responsibility with my mom and we both wanted to input on something it would probably have to be something fairly simplistic caregiver 08 in the caregivers experience they consider not only their own level of technology competency but also that of their care recipients which on occasion takes precedence over their own this has led to instances where opportunities to enhance caregiving using technology are missed as one caregiver taking care of her mother notes as my mother deteriorated and she was in another city about like 45 minutes away i really looked into some technology to sort of bridge that gap because you know itcould hopefully help me in helping her unfortunately shes very antitechnology because she was born in that time when you didnt rely on machines you relied on human beings so its been a bit of a struggle to sort of help with the assistance of technology caregiver 04 caregivers rely on external sources for technology information when it comes to identifying resources such as technology to assist with caregiving caregivers report a disconnect between reality and the support that ought to be available one caregiver taking care of her mother sums up her experience in obtaining support from the health care system the health the community everything else you know all of these supports that were supposed to be there you know none of them are there so you know all the whole burden is come up to me and so once they look at it that im there theyre basically probably you know going to say oh shes doing it so we really dont need to provide that service now caregiver 06 the process of navigating the health care system is perceived as a burdensome process that lasts for a long time for the caregivers there are many obstacles in the process of obtaining help which is mainly caused by a lack of communication between different health care entities owing to a lack of support from the public health infrastructure caregivers turn to their peers for technology information they highlight the importance of using their social networks and connections as an avenue to gain awareness of technology and support them within their roles a case in point is cg07 a caregiver who turns to her son a former computer engineer for technologyrelated information we also well you know we have a son who is an electrician he is actually an industrial electrician now i would ask him to because he was a computer engineer before before he did that so once you know he is a computer person caregiver 07 by approaching these alternative information sources caregivers are introduced to various technologies through word of mouth and experiences of peers who are in similar caregiving situations given similar backgrounds and high levels of rapport caregivers see these sources as credible and well intentioned which represents a stark contrast to their expressions of disappointment and doubts with government support and assistance theme 3 barriers are present in the use and adoption of technology technology is not compatible with personal values and abilities although caregivers recognize the benefits that technology can bring to their lives they continue to face a wide range of challenges related to its use which in turn limits its adoption most caregivers do not have extensive knowledge of the types of technology skills to fully take advantage of its potential and the ability to troubleshoot any technical issues when asked to describe his perceptions of the barriers to technology adoption one caregiver noted the the worries and exhaustion of caring tasks the stress of being the caregiver and the management of the care recipients illness come together and interfere with the ability of caregivers to operate technology which has been described as complicated unintuitive and difficult to navigate this creates even more stress and frustration as caregivers struggle to make sense of their devices as such a vicious circle is created which as cg09 notes makes caregivers feel angry and annoyed at the technology in addition caregivers are also concerned about the security and privacy of their data while using certain technologies they are reluctant to share information about themselves and their care recipients without knowing who will have access and how their data will be used given these challenges in gaining awareness and using technology many caregivers return to previously established caregiving routines that do not involve technology as they are not only familiar with these tasks but also able to preserve a level of inperson interaction which has been gradually eroded with the introduction of technology as one caregiver describes you reach out to try to find help and in real life there really isnt a whole lot of support out there so yes you have to turn to technology which is such an anonymous support and doesnt at the end of the day give you any kind of oh good job no pats on the back caregiver 05 from the caregivers perspectives technology is limited in providing feedback and validation of their actions in contrast to the traditional forms of caregiving support such as peer groups caregivers perceive that they are unlikely to experience the same level of interpersonal connections through technology use as such caregivers will only accept these technologies in situations where they have no other choice such as in rural areas or when they are at a distance from their care recipient technology is not appropriately tailored toward end users caregivers note that the current technology has not been designed with their needs in mind as one caregiver looking after her mother expresses if they have used someone with the lived experience they would have designed all of this technology there people who dont have the lived experience or loved one s with the lived experience so theyre doing this in a vacuum caregiver 01 in addition to lacking a basic understanding of the caregiving experience and perspective caregivers also perceive technology development to be an isolated process that does not consider the diverse needs and preferences across the caregiving population in particular caregivers are concerned about the lack of accommodation in language and cognitive abilities which can vary widely across individuals as one caregiver looking after her mother comments it has to be in their language because youre dealing with people who are aging and have some problems with cognition or ability to adapt and to incorporate new technology into their life caregiver 01 these sentiments are in stark contrast with the perspectives of technology researchers who highlight the importance of involving caregivers during the technology development process as such the conflicting remarks represent a gap between the perceptions of technology researchers during their development process and the reality caregivers are facing technology researchers perspectives for technology researchers building rapport and establishing a relationship with caregivers have been highlighted as important steps in the technology development process technology researchers recognize the need to involve caregivers during the development process through consultations and workshops as a technology researcher working in the field of caregiving technologies for the past 5 years describes i involve the people im building the technology for in the design and development the whole ways through like ideation prototyping feedback on early prototypes and then efficacy its not just building in a vacuum technology developer 05 by involving caregivers in the development process technology researchers have been able to build a level of empathy with these end users not only are technology researchers able to gain a firsthand understanding of the needs and feedback of caregivers but they also expressed a greater motivation to make a positive impact on their lives by building technologies that fully address their needs and preferences furthermore technology researchers report various efforts they have begun making to take a variety of relevant demographic and sociocultural factors of caregivers into consideration within their own work as appropriate these factors span physical characteristics such as ability and body type socioeconomic indicators such as education and rurality and cultural factors such as family background and language for example one technology researcher working on an app that monitors caregiver posture comments that should do definitely i think weight is one thing that would affect it because generally to people who are thinner would be easier to bend so they just go by recognizing the diverse range of factors that influence technology use and perceptions technology researchers have taken a first step in ensuring that the needs of caregivers are being better addressed through technology nonetheless despite acknowledging and incorporating the diverse characteristics among caregivers within their work most technology researchers within our sample continue to hold assumptions about caregivers technology needs and preferences technology researchers perspectives tend toward generalizations grouping caregivers into stereotypical buckets that may not reflect the broad spectrum of needs across diverse populations for example when asked about sex and gender influences on technology and caregivers a technology researcher commented when im trying to imagine a community of caregivers i would think that its much easier to promote a device across the female population as they probably tend to share more among each other and if they come up with a good device theyre probably gonna tell other people or if they need support they are going to ask which is like not as good among the male population and theyre probably not going to be that much sharing and then at the same time not that much caring about their fellow male care providers technology developer 07 beyond the conceptual misunderstandings technology researchers also face challenges in incorporating diversity within their current work which has been attributed to budgetary constraints when asked to describe his research process one technology researcher commented yeah funding is always a problem yes i mean i think thats true of everyone right like even bigger corporations that have a lot more flexibility in terms of that they still have a budget to run and they still have a quarter leg and everything else so you know if money was infinite then things are pretty much infinitely possible technology developer 05 owing to a lack of funding and time constraints technology researchers are often limited in their ability to recruit diverse participants in their development process in addition the sheer range of diversity factors including but not limited to age socioeconomic status education level and geographical location requires the collection of a large number of data points and variables as well as expertise in conducting a sexand genderbased analysis both of which add complexity to the already challenging endeavor of technology development discussion principal findings in this firstofitskind study to our knowledge that included both family caregivers and technology researchers we analyzed interviews to gain a deeper understanding of technology perceptions among caregivers as well as whether these preferences are being incorporated within the technology development process through our analysis it is apparent that caregivers perceive technology as a doubleedged sword caregivers see technology as a valuable addition to their caregiving routines by opening a range of opportunities for them to enhance their care provision and reduce their caregiving burden however caregivers remain wary of the limitations and complications technology use may bring it is associated with privacy concerns with personal health information a lack of personalized feedback and above all an added frustration when things go wrong with respect to sex gender and diversity it is recognized that although sex and gender differences are explicit in technology preferences among caregivers characteristics such as physical and cognitive abilities as well as caregivercare recipient relationships have an influence on other aspects of technology perceptions including barriers and uptake we demonstrated how caregivers needs for technology ranged across caregiving contexts in line with previous literature 7 8 9 10 caregivers described caregiving experience as stressful and filled with numerous challenges faced with these significant physical psychological emotional and financial burdens caregivers have sought support from various sources including health care and governmental organizations for some caregivers these groups have facilitated access to resources including technology to assist with their caregiving tasks however for many other caregivers navigating these organizations proved to be a challenge hence they turn to alternative sources of informal support which include the use of technology as such the findings reveal a need for technology among caregivers driven by not only caregiving burden 45 but also the lack of welladvertised and accessible support within the health care system this presents a pressing need for the current health care systems to implement changes to improve their reach and most importantly streamline their processes for caregivers looking to access support a move that can be facilitated by using technology similar to a previous study on technology adoption conducted with older adults 46 caregivers have identified a wide range of features and characteristics that they are looking for while considering technology these factors include not only the physical function and design but also the acquisition process and the aftersales support given the diverse range of factors to consider these preferences highlight the multifaceted nature of caregivers technology adoption further adding complexity is the caregivers sociocultural backgrounds which play a significant role in informing their perspectives toward technology unlike younger caregivers we found that older caregivers in our sample tended to express a desire for technologies designed and operated in a way that is familiar to them a similar observation was also found with gender with female caregivers in our sample preferring familiar technology these findings are congruent with previous conceptual work on technology adoption across the general population which have highlighted age and gender as important factors that shape technology acceptance 47 48 49 in addition our study uncovered the influence of caregivers external environment in determining technology awareness and uptake caregiving is rarely done in isolation and caregivers recognize the need to consider the views and opinions of their care recipient while considering technology such a collaborative spirit has also been reflected in the caregivers interactions with their informal networks particularly interactions with peers family and friends technology has become an integral part of caregivers conversations with these individuals as such these social networks influence caregivers attitudes toward technology specifically caregivers with a techsavvy family and friends often described technology in a more favorable tone in contrast some caregivers with little or no exposure to technology in their social circles paint a bleaker picture of potential technologies to assist them in their care routines given the prevalence of obtaining technologyrelated information through word of mouth among caregivers it may be worthwhile to explore alternative methods of technology dissemination such as social media and caregiving support groups information about technology could also be made available by health and social care and nongovernmental organizations providing care and support to people living with various conditions that family caregivers support for example the alzheimers society in the durham region of ontario has a selection of currently available technologies that clients can test these clients can also ask questions to an informed staff member our study also highlighted the existing barriers caregivers faced while acquiring technologies to help with caregiving given that most of the caregivers in our study were older adults it is expected that their views would be congruent with findings from recent work on technology adoption among the general older adult population 50 51 52 specifically these barriers are characterized by concerns regarding technology literacy userfriendliness accessibility and privacy caregivers in this study tend to associate technology adoption with a lack of ability to understand or operate them as a result it creates a source of frustration during their interactions with technology which is further exacerbated by the unintuitive and hardtonavigate interfaces of both hardware and software as these older caregivers may not be introduced to technologies until later in their professional careers they may have a lower level of technology literacy that impedes their ability to adapt or welcome new technologies within their lives hence they may have felt more discomfort by changing their routines and embracing foreign technology especially if its use requires a substantial learning curve in addition the physical and cognitive changes associated with the aging process have limited the accessibility of many technologies caregivers often find that technologies are not designed to take account of their physical and cognitive abilities especially in the area of visual and audio enhancements which have been suggested to be inadequate or poorly designed for common uses 50 finally caregivers are hesitant to surrender their personal data to connected technologies such a mistrust in the data handling processes can be a significant obstacle in the development and introduction of technologies driven by big data analyses given the diverse spectrum of technology needs and preferences among caregivers technology researchers need to take steps to better understand and address these when developing solutions aimed at caregivers although the researchers report that they recognize the importance of involving and connecting with caregivers to solicit their perspectives during the technology development process in practice this seems not to be done in any systematic way the technology researchers in this study have reported several internal and external obstacles that limit their ability to understand caregiver perspectives for some researchers the assumptions and stereotypes they make about caregivers and their roles occlude the perceived importance of approaching individuals with actual lived experiences by holding on to personal opinions without corroborating research evidence technology researchers have overlooked the importance of understanding the diverse needs within these groups being interrelated sex and gender are not binary constructs but rather on a continuum which necessitates greater attention and intricacy in disentangling the influence of both concepts in technology perceptions as social identities these interrelated concepts also intersect with other social identities including but not limited to race culture and age to create unique personas and perceptions toward technology across the caregiving population although they appreciate the value added by caregivers to the product these researchers struggle to engage the caregivers of diverse backgrounds during the development process factors such as funding time data availability and expertise have all been cited as obstacles in the process of incorporating diversity within technology development to help overcome these challenges alternative design approaches such as usercentered participatory and experience design have been proposed 53 these approaches provide models for the involvement of end users throughout the development process and in many instances place the focus on the user rather than the product 5354 however as general approaches are applied across a wide range of product developments they may not help in navigating the nuances of technology within the caregiving context and provide guidance on the incorporation of sex gender and diversity considerations which are areas where more training and expertise are needed as such future technology projects can consider the assembly of multidisciplinary research teams that integrate members with experience working with caregivers and studying their perspectives from a diversity perspective strengths and limitations to our knowledge this is a pioneering work in the field of technology perceptions across family caregivers using qualitative research methods by including the caregivers of persons with various conditions and needs we have captured and drawn attention to the diverse technology experiences and perspectives across caregiving contexts with one of the largest samples for such a qualitative study the findings highlight the multifaceted role technology can play in aiding caregiving while highlighting the drawbacks of these technologies perceived by caregivers furthermore by including technology researchers in the study we gathered a more holistic understanding of technology in caregiving from its initial development to eventual uptake by caregivers in particular the findings reveal the diversity of caregivers technology needs and perspectives that will need to be addressed during the technology development process limitations of the study include the rather small sample sizes of technology researchers which is limited in part due to our criteria for a focus on technologies relevant to caregiving future research can be conducted with a greater number of technology researchers to better capture the technology development process across a wider range of technology fields although our work includes both caregivers and technology researchers the 2 main players within the field of caregiving and technology we recognize that there are other stakeholders such as care recipients health care providers and policy makers as such future work should consider the perspectives of these stakeholders and explore the interactions between them this is very relevant for exploring issues related to access to technology including financial barriers that caregivers with their special needs to support their caregiving routines face finally it is recognized that the findings may not be generalizable to the entire caregiving population hence it is important for technology researchers to engage their target audiences to learn more about their specific needs and view these results as a guide to the range of worthwhile factors to consider during the development process conclusions family caregivers are turning toward technology to receive assistance in managing the demands of providing care at home technology has been helpful in a wide range of caregiving apps however there remain several barriers and unmet needs related to its use and uptake as such caregivers need support through the course of technology adoption to provide this support technology researchers ought to move beyond the current practices of technology development to gather greater knowledge and awareness of caregivers diverse needs and preferences future work should focus on developing tools and resources for technology researchers to support a greater engagement with diverse caregivers such that their input can be used to develop products that better address their needs authors contributions cx and ac came up with the study concept and design cx gekr and ad contributed to the acquisition of data and provided administrative technical and material support cx gekr ac and ad analyzed the data cx drafted the manuscript cx ad gekr am jic aa en and ac reviewed and revised the manuscript for important intellectual content all authors read and approved the final manuscript conflicts of interest none declared multimedia appendix 1 semistructured interview guide for informal caregivers docx file 19 kbmultimedia appendix 1 multimedia appendix 2 semistructured interview guide for technology docx file 17 kbmultimedia appendix 2

background caregiving is highly stressful and is associated with poor mental and physical health various technologies including mobile and ehealth apps have been developed to address caregiver needs however there is still a paucity of research examining the technology perceptions of informal caregivers especially from the perspectives of sex gender and diversity objective to address the research gap and inform the development of future caregiving technologies this study aims to examine how family caregivers perceive using technology to assist with their caregiving routines identify the sex gender and diversity factors that shape these perceptions and understand how these perceptions and needs are reflected within the current technology development process methods semistructured interviews were conducted with 16 informal caregivers of individuals with a range of chronic medical conditions and 8 technology researchers involved in caregiving technology projects results three main themes with subthemes were developed the first main theme is that caregivers see a need for technology in their lives and it comprises the following 3 subthemes caregiving is a challenging endeavor technology is multifaceted and caregiver preferences facilitate technology use the second main theme is that relationships play a vital role in mediating technology uptake and it comprises the following 2 subthemes the caregivercare recipient dynamic shapes technology perceptions and caregivers rely on external sources for technology information finally the third main theme is that barriers are present in the use and adoption of technology and it comprises the following 2 subthemes technology may not be compatible with personal values and abilities and technology that is not tailored toward caregivers lacks adoptionthe findings highlight the multifaceted role that technology can play in aiding caregiving while drawing attention to the perceived drawbacks of these technologies among caregivers the inclusion of technology researchers in this study provides a more holistic understanding of technologies in caregiving from their initial development to their eventual uptake by caregivers

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introduction biomedical sciences have become increasingly data driven in the past two decades we have witnessed revolutionary new technologies for generating and collecting biomedical data exemplified by dna and rna sequencing and databases containing millions of electronic health records genomic transcriptomic and other highthroughput technologies have become a primary driving force in discovering the molecular basis of disease large biobanks are systematically generating genomics and other biomedical data for the participants whose ehrs have also been collected such biomedical datasets provide essential training and testing data for machine learning model development and have become the foundation for building artificial intelligence capacity for precision medicine researchers are developing ai models to utilize biomedical data for disease risk prediction and prognosis however the current data foundation for biomedical ai is biased as most of the critical biomedical datasets were collected from cohorts of predominantly european ancestry recent statistics show that over 80 of the data from genomewide association studies and clinical omics studies were collected from individuals of european ancestry which constitute less than 20 of the world population ai is revolutionizing biomedical research and healthcare but in the meantime it is opening a major pathway for data inequality to assert its negative impacts the inadequate training data have resulted in inaccurate ai models for disease risk assessment prognostic prediction and medication usage for the datadisadvantaged populations the disparity in ai model performance is a significant impediment to equitable precision medicine precision medicine is poised to be less precise for most of the worlds population because of biomedical data inequality recent studies show that multiethnic machine learning schemes differ significantly in their performance in the presence of data inequality and that transfer learning is an effective strategy to improve machine learning model performance on datadisadvantaged populations in the following sections we discuss the current status of biomedical data inequality among ethnic groups the ongoing efforts to increase ethnic diversity in biomedical data the impacts of data inequality and subpopulation shift on multiethnic machine learning and the advances in machine learning strategies to mitigate the negative impacts of biomedical data inequality biomedical data inequality biomedical data inequality has existed for a long time but has only recently been brought to wide attention as biomedical research enters the era of big data many largescale datasets have been generated in recent years these datasets provide unprecedented opportunities for datadriven knowledge discovery and enable the development of sophisticated ai models however severe data inequality widely exists in biomedical datasets table 1 shows examples of data inequality in some highly influential biomedical datasets providing a snapshot of the degree of biomedical data inequality in a wide range of studies on health and disease the data inequality is particularly severe in largescale genomic transcriptomic proteomic and other omic data statistics from the national human genome research institute provide an overview of the populations included in largescale genomic studies 87 european 10 asian 85 unreported 2 african 1 hispanic and 05 others during the past decade gwas have become the most important source of knowledge on the genetic architecture of complex diseases gwas data also provide the basis for developing polygenic disease prediction models recent studies show that gwas data inequality between the european and other ancestry populations is overwhelming the gwas ai models that work well for all equitable precision medicine equitable precision medicine equitable precision medicine algorithmic interventions inaccurate ai models for datadisadvantaged populations global biomedical data equity figure 1 addressing the challenge of data inequality for aipowered precision medicine the path of the status quo leads to data inequality a significant obstacle to achieving equitable precision medicine for all the ring graph on the left shows the ethnicancestry compositions of gwas using data from the gwas diversity monitor and several representative clinical omics studies including gtex target tcga and genie using data from gtex portal and nci genomic data commons the ring graph on the right is a conceptual illustration of the goal of biomedical data equity for global populations represented by the five superpopulations defined by the 1000 genomes project algorithmic interventions can attenuate but may not be able to eliminate the negative impacts of data inequality a new path is essential to achieve equitable precision medicine that works well for all ethnicancestry groups abbreviations genie genomics evidence neoplasia information exchange gtex genotypetissue expression project gwas genomewide association studies nci national cancer institute target therapeutically applicable research to generate effective treatments tcga the cancer genome atlas diversity monitor tracks the ancestral diversity of thousands of gwas and shows that over 85 of gwas data were collected from individuals of european descent and the diversity has not improved in recent years as we discuss more thoroughly in the following sections such data inequality hinders equity in multiethnic machine learning and may lead to new health disparities subpopulation shift in machine learning subpopulation shift refers to data distribution discrepancies among subpopulations here we focus on subpopulations defined by ancestry or ethnicity researchers have observed ancestryor ethnicityassociated differences in genetic and somatic dna mutation epigenetic modification rna and protein expression metabolic signatures and microbiome profiles in a wide range of biological processes critical to human health and diseases from the data science perspective this indicates that the natural data generation mechanism may vary among populations of different ancestries such variations can lead to discrepancies in biomedical data distribution among ancestry groups which has profound implications for multiethnic machine learning strategies a machine learning problem consists of a domain d and a learning task t the domain d x p consists of a feature space x and a probability distribution p where x ∈ x represents the input features the learning task t y f x → y consists of a label space y and a predictive function f learned from the featurelabel pairs from the probabilistic perspective f can be written as p where y ∈ y represents the prediction targets in machine learning it is generally assumed that each is drawn from a single distribution p however this assumption is violated due to the data distribution discrepancy across subpopulations given p pp both the marginal distribution p and the conditional distribution p may contribute to the joint distribution discrepancy the marginal distribution and the conditional distribution correspondence to two types of dataset shift and have different implications for multiethnic machine learning here we consider a population consisting of two subpopulations a covariate shift is a scenario where p 1 p 2 but p 1 p 2 while a concept drift is a scenario where p 1 p 2 but p 1 p 2 a dataset shift is a more general scenario where at least one of the marginal or conditional distributions is different subpopulation shift is essentially a dataset shift caused by a data distribution discrepancy among subpopulations marginal distribution conditional distribution joint distribution concept drift covariate shift dataset shift subpopulation 2 subpopulation 1 subpopulation 2 subpopulation 1 subpopulation 2 subpopulation 1 x 2 x 1 x 2 x 1 x 2 x 1 x 2 x 1 x 2 x 1 x 2 x 1 y 0 y 1 p p • p figure 2 a conceptual framework for elucidating the data distribution discrepancies among subpopulations and their implications for machine learning we consider a population consisting of two subpopulations 1 and 2 where x represents the input features for machine learning and y represents the prediction target variable from the machine learning perspective the two subpopulations can be viewed as two domains covariate shift is the situation where the marginal distributions of the two domains are different while the conditional distributions of the two domains are the same concept drift is the situation where the conditional distributions of the two domains are different while the marginal distributions of the two domains are the same dataset shift is a more general situation where the joint distributions of the two domains are different because at least one of the conditional and marginal distributions is different given the relationship between the joint conditional and marginal distributions covariate shift and concept drift are two special cases of dataset shift the dashed curves represent the decision boundaries separating the two classes of the samples a decision boundary is determined by the conditional distribution that represents the causal mechanism the genetic architectures of many diseases mainly represented by the allele frequencies and effect sizes of the causal genetic variants vary among ancestry groups for instance the allele frequency of rs699 a singlenucleotide variant associated with hypertension varies across different populations this snv has two alleles a and g with overall allele frequencies of 29 and 71 respectively however the allele frequencies vary significantly among the five global superpopulations defined by the 1000 genomes project admixed american african east asian european and south asian allele a is the major allele in the european population with a frequency of 59 while being the minor allele in the noneuropean populations the allele frequency also varies among the subpopulations of each of the five global ancestry populations the effect size of rs699 on preeclampsia a severe pregnancy complication characterized by hypertension varies among ancestry groups the genetic architecture of covid19 also varies among ancestry groups the allele frequencies and effect sizes of four genetic variants associated with the critical illness caused by covid19 vary significantly across the ancestry groups in polygenic disease prediction genotypes of the genetic variants associated with the disease are used as input features and the disease status is the prediction target the marginal distribution p represents the allele frequencies of the causal genetic variants the conditional distribution p represents the dependency of the disease on the genotype of the causal genetic variants which is mainly determined by their effect sizes on the disease the allele frequencies and effect sizes of these causal genetic variants may vary among different subpopulations leading to marginal and conditional distribution discrepancies similarly the distribution of other molecular features and their effects on the diseases may also vary among ancestry or ethnic groups leading to subpopulation shift data inequality and subpopulation shift also exist in ehr datasets for example about 77 of patients with known ethnicities in mimiciv the largest publicly available ehr dataset are white for many clinical laboratory tests there are significant value distribution differences among ancestry or ethnic groups suggesting the reference intervals for these tests should be ethnicity dependent making clinical decisions with ai models built using inadequate and incompatible data confers health risks for datadisadvantaged populations polygenic scores and medical ai models developed using data from cohorts of predominantly european ancestry show significantly lower performance on noneuropean populations despite the highly nonlinear genotypephenotype relationship and nonadditive genetic interactions linear polygenic models are widely used for disease risk prediction in the multiple linear regression framework polygenic prediction for disadvantaged populations can be enhanced by calibrating parameters for genetic effect sizes or model sparsity patterns across ethnic groups however the linear polygenic models do not have the sufficient expressive capacity to learn and transfer complex representations across subpopulations with different genetic architectures recent studies indicate that the deep learning models capable of capturing complex nonlinear interactions generally outperform the linear disease prediction models multiethnic machine learning we have defined three categories for multiethnic machine learning schemes based on how they utilize the data from different subpopulations mixture learning independent learning and transfer learning the mixture learning scheme indistinctly uses data from all subpopulations for model training currently mixture learning is used as the standard machine learning scheme for multiethnic data in the presence of data inequality the performance of the mixture learning model on different subpopulations can be very different the overall performance of the mixture learning model is mainly driven by its performance for the predominant subpopulation in the dataset its performance for the smaller subpopulations is often significantly lower due to inadequate representation in the training data and data distribution discrepancies with the predominant subpopulation another multiethnic machine learning scheme is independent learning which uses data from different subpopulations separately to train an independent model for each subpopulation the independent learning scheme also tends to generate machine learning models with low performance for the smaller subpopulations due to inadequate training data in the transfer learning scheme knowledge learned from the datarich subpopulation is transferred to assist the learning task for the datadisadvantaged subpopulation the current prevalent machine learning scheme for multiethnic data the mixture learning scheme and its main alternative the independent learning scheme have major obstacles in training optimal machine learning models for datadisadvantaged subpopulations the two multiethnic machine learning schemes the mixture learning scheme indistinctly uses data from all subpopulations in model training the independent learning scheme uses data from different subpopulations separately to train an independent model for each group in the transfer learning scheme knowledge learned from the datarich subpopulation is transferred to assist the learning task for the datadisadvantaged subpopulation major challenges in multiethnic machine learning are data inequality and subpopulation shift both challenges can be addressed with transfer learning in transfer learning we consider a source domain d s ns i1 with n s labeled samples and a target domain d t nt j1 with n t labeled samples where the xs represent features and the ys represent labels for multiethnic machine learning tasks data from an ethnic group with a larger sample size are designated as the source domain and data from an ethnic group with a smaller sample size are designated as the target domain the knowledge learned from the source domain can be transferred to assist in developing a machine learning model for the target domain as the primary driving force of the recent ai advances deep neural networks consisting of multiple layers of connected artificial neurons have outperformed traditional machine learning systems in a wide range of applications dnns are also particularly suitable for transfer learning as they can learn transferable features that generalize well to novel tasks for domain adaptation however most deep learning and deep transfer learning algorithms were developed initially for visual recognition and language processing tasks which provide rich algorithm resources but not an offtheshelf solution that one can directly apply to tabular biomedical data machine learning experiments on genomic prediction of disease occurrence and omicsbased disease prognosis have shown that transfer learning can significantly improve the predictive accuracy for datadisadvantaged subpopulations here we discuss three transfer learning strategies that have been adapted and applied to mitigate the negative f x x x x f1 f1 h g g l c l sa l s f1 x x x f2 f2 f1 c c c figure 5 the ccsa minimizes the loss function l ccsa l c γ l s where f h ‫ؠ‬ g represents the composition of a function g that maps the input data x to an embedding space z and a function h used to predict the output label from z c is a classification layer l c is the classification loss l sa is the semantic alignment loss l s is the separation loss and γ is the weight used to balance the classification loss versus the contrastive semantic alignment loss l sa l s impacts of biomedical data inequality a finetuning method an autoencoderbased method and a domain adaptation method finetuning is frequently used as a transfer learning method to improve dnn model performance and generalization the general finetuning procedure involves training a dnn on the source domain cutting off some layers of the network and autoencoder a type of neural network for unsupervised learning of efficient data representations through a process of encoding and decoding for reconstructing the input data loss function the difference between estimated and true outputs of the machine learning model during training and validation it is used to optimize the model parameters for high prediction accuracy pareto improvement a change in a system that results in a new situation where some parties in the system are better off and no party is worse off replacing them with randomly initialized layers and tuning the network using backpropagation on the target domain until the validation loss starts to increase the key issue in the finetuning approach is the transferability of the layers one can test the transferability of the layers along the dnns by changing the cutoff point in the network from where the bottom or top n layers will be frozen or finetuned and setting different learning rates for each layer to find the optimal cutoff point and learning rate distribution for finetuning we developed an autoencoderbased transfer learning strategy for improving cancer classification and improving cancer prognosis prediction for datadisadvantaged ethnic groups the method is based on stacked denoising autoencoders and uses unlabeled data from the source domain and labeled data from the target domain the basic idea is that using unlabeled data of the source domain to initialize the network parameters would improve the performance for the target domain the sae maps the input feature into different levels of representation and reconstructs it from the mapped space during the training the source domain data are used to pretrain an sae and then the model is finetuned using target domain data the key parameters for this method include the number of sae layers and their sizes domain adaptation is a class of transfer learning methods that improve machine learning performance on the target domain by adjusting the distribution discrepancy across domains the source domain and target domain are sampled from two different joint distributions p s and p t respectively as discussed in the previous section the difference between joint distributions may stem from the conditional distribution p or the marginal distribution p many domain adaptation methods can only handle marginal distribution adjustment however both marginal and conditional distributions may differ between subpopulations it is essential to select domain adaptation methods that can simultaneously address the two significant challenges in multiethnic machine learning the small sample size of the datadisadvantaged subpopulation and the discrepancy of data distribution between subpopulations lowresource domain adaptation methods such as classification and contrastive semantic alignment are particularly suitable for addressing these challenges because these methods can significantly improve target domain prediction accuracy by using very few labeled target samples in training and these methods include semantic alignment in training and therefore can handle the domain discrepancy in both marginal and conditional distributions the ccsa domain adaptation method utilizes a loss function comprising three terms classification loss semantic alignment loss and separation loss the semantic alignment loss is used to minimize the distance between samples of the same class but from different domains the separation loss is used to maximize the distance between samples of different classes and domains and the classification loss is used to maximize the prediction accuracy subpopulation shift has been addressed by enforcing predictive performance parity on subpopulations however a fundamental challenge for machine learning fairness research is the inherent tradeoff between fairness and prediction accuracy the transfer learning scheme is not subject to this dilemma in transfer learning a machine learning model trained on a datarich subpopulation can aid in training a model for a datadisadvantaged subpopulation without affecting its own prediction accuracy thus transfer learning provides a pareto improvement for multiethnic machine learning pareto improvement is a generally desired scenario in which some parties are better off without negatively impacting other parties in the system in studies of the impacts of data inequality on machine learning the gap or ratio of the model performance metrics between groups is often used to measure the disparity of data inequality and subpopulation shift are the two key challenges in multiethnic machine learning these challenges are being addressed on two fronts collecting more ancestrally diverse data will gradually reduce the degree of data inequality and algorithmic intervention can mitigate the impacts of data inequality and subpopulation shift on multiethnic machine learning machine learning model performance across subpopulations it should be noted that some performance metrics may not be suitable for evaluating machine learning model performance on datadisadvantaged populations with small sample sizes as shown by davis goadrich the interpolation property of the precisionrecall curve may lead to inaccurate calculation of the area under the pr curve when the sample size is small in contrast the receiver operating characteristic curve does not have this problem thus providing a more stable performance metric for datadisadvantaged populations machine learning with more ancestrally balanced data machine learning experiments on synthetic data show that data inequality and subpopulation shift are the key factors underlying model performance disparities currently these challenges in multiethnic machine learning are being addressed on two fronts data collection and algorithmic intervention largescale efforts are underway to collect biomedical data from diverse populations table 2 lists some examples of current efforts to collect data from diverse or datadisadvantaged populations given the severe and ubiquitous biomedical data inequality that has accumulated for decades there is a long way to go to achieve global biomedical data equity as a result medical ai faces a longterm challenge in attenuating the negative impacts of biomedical data inequality however we can expect the degree of data inequality to decrease gradually therefore it is crucial to understand how the performance of different machine learning schemes changes as a function of the degree of data inequality recent experiments on synthetic data indicate that multiethnic machine learning schemes still perform differently even when data inequality is eliminated because of different responses to the data distribution discrepancy among ancestry groups understating the influence of data inequality on machine learning has important implications for resource allocation in biomedical data collection and generation for example proportional representation is widely accepted and implemented as a criterion for equity in resource allocation however although the population of the united states is more ancestrally diverse than most developed countries proportional representation in the united states means that only about 27 of the data will be collected from all noneuropean ancestry groups combined which can still lead to significant disparities in ai model performance therefore using proportional representation in the developed countries where most biomedical studies are conducted is not adequate for achieving health equity from a machine learning perspective collecting approximately equal amounts of biomedical data from all ancestry groups is essential to achieving equitable aiempowered precision medicine detection of the africanspecific dna variants at this point it is unclear whether there is a widespread data quality disparity among ancestry or ethnic groups in biomedical datasets the data quality disparity is a serious issue that can broadly impact biomedical research and healthcare and it warrants a thorough investigation the data quality disparity can also exacerbate the existing disparity in multiethnic machine learning because lowquality data from the disadvantaged populations provide weaker and noisier signals that are more difficult for machine learning models to capture and utilize in light of the discovery of biomedical data quality disparity the concept of data inequality can be expanded to include not only disparity in data quantity but also disparity in data quality data quality disparity current research on biomedical data inequality almost exclusively focuses on the disparity in data quantity however recent research provides evidence of significant disparity in data quality between ancestry groups wickland et al found that exome sequencing coverage is lower for patients of african ancestry in data from the cancer genome atlas which may hamper the summary points 1 biomedical data inequality confers a significant health risk for people of noneuropean ancestry which constitute over 80 of the worlds population 2 artificial intelligence greatly empowers precision medicine but in the meantime it opens a major pathway for biomedical data inequality to manifest and amplify its health risks to datadisadvantaged groups 3 aiempowered precision medicine is set to be less precise for datadisadvantaged populations which can generate new health disparities 4 these new health disparities can impact any disease where data inequality exists so the negative impacts would be broad 5 algorithmic interventions such as using transfer learning can mitigate the negative impacts of data inequality 6 in many cases transfer learning provides a generally desired pareto improvement in multiethnic machine learning and it is not subject to the dilemma between fairness and prediction accuracy 7 there is an urgent need to improve the ethnic diversity in biomedical data and proportion representation is insufficient to build the data foundation for equitable aiempowered precision medicine in developed countries 8 even as the ethnic diversity in biomedical data increases the subpopulation shift will remain a significant challenge for multiethnic machine learning which can be addressed with algorithms such as transfer learning disclosure statement the authors are not aware of any affiliations memberships funding or financial holdings that might be perceived as affecting the objectivity of this review

artificial intelligence ai and other datadriven technologies hold great promise to transform healthcare and confer the predictive power essential to precision medicine however the existing biomedical data which are a vital resource and foundation for developing medical ai models do not reflect the diversity of the human population the low representation in biomedical data has become a significant health risk for noneuropean populations and the growing application of ai opens a new pathway for this health risk to manifest and amplify here we review the current status of biomedical data inequality and present a conceptual framework for understanding its impacts on machine learning we also discuss the recent advances in algorithmic interventions for mitigating health disparities arising from biomedical data inequality finally we briefly discuss the newly identified disparity in data quality among ethnic groups and its potential impacts on machine learning biomedical data inequality the significant disparity in the amount of data collected from populations of different ancestries or ethnicities multiethnic machine learning machine learning using data from a population consisting of multiple subpopulations of different ancestries or ethnicities polygenic disease prediction predicting disease risk or occurrence using the genotype data of multiple genetic variants associated with the disease

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introduction early child hood ed u ca tion and care pro grams have in creas ingly been ad vanced for fos ter ing child de vel op ment and re duc ing early inequalities there in as such both de mand for and ac cess to cen terbased childcare have dra mat i cally ex panded across de vel oped countries in re cent de cades in a con text of welldocumented longterm returns to highqual ity early in vest ments par tic u larly for dis ad van taged chil dren cou pled with ev i dence that so cio eco nomic gaps in school read i ness do not nar row and may fur ther widen as chil dren prog ress through school pol i cies that pro mote highqual ity for mal childcare may have im pli ca tions for re duc ing longterm pop u la tion inequalities the most rig or ous ev i dence to date in di cates that highqual ity cen terbased childcare has pos i tive im pacts on child de vel op ment es pe cially for dis ad van taged chil dren however much of this ev i dence has come from ran dom ized eval u a tions of smallscale in ten sive pro grams from the united states and to a lesser ex tent other an gloenglishspeak ing countries evidence is more mixed with re spect to wide spread or uni ver sal pro grams moreover much of the ev i dence re flects cen terbased childcare pro vi sion for 3to 5yearold chil dren less is known about its im pact in ear lier child hood of par tic u lar con cern iso lat ing a causal im pact of cen terbased childcare on child de vel op ment in ob ser va tional stud ies is chal lenged by sys tem atic se lec tion into childcare type and het ero ge ne ity in qual ity of childcare furthermore het ero ge ne ity by pop u la tion sub groups or by coun ter fac tual con di tion is a chal lenge to gen er al iz ing causal im pacts across dif fer ent pop u la tions we use a data from a na tion ally rep re sen ta tive french birth co hort the étude longitudinale français depuis lenfance and an in stru men tal var i ables strat egy that harnesses ex og e nous var i a tion in birth tim ing and lo cal cen terbased childcare sup plyboth of which af fect a childs like li hood of childcare cen ter at ten dance while ar gu ably be ing or thog o nal to fam ily choices con di tional on other char ac ter is tics of the lo caleto es ti mate whether age 1 at ten dance in highqual i ty statereg u lated childcare cen ters known as crèches im pacts child de vel op ment at ap prox i ma tely age 2 we ex am ine whether ef fects dif fer across de vel op men tal do mains and whether there is het ero ge ne ity in ef fects by so cio eco nomic char ac ter is tics the french con text is par tic u larly wellsuited to in ter ro gat ing these ques tions for sev eral rea sons first al though ac cess to pub licly spon sored childcare is uni ver sal the form of that carewhether in a crèche or in a pro vid ers homeis not guaranteed rather it varies by lo cal avail abil i ty cre at ing the op por tu nity to le ver age a nat u ral ex per i ment based on when dur ing the year a child is born and the sup ply of childcare cen ter slots in the fam i lys mu nic i pal i ty second the ma jor ity of french children at tend ing cen terbased care are placed in homogenously highqual i ty pub licly funded and heavily reg u lated cen ters pro vid ing a con text for test ing the ef fects of highqual ity cen terbased care at a pop u la tion lev el third chil dren whose fam i lies are un able to se cure a cen terbased place ment are en ti tled to a sub sidy to re ceive childcare in the home of a gov ernment li censed and reg u lated childcare pro vid er nonetheless not all french chil dren areplacedinafor malchildcarear range mentasig nif cantpro por tionarecaredfor by a par ent who can re ceive mod est f nan cial com pen sa tion through pa ren tal leave of up to three years this di ver sity in childcare ar range ments al lows us to com pare crèche at ten dance with a range of coun ter fac tual ar range ments assessing the im pact of gov ern mentpro vided cen terbased care is also im por tant within the french con text given that the cur rent ad min is tra tion has put early for mal childcareand in par tic u lar in creas ing for mal cen terbased childcare en roll ment for dis ad van taged chil drenat the heart of its pol i cies to tackle in ter gen er a tional transimpact of centerbased childcare attendance mis sion of dis ad van tage to date how ev er there is lit tle ev i dence on whether such care in france has pos i tive im pacts on child de vel op ment in gen eral and for chil dren from dis ad van taged fam i lies in par tic u lar background the impact of centerbased childcare on child development early child hood is a crit i cal stage for brain de vel op ment and forming the struc tures and mech a nisms that shape cog ni tive phys i cal so cial and emo tional wellbe ing throughout the life course an ex ten sive lit er a ture has ex am ined the role of early child hood ed u ca tion and care pro grams on var i ous do mains of child de vel op ment most com mon ly assessing the de ter mi nants of child de vel op mentand the role of so cial in ter ven tion there inis approached from an in vest ment framework in which in vest ments by fam i lies and in sti tu tions in flu ence chil drens de vel op ment in cas cad ing fash ion such that ear lier in vest ments are likely to have the larg est im pacts through out the life course be cause they pro vide the in fra struc ture for responding to later in vest ments and ex pe ri ences and the more one skill or do main of wellbe ing is de vel oped the more other do mains will also im prove in other words skills be get skills highqual ity cen terbased care in early child hood may have both di rect and in directef fectsonchildde vel op mentchildrenmayben e ftdi rectlythroughcog ni tive ly emo tion al ly and phys i cally stim u lat ing and sup port ive in ter ac tions with trained staff andex plicitop por tu ni tiesforskillde vel op mentandso cial i za tiontheymayben e ft in di rectly if such care has pos i tive spill over ef fects into the fam ily en vi ron ment and im proves fam ily func tion ing by for ex am ple en abling par ents to bet ter bal ance work and fam ily roles thereby re duc ing pa ren tal stress and im prov ing the qual ity of par entchild in ter ac tions evidence thatearlyin putsplayasig nif cantroleinthelongtermpro duc tionofhu mancap i tal has bol stered calls for so cial in vest ment to be gin well be fore for mal ed u ca tion the most rig or ous stud ies to date have pre dom i nantly been conducted in the united states be gin ning in the 1960s and con sist of small in ten sive ex per i men tally eval u ated in ter ven tions targeting lowin come fam i lies dur ing the pre school pe ri od these pro grams typ i cally in cluded highqual ity cen terbased care along with com po nents di rectly targeting par ents more over the qual ity of care pro vided was strictly enforced and mon i tored such pro grams have dem on strated sub stan tial longterm pos i tive ef fects that ex tend into adult hood and span cog ni tive skills and ac a demic achieve ment phys i cal and men tal health em ploy ment and earnings crim i nal jus tice in volve ment and wel fare de pen den cy there have also been largescale ex per i men tal eval u a tions of the head start and early head start pro grams in the united states head start dem on strates shortterm ben e fts for lan guage de vel op ment for 4yearolds and shortterm ben e fts for lan guage math be hav iorandhealthfor3yearoldstheseben e ftstendtofadeovertimebutare larger and more likely to per sist for less advan taged chil dren they also vary by coun ter fac tual con di tion with gains be ing larger rel a tive to homebased care than to other forms of cen terbased care despite ev i dence of fadeout found in the ex per i men tal im pact eval u a tion econo met ric an a ly ses have iden ti fedlongtermpos i tiveim pactsofheadstartthrough outthelifecourse the early head start ex per i men tal eval u a tion iden ti fedpos i tiveim pactsonlan guagede vel op mentandbe hav iorwiththelarg est and most per sis tent ef fects found among the most dis ad van taged chil dren and children who attended cen terbased care sub se quent to pro gram exit in con trast to these stud ies nonex per i men tal stud ies of largescale cen terbased ini tia tives have pro duced de cid edly mixed re sults this may re flect dif fer ences in in sti tu tional con texts data qual ity and tim ing of as sess ments iden ti f ca tion strat e gies and operationalization of cen terbased childcare re ceipt coun ter fac tual con di tions and de vel op men tal out comes most ob ser va tional stud ies have also been conducted in the an gloen glishspeak ing countries which may limit their gen er al iz abil ity to con texts with wide spread or uni ver sal pro vi sion of highqual ity care given that avail abil i ty type and qual ity of childcare vary con sid er ably across de vel oped countries most no ta bly there is sub stan tial het ero ge ne ity in ac cess to and qual ity of care in the an gloen glishspeak ing countries which pre dom i nantly rely on mar ketbased childcare pro vi sion whereas childcare ser vices in con ti nen tal europe are more heavily reg u lat ed ho mo ge neous and uni ver sal a grow ing lit er a ture has harnessed nat u ral ex per i ments to ex am ine the im pact of wide spread or uni ver sal pro vi sion of care fre quently leverag ing var i a tion in the tim ing of pro gram ini ti a tion and ex pan sion to iden tify ef fects such stud ies have pro duced mark edly di verg ing es ti ma tes al though the ev i dence is more prom is ing for chil dren from dis ad van taged fam i lies it is also im por tant to con sider that documented ef fects of cen terbased care tendtodif ferbyde vel op men taldo mainwithmoreprom is ingfnd ingsforcog ni tive skills and achieve ment than be hav ior for which some stud ies fnd ad verse shortterm ef fects for at least some groups of chil dren heterogeneity by centerbased care characteristics the im pact of cen terbased childcare is likely to vary by age at pro gram ini ti a tion qual ity and in ten sity of care whether care includes com ple men tary sup ports for parents and coun ter fac tual con di tions con sid ered in a re view of 32 stud ies from de vel oped countries for ex am ple burger con cluded that more in ten sive programs are gen er ally as so ci ated with sub stan tial shortterm and smaller longterm impact of centerbased childcare attendance im prove ments in cog ni tive skills but shortterm in creases in be hav ioral prob lems positive im pacts are also larger for pro grams that in clude in ter ven tions to im prove par ent ing and the home en vi ron ment a re cent metaanal y sis of 30 qua siex per i men tal stud ies from de vel oped countries fur ther found con sis tent ev idence that childcare qual ity is a key fac tor visàvis child de vel op ment as well as mod est ev i dence that higherin ten sity care leads to bet ter out comes however child out comes were not found to vary by age at pro gram en try a metaanal y sis of us studies over nearly a 50year pe riod documented that smaller group sizes and childteacher ra tios are as so ci ated with larger pos i tive im pacts on cog ni tive de vel op ment and that higherqual ity pro grams with an ex plicit fo cus on so cial and emotional de vel op ment have larger pos i tive ef fects on be hav ior in short qual ity and in ten sity mat ter as do com ple men tary com po nents aimed at im prov ing fam ily func tion ing and the qual ity of chil drens home en vi ron ments the french con text of fers the op por tu nity to eval u ate the im pact of homogenously highqual ity cen terbased care which does not in clude com ple men tary com po nents aimed at im prov ing fam ily func tion ing thereby allowing for as sess ment of the ef fect of cen terbased care alone on child de vel op ment moreover chil dren who at tend crèche tend to do so at rel a tively high lev els of in ten sity heterogeneity by developmental domain child de vel op ment spans mul ti ple do mains across which a va ri ety of skills emerge at dif fer ent times in a dy namic and cu mu la tive man ner thus ex am in ing the im pact of early childcare on dif fer ent de vel op men tal do mains is warranted both to iden tify ar eas of prom ise and con cern and to il lu minate pro cesses linking at ten dance to later as pects of func tion ing and wellbe ing we fo cus on three dis tinct out comes early lan guage mo tor skills and be hav ior first early lan guage de vel op ment is a key in di ca tor of school read i ness that may be par tic u larly sen si tive to childcare qual i ty early lan guage de vel op ment is as soci ated with sub se quent cog ni tive skills ed u ca tional achieve ment and la bor market suc cess second to the ex tent that childcare is as so ci ated with in creases in phys i cal ac tiv ity for young chil dren it may im prove mo tor skills indeed many pro grams in clude an ex plicit fo cus on mo tor skills fine mo tor skills are as so ci ated with bet ter later writ ing read ing and math scores and may there fore be im por tant for school read i ness gross mo tor skills are rel e vant to iden ti fy ing de vel op men tal de lay and are as so ci ated with later phys i cal wellbe ing be hav ior and socioemotional skills third child be hav ior is linked to fu ture ac a demic and la bor mar ket out comes through out the life course as noted ear li er how ev er some ev i dence sug gests that the shortterm de vel op men tal ben e fts of highqual ity cen terbased care visàvis school read i ness and per for mance tend to fade out rel a tively rap idly nonetheless ev i dence also links highqual ity cen terbased care to a rangeoflongtermeco nom ichealthandso cialben e ftsinadult hood prior re search on the shortterm ef fects of cen terbased care has most fre quently assessed cog ni tive skills and achieve ment and this is the do main in which the larg est ef fects have been found current es ti ma tes sug gest pos i tive ef fect sizes in the range of 014 to 028 stan dard de vi a tions for cognitive skills evidence on mo tor skills is rel a tively rare however gormley and gayer reported a 024 sd im prove ment in mo tor skill as a re sult of attendance in tulsas prek program given welldocumented het ero ge ne ity in im pacts of cen terbased childcare on child be hav ior ef fect sizes range wide ly from 013 to 050 sds heterogeneity by socioeconomic characteristics a con sid er able lit er a ture has documented that more advan taged fam i lies are dis propor tion ately likely to se lect into highqual ity cen terbased care and that less advantaged chil dren are dis pro por tion ately likely to re ceive in for mal care or care in the pro vid ers home these pat terns un der score the im por tance of ac count ing for such se lec tion in attempting to iso late the causal ef fect of childcare ar range ment on child de vel op ment as noted ear li er how ev er ev i dence also in di cates that less advan taged chil dren who do at tend highqual ity cen terbased care re al ize greater gains there from than do their more advantaged coun ter parts al though there are no ta ble ex cep tions to this gen eral pat tern totheex tentthatcen terbasedcaredis pro por tion atelyben e ftsdisad van taged chil dren at ten dance may re duce so cio eco nomic inequalities in school read i ness and be yond we ap prox i mate so cio eco nomic dis ad van tage by ma ter nal ed u ca tion house hold in come and ma ter nal im mi grant sta tus1 the french context france is an in ter est ing case study both be cause crèche care is of ho mo ge neously high qual ity and be cause there is con sid er able var i abil ity in the types of ar rangements in which chil dren are placed fagnani reported that crèchesarehighlyval uedbyfam i liesasare sultofthestaffsqual i f ca tionre quirements and of the prev a lent idea that crèches pro vide an ide al prep a ra tion for the tran si tion to nurs ery school and con se quently to pri mary ed u ca tion nationally mandatedra tiosareonestaffperfvechil drenwhoarenotyetwalk ingandonestaffper eight older chil dren staff are ex ten sively su per vised and trained on early child hood con tent such as early health de vel op ment and agerel e vant ed u ca tional and health impact of centerbased childcare attendance prac tices crèche staff must in clude one or more pe di at ric nurses early child hood ed u ca tors and as sis tant pe di at ric nurses in ad di tion all per son nel in con tactwithchil drenmusthaveatleastsub jectspe cifcsec ond aryoruni ver si tylevel qual i f ca tions a fea ture of ten linked to highqual ity childcare pro vi sion each child is assigned a ref er ence staff per son who over sees their wellbe ing aboutoneffthoffrenchchil drenun derage3attendedacrècheinin2013however there are large re gional dif fer ences in crèche avail abil i ty families have a 17 to 20 chance of obtaining a place in crèche in for ex am ple pays de loire an al most 30 chance in the paris re gion and a nearly 50 chance in provencealpescôte dazur and in corsica although staff train ing and salaries as well as subsidies to par ents are centrally funded pro gram man age ment and in fra struc ture costs are del e gatedtomu nic i pal i tiesgiventhesecostsal lo cat ingsuf f cientcrècheslotsisnot al ways pri or i tized by mu nic i pal au thor i ties moreover de spite the french gov ern ments goal of pro vid ing crèche to dis ad van taged fam i lies more advan taged ur ban fam i lies are typ i cally most suc cess ful in accessing crèche crèche is avail able to chil dren up to about 3 years of age chil dren age 3 and older are guaranteed a place in free pre school although the ma jor ity of par ents in di cate that crèche is their pre ferred childcare ar range ment it re mains the sec ond most com mon form of for mal childcare in france be hind sub si dized statereg u lated care giv ers who care for chil dren in their own home assistantes maternelles pro vided care for about onethird of french chil dren un der 3 years of age in 2013 in the o ry crèche and assistante maternelle care are intended to pro vide compa ra bly highqual ity care yet train ing and ed u ca tion re quire ments are more strin gent for crèche staff than for assistantes maternelles the lat ter need not hold for mal quali f ca tionsrath ertheymustat tend120hoursoftrain ingovertheirfrstthreeyearsof ac tiv ity they are how ev er held to strict struc tural re quire ments in terms of in fra struc ture hy giene and the like and are li censed to care for no more than three chil dren at a time furthermore al though there is no na tional cur ric ula for early care pro vi sion strict struc tural re quire ments are centrally de ter mined and reg u lated for both crèche and assistante maternelle care both crèches and assistantes maternelles re ceive reg u lar qual ity in spec tions which in clude ob ser va tions in ter views and selfas sess ments and are designed to mon i tor both struc tural and pro cess qual ity oversight reg u la tion and li cens ing are ad min is tered at the na tional lev el interviews were car ried out in the ma ter nity unit shortly af ter a childs birth by telephone roughly two months postbirth and again when the child was ap prox i ma tely 1 and 2 years of age data were col lected on di verse top ics in clud ing so cio eco nomic back ground par ent ing child de vel op ment and liv ing con di tions from the ini tial elfe sam ple of 18329 births we re tain fam i lies with no missing in ter view waves be tween birth and age 2 leav ing a po ten tial anal y sis sam ple of 12574 2 we then ex clude 343 fam i lies with miss ing data on all three out comes and an ad di tional 244 fam i lies with miss ing data on their pri mary childcare ar range ment this re sults in an anal y sis sam ple of 11987 fam i lies of which 11986 had nonmissing lan guage da ta 11190 had nonmissing mo tor skills da ta and 11983 had nonmissing be hav ior da ta we al low the sam ple to vary across out comes 3 notably dis ad van taged fam i lies were dis pro por tion ately lost to fol lowup and are there fore un der rep re sented in our anal y sis sam ple com pared with the ini tial elfe sam ple compared with fam i lies in the ini tial elfe sam ple those in our anal y sis sam ple had higher lev els of ma ter nal ed u ca tion ma ter nal em ploy ment and fam ily in come they were also more likely to have a na tive french mother and less likely to be headed by a sin gle moth er4 thusourfnd ings may not be fully gen er al iz able to the most dis ad van taged chil dren and may po tentially un der es ti mate the ef fects of crèche at ten dance for such chil dren measures childcare arrangement at age 1 our key var i able of in ter est is the fo cal childs pri mary childcare set ting at the time of the age 1 in ter view in clud ing pa ren tal care crèche assistante maternelle pri vate nanny or in for mal care pro vided by grand par ents friends or neigh bors developmental outcomes we fo cus on three de vel op men tal out comes lan guage skills mo tor skills and child be hav ior we use the french short ver sion of the macarthurbates in ven tory to as sess impact of centerbased childcare attendance vo cab u lary size when chil dren were about 2 years old the macarthurbates is used ex ten sively and has strong psy cho met ric prop er ties it mea sures childrens vo cab u lar ies by ask ing moth ers to re port whether the child can spon ta ne ously pro duce words used in daily life from a pro posed list of 100 words a higher score in di cates a larger vo cab u lary we as sess mo tor skills us ing the sum of seven fa therreported items in di cat ing the childs abil ity to walk up stairs kick a ball run use a tri cy cle put on slip pers or socks eat alone and drink alone these items were asked mainly of the fa ther and of the mother only if the fa ther was not interviewed or did not re spond a higher score in di cates more ad vanced mo tor de vel op ment we as sess be hav ior us ing the sum of three moth erreported items in di cat ing how of ten on a 5point scale the child re sists what the caregiversug gestschal lengesordefesthecare giverwhenreprimandedandhits the care giver or de stroys things when an gry items were re verse coded such that a higher score in di cates fewer be hav ior prob lems because fo cal chil drens age at the twoyear in ter view ranged from 23 months to 28 months we agestan dard ize each out come to have a mean of 0 and an sd of 1 this also fa cil i tates com par i son of ef fect sizes across out comes covariates our mod els con trol for child house hold and con tex tual char ac ter is tics child char acter is ticsin cludesexlowbirthweighttwinfrstchildandthepres enceofayoun ger sib ling we do not con trol for child age be cause our out comes are agestan dard ized household char ac ter is tics in clude the moth ers age at the twomonth in ter view and mea sured at age 1 her ed u ca tion im mi grantsta tus work sta tus and work sec tor as well as to tal house hold equivalized in come and an in di ca tor for in come miss ing fam ily struc ture whether a for eign lan guage is pri mar ily spo ken in the home and the moth ers re ac tion to the tim ing of her preg nancy in ad di tion to re duce the risk of omit ted var i able bi as we con trol for whether the mother expressed a pref er ence for crèche care at the twomonth in ter view we also con trol for whether the fam ily moved be tween learn ing of the preg nancy and the oneyear in ter view be cause such moves may have been crècheseek ing in na ture these lat ter con trols are par tic u larly im por tant for adjusting for sys tem atic se lec tion into crèche at ten dance for mod els in which mo tor skills is the out come we fur ther con trol for whether the moth er rather than the fa ther pro vided the mo tor skills da ta contextual var i ables in clude cat e gor i cal mea sures of the lo cal5 fe male em ployment rate and the lo cal un em ployment rate as well as in di ca tors for miss ing data on each of these mea sures 6 to ac count for ad di tional het ero ge ne ity at the lo cal lev el we also add to some mod els a birth hos pi tal fxed ef fect un der the as sump tion that chil dren born in the same hos pi tal are ex posed to sim i lar lo cal en vi ron ments instruments quarter of birth is represented by an in di ca tor that the child was born in spring ver sus other quar ters of the year we fo cus on spring births be cause chil dren born in spring have a higher prob a bil ity of re ceiv ing crèche than chil dren bornatothertimesoftheyearthisre flectsthatcrècheslotstendtobe comeavailable when older chil dren move to pre school in sep tem ber which also cor re sponds with when moth ers of chil dren born in spring typ i cally return to work from ma ter nity leave in ad di tion mu nic i pal com mit tees typ i cally as sign crèche slots each may or june and a child must al ready be born to be con sid ered for the com ing year 7by the time of the elfe co hort births in 2011 there was lit tle sea sonal var i a tion inbirthtim ingandthelim itedfluc tu a tionsthereinsug gestsasum mer peak and win ter low point 8 there are also few dif fer ences in birth tim ing by so cio eco nomic sta tus and those dif fer ences do not sug gest sys tem atic vari a tion in spring births in 2007 the only ob served dif fer ences by ma ter nal oc cu pational class were that births to ag ri cul tural work ers peaked in win ter and those to pri mary school teach ers peaked in spring in ad di tion data from the gender and generation survey for france in di cate that only 14 of mothers reported attempting to time their births among those who reported try ing to do so the most com mon rea sons were to align the birth with the sum mer hol i days to al low in creased time for the fa ther to pro vide childcare and for rea sons re lated to the health of the mother or baby as such it does not ap pear that there is sys tem atic se lec tion into birth tim ing to in crease the prob a bil ity of re ceiv ing a crèche slot local crèche sup ply is mea sured by the num ber of crèche slots per 100 chil dren age 3 and youn ger in the mu nic i pal i ty childcare sup ply has been used to in stru ment cen terbased care par tic i pa tion in prior work 9 there are 35000 french mu nic i pal i ties that sub stan tially vary in size and pop u la tion den si ty and the lo cal crèche sup ply dis tri bu tion is quite skewed 31 of chil dren in our sam ple live in a mu nic i pal ity that of fers no crèche slots 51 live in a mu nic i pal ity with fewer than 12 slots 20 live in a mu nic i pal ity with more than 20 slots and 10 live in a mu nic i pal ity with more than 25 slots per 100 chil dren ages 03 given the skew ness of the dis tri bu tion we top code crèche sup ply at the 99th per cen tile and model its nat u ral log a rithm 10 empirical strategy wefrstes ti mateor di naryleastsquaresre gres sionsinwhichwere gresseach out come on crèche at ten dance and the covariates the mod els take the fol low ing form dev im β 0 β 1 crèche im β 2 child im β 3 hh im β 4 cntxt m ε im where dev im is an age 2 de vel op men tal out come for child i in mu nic i pal ity m crèche is an in di ca tor of crèche at ten dance at age 1 child hh and cntxt are vec tors ofchildhouse holdandcon tex tualchar ac ter is ticsandεisaner rorterm the ols re sults pro vide de scrip tive ev i dence of the as so ci a tion be tween crèche at ten dance and child de vel op ment net of the covariates however sys tem atic se lection into crèche at ten dance is likely based on un ob served fac tors that are also as soci ated with chil drens de vel op men tal prog ress thus to iden tify a causal im pact of crèche care on child de vel op ment we em ploy an iv ap proach that le ver ages ex og enous var i a tion in crèche par tic i pa tionby birth quar ter and lo cal crèche sup plyto es ti mate the un bi ased lo cal av er age treat ment ef fect of crèche at ten dance on childde vel op mentspecifcallyweuseatwostageleastsquaresre gres sion ap proachtofrstes ti matetheprob a bil ityofcrècheat ten danceasafunc tionofspring birth and lo cal crèche sup ply net of child house hold and con tex tual char ac ter istics the predicted prob a bil ity of crèche par tic i pa tion is then forwarded to a sec ondstage re gres sion to pre dict the un bi ased late of crèche at ten dance on the out come leverag ingonlyex og e nousvar i a tionincrècheat ten dancethefrststageequa tion takes the fol low ing form crèche im β 0 β 1 springbirth im β 2 crèchesupply m β 3 child im β 4 hh im β 5 cntxt m ε im 2 where crèche is an in di ca tor of crèche at ten dance at age 1 springbirth is an in dica tor that the child was born in spring and crèchesupply is the ln of crèche slots per 100 chil dren ages 3 or youn ger in the mu nic i pal i ty the sec ondstage equa tion takes the fol low ing form dev im β 0 β 1 crèche im β 2 child im β 3 hh im β 4 cntxt m ε im where crèche is the predicted prob a bil ity of crèche at ten dance we es ti mate whitehuber heteroscedasticity ro bust stan dard er rors for all mod els the iv strat egy re quires that two as sump tions be met first the in stru ments must be highly pre dic tive of crèche at ten dance second they must be un cor re lated with the er ror term in the ex plan a tory equa tion such that they af fect child de vel op ment only through their ef fect on crèche par tic i pa tion thefrstas sump tioniseas ilytestedandasshowninthe results sec tion holds true in all our mod els the sec ond may be vi o lated if for ex am ple par ents time their childs birth or move be tween mu nic i pal i ties to max i mize the prob a bil ity of a crèche place ment it may also be vi o lated if mu nic i pal i ties with greater crèche sup ply pro vide bet ter en vi ron ments for supporting child de vel op ment in other ways although we can not fully rule out these pos si bil i ties we at tempt to min i mize them by adjusting for an ex ten sive ar ray of covariates first we con trol for both ma ter nal pref er ence for crèche when the child was ap prox i ma tely 2 months old and whether thefam ilymoveddur ingthepreg nancyorinthefrstyearofthechildslifethese fac tors should be highly cor re lated with crècheseek ing be hav iors such as tim ing a childs birth or mov ing to mu nic i pal ity with greater crèche sup ply adjusting for them should re duce the risk of bias from such second we con trol for the lo cal fe male em ploy ment rate and the lo cal un em ploy ment rate which should be cor re lated with both de mand for childcare and mu nic i pal so cio eco nomic sta tus third we in clude in ourmod elsbirthhos pi talfxedef fectstocap turead di tionalun ob serveden vi ron mental ho mo ge ne ity among fam i lies who gave birth in the same hos pi tals to em pir i cally ex am ine the likely exogeneity of the in stru ments we com pare the predicted prob a bil ity of crèche at ten dance across the dis tri bu tions of the in stru ments when es ti mated as a func tion of only the ob served covariates and when es ti mated as a func tion of both the in stru ments and covariates these re sults are presented in figures 1 and 2 11 figure 1 shows that the predicted prob a bil ity of crèche at ten dance is 11 descriptive sta tis tics by lev els of the in stru ments are shown in tables a3 and a4 of the online ap pen dix notably par ents ex pe ri enc ing a spring birth are slightly more likely to re port a pref er ence for crèche care than those ex pe ri enc ing a sum mer fall or win ter birth po ten tially be cause they are more likely to have se cured a crèche slot although these dif fer ences are gen er ally mod est in mag ni tude we can not com pletely rule out that some par ents may at tempt to time their births in or der to max i mize their chances of re ceiv ing crèche care the rel e vant ques tion is whether the chil dren from fam i lies most en gaged in crècheseek ing be hav iors are af fected dif fer ently from crèche at ten dance such that the es ti mated im pacts of crèche at tendance is bi ased by this sub group as de scribed in the text we en gage in a range of strat e gies and ro bust ness tests to check for ev i dence of such we also es ti mate our pri mary mod els us ing lo cal crèche sup ply as the sole in stru ment results in di cate that this ap proach gen er ates qual i ta tivelycon sis tentfnd ingstothosewhenbothlo calcrèche sup ply and spring birth are in cluded as in stru ments impact of centerbased childcare attendance con sid er ably higher for chil dren born in spring when es ti mated us ing the in stru ments than when es ti mated us ing only the covariates but that it is sim i lar for chil dren born at other times of the year when es ti mated with and with out the in stru ments suggesting that the in stru ments pro vide ex og e nous var i a tion in crèche at ten dance figure 2 shows the predicted prob a bil i ties of crèche at ten dance plot ted by lo cal crèche supply we see a clear pat tern such that the predicted prob a bil i ties of crèche at ten dance us ing the in stru ments ex hibit a much steeper slope across the lo cal crèche sup ply dis tri bu tion than do the predicted prob a bil i ties of crèche at ten dance us ing only the covariates this again sug gests that the in stru ments pro vide ex og e nous var i a tion in crèche at ten dance we also en gaged in a se ries of an a ly ses to fur ther val i date our iv ap proach first we tested as a sec ond ary in stru ment the in ter ac tion be tween ln lo cal crèche sup ply and spring birth because fam i lies are highly un likely to have both timed their birth to oc cur in spring and moved to a high crèche sup ply mu nic i pal i ty this in stru ment should be par tic u larly likely to meet the ex clu sion re stric tion we do not pri or i tize the in ter ac tion term as our pri mary in stru ment how ev er be cause only 10 of chil dren were both born in spring and lived in a mu nic i pal ity with any crèche slotsand only 5 of chil dren were both born in spring and lived in a mu nic i pal ity with a crèche sup ply at or above the me dian among this group thereby lim it ing the sta tis ti cal power of this in stru ment second we es timated the ols and iv mod els with out covariates to ex am ine how dif fer ences in the char ac ter is tics of fam i lies by crèche at ten dance sta tus may bias the re sults of each third we conducted sup ple men tal an a ly ses in which we ex am ined whether there are dif fer ences in re sults both by ini tial pref er ence for crèche and by res i den tial moves dur ingthepreg nancyorfrstyearofthechildslifetoruleoutthatthesefac torsare driv ingtheivre sultsfourthween gagedinase riesoffal si f ca tiontestsinwhich we es ti mated mod els us ing out comes that should not be af fected by crèche par tic i pationin clud ingbirthweightandonemin uteandfvemin uteapgarscoresruling out a re la tion be tween crèche at ten dance and these out comes us ing our iv ap proach may pro vide fur ther in di ca tion that the iv re sults are not driven by se lec tion into birth tim ing or lo cal i ty because our pri mary fo cus is es ti mat ing the ef fect of crèche care ver sus all other childcare ar range ments we frst pres ent ols and iv es ti ma tes of this difference however we also pres ent ols es ti ma tes com par ing out comes for chil dren at tend ing crèche with those in each of the other childcare ar range ments pa ren tal care assistante maternelle inhome nan ny and in for mal care we pres ent only ols es tima tes for these an a ly ses be cause iv an a ly ses would re quire a sep a rate in stru ment for each childcare type and we have been un able to iden tify such in stru ments we then pres ent ols es ti ma tes of as so ci a tions of crèche dos age with the de vel op men tal out comes here we again pres ent only ols es ti ma tes be cause whereas our in stru ments should pre dict whether a fam ily is of fered crèche care there is no rea son to be lieve the in stru ments should be re lated to hours in crèche care con ditional on re ceipt finally we ex am ine po ten tial het ero ge ne ity in any ef fects of crèche care on child de vel op ment by ma ter nal ed u ca tion fam ily in come and ma ter nal im migrantsta tusus ingourpri maryspec i f ca tion children at tend ing crèche scored highest on av er age on the lan guage as sess ment followed by those cared for by a pri vate nan ny those cared for by an assistante maternelle and those in in for mal care chil dren in pa ren tal care exhibited the poorest language skills children at tend ing crèche are able to say an av er age of 80 words which con sti tutes 6 words more than the sam ple mean they are able to say 12 more words than those in pa ren tal care 3 words more than those in assistante maternelle care 2 words more than those cared for by a pri vate nan ny and 8 words more than those in in for mal care differences in mo tor skills are con sid er ably smaller in mag ni tude than those for lan guage however chil dren at tend ing crèche are reported to have greater mo tor skills than those in all other forms of care the pat tern for be hav ior is dif fer ent on av er age chil dren cared for by their par ents are reported to have bet ter be hav ior than chil dren in all other care ar range ments with the dif fer ence attainingsta tis ti calsig nif cancecom paredwithbothcrècheandassistantematernelle carechildrenincrèchearereportedtohavesig nif cantlypoorerbe hav iorthanthose in assistante maternelle care results descriptive statistics descriptive sta tis tics for the covariates and in stru ments shown in table 2 re inforce that there is likely sys tem atic se lec tion into childcare ar range ments children born low birth weight are dis pro por tion ately likely to be in pa ren tal or in for mal care and twins are more likely to be in pa ren tal or pri vate nanny care firstborn children dis pro por tion ately ex pe ri ence nonparental care par tic u larly crèche assistante maternelle or in for mal care differences are also ev i dent by both ma ter nal and contex tual char ac ter is tics for ex am ple chil dren of less ed u cat ed low erin come and sin glemother fam i lies are more likely to re ceive in for mal or pa ren tal care and less likely to re ceive crèche or assistante maternelle care they are par tic u larly un likely to have a pri vate nan ny however crèche use is more com mon among sin glemother and low est in comequin tile fam i lies that use nonparental care than among the full sam ple children of frenchna tive moth ers are more likely to re ceive care from an assistante maternelle or a pri vate nan ny and they are less likely to re ceive pa ren tal or in for mal care than chil dren of im mi grant moth ers about threequar ters of chil dren with work ing moth ers at tend nonparental childcare com pared with about onehalf of those with non work ing moth ers crèche is par ticu larly com mon when moth ers work in the pub lic sec tor whereas pri vate nan nies are more com mon when moth ers work in the pri vate sec tor or are selfemployed notably whereas ma ter nal pref er ence for crèche care is pos i tively as so ci ated with crèche at ten dance many chil dren whose moth ers pre fer crèche care re ceive other forms of care whereas 49 of chil dren whose moth ers reported a pref er ence for crèche care at the twomonth in ter view attended crèche at age 1 only 45 of moth ers whose chil dren attended crèche at age 1 reported a pref erence for crèche care at the twomonth in ter view turning to the con tex tual fac tors chil dren in lo cales with a high fe male em ploy ment rate are dis pro por tion ately likely to re ceive crèche assistante maternelle and pri vate nanny care with re spect to the in stru ments chil dren in mu nic i pal i ties with greater rel a tive crèche sup ply and those born in spring are dis pro por tion ately likely to re ceive crèche care regression results primary estimates our pri mary re sults are presented in table 3 we show these es ti ma tes for the full sam ple of chil dren as well as the sub sam ple whose moth ers were employed at the age 1 in ter view the fullsam ple ols re sults in di cate that net of the covariates at tend ing crèche at ap prox i ma tely age 1 is as so ci ated with greater lan guage and mo torskillsbutalsogreaterbe hav iorprob lemsatage2thesefnd ingsarero bust tothein clu sionofbirthhos pi talfxedef fectsonav er agecom paredwithchil dren in other ar range ments chil dren at tend ing crèche have age 2 lan guage scores that are 018 to 019 sds bet ter and mo tor skills that are 011 to 013 sds bet ter but also be hav ior scores that are roughly 007 sds worse turning to the iv re sults the in stru ments per form quite wellthe frststage f sta tis ticsarelargeandtheunderidentifcationtestis sat is fedineachmod eltheweakin stru mentro bust nesstestof thejointsig nif canceofthein stru mentsinthere ducedformmodelis sat is fedfor lan guage and be hav ior but not for mo tor skills 13 thefrststagees ti ma tes sug gest that a 10 greater lo cal crèche sup ply is as so ci ated with roughly a 4 per cent age point greater prob a bil ity of crèche at ten dance and that be ing born in spring is as so ci ated with roughly a 3 per cent age point greater prob a bil ity of crèche at ten dance the sec ondstage iv re sults for lan guage and be hav ior are larger in mag nitude than the ols es ti ma tes and re tain sta tis ti cal sig nif cance in the nonfxedef fectsmod elstheives ti ma tesformo torskillsarenon sig nif cantand smaller in mag ni tude than the ols es ti ma tes in all mod els the iv re sults in di cate a late of crèche of 033 to 034 sds for lan guage skills and 025 to 036 for 13 reducedform es ti ma tes are presented in table a5 for the full sam ple for employed moth ers and for a pla ce bo sam ple of non work ing moth ers who should in the o ry not re quire ex ter nal childcareourin stru mentsareei thersig nif cantandintheexpecteddi rec tionornon sig nif cantbutinthe expected di rec tion in the full sam ple and in mod els lim ited to employedmother fam i lies however they are never sig nif cantonthepla cebosam plethissug geststhatourivmod elsarenotlikelyiden ti fy ing spu ri ous re la tions be hav ior these are rel a tively large ef fects the over all pat tern of re sultsthat the lates from the iv mod els for lan guage and be hav ior are larger than the ates from the ols mod elsis con sis tent when our sec ond ary in stru ment the crèche sup ply × spring birth in ter ac tion is used in place of the two sep a rate in stru ments how ev er the lan guage and be hav ior co ef f cients are much larger in mag ni tude inthisspec i f ca tionpo ten tiallyreflectingthesmallnumber of fam i lies with non zero val ues on the in stru ment in ad di tion re sults when these an a ly ses are rep li cated for the sub sam ple of chil dren whose moth ers were work ing at the age 1 in ter view are sub stan tively con sistentwiththoseforthefullsam plein di cat ingthatthefnd ingsdonotpri mar ilyreflectpoorout comesforchil drenwhowerenotat tend ingfor malchildcarebe cause their moth ers were not work ing thedif fer encebe tweentheolsandivre sultsmayre flectthatchil drenwhoare ex og e nously in duced into crèche par tic i pa tion based on be ing born in spring andor in a mu nic i pal ity with a greater lo cal crèche sup ply are more heavily im pacted by crèche at ten dance than chil dren whose par ents se lect them into crèche par tic i pa tion re gard less of their birth tim ing and mu nic i pal crèche availabil i ty more gen er al ly the over all pat tern of re sults sug gests that any bias in duced by the endogeneity of crèche at ten dance and lan guage or be hav ioral de vel op ment likely re sults in un der es ti ma tion of the pos i tive ef fect of crèche par tic i pa tion on lan guage de vel op ment and neg a tive ef fect of crèche par tic i pa tion on child be hav ior con ditionalonthecovariatesassuchtheives ti ma tioncanbeviewedasconfrmingthe di rec tionandsig nif canceoftheolsre sults robustness checks we conducted a range of ro bust ness checks to test the sen si tiv ity of our an a ly ses tovar i ousmodelspec i f ca tionsfirstwetestedsev eralal ter na tivein stru mentsspecifcallywecom paredthere sultsfromivmod els us ing our pri mary in stru ments ln lo cal crèche sup ply and spring birth and the in ter ac tion of both in stru ments with those from mod els in which we used as in stru ments ln lo cal crèche sup ply spring birth and the in ter ac tion me dian lo cal crèche sup ply and spring birth me dian lo cal crèche sup ply spring birth and the in ter ac tion of both in stru ments me dian lo cal crèche sup ply × spring birth 0 lo cal crèche sup ply and spring birth 0 lo cal crèche sup ply spring birth and the in ter ac tion of the two and 0 lo cal crèche sup ply × spring birth although the es ti mated mag ni tude of the latesdif ferssome whatacrossspec i f ca tionsthepat ternofre sultsisquitecon sistent re gard less of the par tic u lar in stru ments used and whether birth hos pi tal fxed ef fects are in cluded in the mod el the iv es ti ma tes for lan guage and be hav ior sug gest that the ols es ti ma tes are down wardly bi ased second we es ti mated the ols and iv mod els with out covariates to ex am ine how adjusting for dif fer ences in the char ac ter is tics of fam i lies by crèche at ten dance sta tus may al ter our re sults again the over all pat tern of es tima tesisquitecon sis tentwiththosefromourpri maryspec i f ca tionsinad di tionthe un ad justedolsandives ti ma tesforlan guage are larger in mag ni tude suggesting that they are up wardly bi ased if not ad justed for dif fer ences in the covariates by crèche at ten dance sta tus how ev er the es ti ma tes for mo tor skills and be hav ior are rel a tively sim i lar in mag ni tude re gard less of whether the covariates are con trolled third to fur ther ac count for po ten tial un ob served char ac ter is tics as so ci ated with pa ren tal pref er ence for crèche and child de vel op ment we es ti mated sep a rate mod els for fam i lies in which the mother did and those in which the mother did not re port an ini tial pref er ence for crèche here the con cern is that par ents who pre fer crèche may take ac tions such as tim ing their births or mov ing to a mu nic i pal ity with a more gen er ous crèche sup ply that may bias our iv re sults on the con trary how ev er these re sultsin di catethatifany thingtheben e f cial ef fect of crèche care for lan guage is larger and to a lesser ex tent the neg a tive ef fect for be hav ior is smaller for chil dren whose moth ers did not pre fer crèche care than for those whose moth ers pre ferred crèche care we would not ex pect the for mer to en gage in crècheseek ing be hav iors to ac count for the pos si bil ity that fam i lies may have moved mu nic i pal i ties to in crease their prob a bil ity of get ting crèche we es ti mated sep a rate mod els for fami lies that did and fam i lies that did not move be tween learn ing of the preg nancy and theage1in ter viewthecrècheben e ftforlan guageskillsis slightly larger for chil dren whose fam i lies moved than for those whose fam i lies did not move in the ols mod els however this pat tern is re versed in the iv es ti ma tion lan guageben e ftsforchil drenofnonmoversaregreaterthanthoseformov ersthis sug gests that our pri mary re sults for lan guage are not driven by chil dren whose fami liesmovedtoob tainagreaterlike li hoodofcrèchere ceiptwefndalessclearand con sis tent pat tern for mo tor skills and be hav ior finallywees ti matedsev eralfal si f ca tionteststoconfrmthatourives ti ma tiondidnotpre dictchildout comesatthetimeofbirthwhich couldnotbeaf fectedbycrècheat ten danceatage1specifcallywees ti matedthe ef fect of crèche at ten dance on birth weight and the childs apgar score one min ute andfvemin utesaf terbirthineachcasewefoundnore la tionbe tweencrècheat tendance and the out come counterfactual childcare arrangements table 4pres entsre sultsfromolsre gres sionfor as so ci a tions of crèche at ten dance with child de vel op ment rel a tive to each of the al terna tive childcare ar range ments pa ren tal care assistante maternelle inhome nan nyandin for malcarethefrstcol umnforeachout comepres entstheas so ci a tion of noncrèche care with the out come these es ti ma tes are the same as those presented in table 3fortheolswithbirthhos pi talfxedef fectsre gres sions ex cept that the signs of the co ef f cients are re versed be cause here we model noncrèche care rather than crèche care the sec ond col umn pres ents re sults from a re gres sion in which crèche care is the ref er ence cat e gory with which the other forms of care are com pared children in all other types of care ex hibit poorer lanimpact of centerbased childcare attendance guage de vel op ment than those in crèche care but the dif fer ences are par tic u larly large with re spect to pa ren tal care and in for mal care and are some what smaller with regard to assistante maternelle and inhome nanny careformo torskillsweseesig nif cantdif fer encesofsim i larmag ni tude be tween crèche care and pa ren tal assistante maternelle and in for mal care crèche care is as so ci ated with 009 to 015 sds bet ter mo tor skills finally crèche care is as so ci ated with poorer be hav ior com pared with both pa ren tal care and inhome nanny care but not com pared with assistante maternelle or in formal care dosage table 5 pres ents ols es ti ma tes of as so ci a tions of crèche dos age with the de vel op men tal out comes these re sults sug gest a clear dosere sponse re la tion such that ad di tional hours or days per week in crèche are as so ciated with greater lan guage skills for ex am ple rel a tive to chil dren in all other types ofcarechil drenwhospendthreefourorfvedaysperweekincrècheex hibit010 019and020sdsgreaterlan guageskillsre spec tive lywealsofndev i denceof a dosere sponse re la tion for mo tor skills and be hav ior for mo tor skills chil dren whospendfvedaysperweekincrècheex hibit015sdsgreaterskillsthanchil dren whouseothertypesofcareforbe hav iorchil drenspend ingthreeandfvedaysin crèche ex hibit 012 and 010 sds poorer be hav ior than those ex pe ri enc ing other types of care subgroup analyses we con duct a se ries of sub group an a ly ses based on fam ily so cio eco nomic char ac teris tics the re sults are shown in table 6 we pres ent only ols re sults for these an a ly ses given that the in stru ments do not al ways per form well in the con text of smaller sub group sam ple sizes14 with re spect to fam ily char ac ter is tics the re sults sug gest that the pos i tive as so ci a tions of crèche at ten dance with lan guage de vel op ment are par ticu larly con cen trated among dis ad van taged chil dren those with less ed u cated moth ers those liv ing in low erin come house holds and those borntoim mi grantmoth ersthereisalsosome in di ca tion that crèche at ten dance is more strongly as so ci ated with greater mo tor skills among less advan taged chil dren finally the as so ci a tion of crèche at ten dance with in creased be hav ior prob lems ap pears to be most con cen trated among more advantaged chil dren on the whole these fnd ings sug gest that re gard less of di men sion con sid eredcrècheat ten danceap pearstobesome whatmoreben e f cialfordis ad vantaged chil dren than for their more advan taged coun ter parts15 discussion onthewholewefndthatrel a tivetoall othertypesofearlychildcarear range ments at tend ing crèche at age 1 is as so ci ated with rel a tively large gains in lan guage skills butalsoin creasedbe hav iorprob lemsatage2thesefnd ingsarero busttoarangeof sen si tiv ity tests moreover our iv re sults sug gest both that re la tions be tween crèche at ten dance and child de vel op ment are likely causal in na ture for lan guage and be havioral de vel op ment and that the more naïve ols es tima tes likely un der es ti mate the causal ef fect of crèche at ten dance on lan guage and be hav iorwealsofndde scrip tiveev i dencethattheas so ci a tionsofcrècheat ten dance with child de vel op ment are es pe cially pro nounced when crèche at ten dance is compared with pa ren tal and in for mal care and are less pro nounced but still pres ent when it is com pared with assistante maternelle and pri vate nanny care these dif fer ences arepar tic u larlylargeforlan guagede vel op mentinad di tionwefndde scrip tiveev idence that greater in ten sity of crèche par tic i pa tion is as so ci ated with larger de vel op men tal ef fectsboth pos i tive and neg a tive results from our sub group an a ly ses fur ther sug gest that there is het ero ge ne ity in the mag ni tude and do mains of im pacts across pop u la tion sub groups most no tably less advan taged chil drenpar tic u larly those with lowed u cated and im mi grant moth ersandthoseinlow erin comehouse holdsap peartoben e ftmostfromcrèche at ten dance es pe cially with re spect to lan guage de vel op ment this fnd ing is consis tent with prior re search on the im pact of highqual ity cen terbased care on child de vel op ment and sug gests that in the french setting fa cil i tat ing dis ad van taged fam i lies in accessing crèche may hold po ten tial for impact of centerbased childcare attendance de creas ing early so cio eco nomic disparities in child de vel op ment this may be partic u larly im por tant given that dis ad van taged chil dren are less likely than their more advan taged coun ter parts to at tend cen terbased childcare in the ma jor ity of eu ro pean countries howdoourre sultsftwithinaverymixedlit er a turefirstitisno ta blethatour es ti mated ef fect sizes are not out of line with the range of prior es ti ma tes from other set tings for lan guage and mo tor skills al though they tend to be larger when es ti mated us ing iv for ex am ple our fullsam ple ols es ti mated ef fect sizes for lan guage skills are 018 to 019 whereas cog ni tive skills ef fect sizes in the prior lit er a ture range from 014 to 028 our ols es ti mated ef fect sizes for mo tor skills are 011 to 013 by com par i son gormley and gayer reported an ef fect size of 024 for mo tor skills in their eval u a tion of the tulsa prek program although our es ti mate is smaller in mag ni tude it is not dras ti cally so finally as discussed ear li er es ti ma tes for be hav ior vary widely across set tings rang ing from 013 sds to 050 sds our ols es ti mate sug gests an ef fect size of ap prox i ma tely 007 however our subgroup an a ly ses sug gest that this re sult does not hold for all groups of chil dren our iv re gres sions tend to pro duce con sid er ably larger ef fectsize es ti ma tes how ev er these es ti ma tes rep re sent lates rather than av er age treat ment ef fects as such they are less read ily com pa ra ble to ef fect size es ti ma tes from prior work withre specttotherel a tivemag ni tudeofourfnd ingsforlan guageafrstav e nue to ward un der stand ing how to con tex tu al ize these re sults may be to con sider that the french crèche sys tem is al most en tirely based on pub lic pro vi sion that structural qual ity of pro vi sion is strictly enforced na tion al ly and that crèche work ers tend to be rel a tively highly ed u cated in child de vel op mentspe cifc felds and are sub ject to the ex ten sive crèche mon i tor ing and in spec tion pro cesses these factors point to ward high lev els of pro cess qual ity as well al though we are not aware of stud ies em pir i cally assessing pro cess qual ity of crèche care our re sults there fore sup port hy poth e ses that a pos i tive im pact of cen terbased childcare is pos si ble when qual ity of pro vi sion is high moreover chil dren at tend ing crèche in france do so mostly in staterun sub si dized pro grams that are open to all chil dren and that ac tively at tempt to re cruit a so cio eco nom i cally di verse pop u la tion researchfromtheunitedstatessug geststhatmoredis ad van tagedchil drenben e ft more from so cially mixed pre school set tings than from so cio eco nom i cally ho mog enous pro grams whichmightex plainwhywefndapar tic u larben e ft of crèche at ten dance for more dis ad van taged chil dren our re sults should be interpreted in the con text of a num ber of lim i ta tions first theyarefrenchspe cifcandmaynotap plytootherset tingswithdif fer entchildcare frame works key el e ments of the french con text which may not be found in other set tings in clude the rel a tively ho mo ge neous highqual i ty statesub si dized and statemon i tored na ture of the care pro vid ed second all of the in di vid u allevel data used in this study were reported by par ents to the ex tent that par ents selecting dif fer ent childcare types may sys tem at i cally re port dif fer ently on their chil drens de vel op ment our es ti ma tes could be bi ased however al though this would be prob lem atic for our ols re gres sions the iv strat egy should re duce such bi as third the de vel op men tal mea sures of fo cuspar tic u larly those for mo tor skills and be hav iormay lack the sen si tiv ity to fully and mean ing fully as sess dif fer ences in de vel op ment for the young chil dren in our sam ple indeed there is rel a tively lim ited var i a tion across chil dren on these mea sures most no ta bly for mo tor skills fourth we mea sure rel a tively shortterm out comes only a year af ter crèche at ten dance is ob served we there fore can not com ment on whether these ef fects will per sist ex ac er bate or fade out over time for ex am ple ev i dence sug gests that shortterm neg a tive im pacts of cen terbased childcare at ten dance on child be hav ior do not hold in the lon ger term fifth as is the case with all lon gi tu di nal stud ies the elfe sam ple experienced at tri tion over time attrition ap pears to oc cur dis pro por tion ately among more dis advan taged and res i den tially mo bile fam i lies this too may limit the gen er al iz abil ity of our re sults par tic u larly for dis ad van taged fam i lies it may also im ply that we are underestimating the ef fects of crèche at ten dance for dis ad van taged chil drens lan guage skills given that the ef fect of crèche at ten dance on lan guage skills is par tic u larly large for such chil dren it is fur ther pos si ble that the chil drenlosttofol lowupmayhavebeneft tedevenmorethanthosein cludedinour sam ple conversely the neg a tive ef fect of crèche at ten dance on be hav ior is smaller for dis ad van taged chil dren than their more advan taged coun ter parts thus we might be overestimating the ad verse ef fect of crèche at ten dance on be hav ior for such chil dren sixth the coun ter fac tual con dition to crèche care in our iv an a ly ses is het er og e nous and may dif fer by birth tim ing and lo cal crèche sup ply heterogeneity in the coun ter fac tual con di tion is a com mon lim i ta tion of stud ies of childcare moreover rig or ous econo met ric stud ies in di cate thattheben e ftsofhighqual itycen terbasedcarearemorepro nouncedwhencompared with pa ren tal care than with other types of for mal childcare whichiscon sis tentwithourolsfnd ingsnonetheless our iv mod els pro duce only a late of crèche rel a tive to all other ar range ments finally our iv an a ly ses rely on the as sump tion that fam i lies do not move to par tic ular mu nic i pal i ties and do not time their births to in crease their chances of obtaining crèche care for their in fants if this as sump tion is in cor rect our iv es ti ma tes will be bi ased although our sen si tiv ity an a ly ses help to al lay such con cerns we can not be cer tain of the ab sence of such be hav iors keeping these lim i ta tions in mind our re sults sug gest that within the uni ver sal sub si dized highqual ity french childcare sys tem ex pe ri ences of early col lec tive care ap peartoben e ftchil drenslan guagede vel op mentbutalsohaveaneg a tivein flu ence on be hav ior moreover pos i tive ef fects on lan guage skills ap pear to be par tic u larly con cen trated among dis ad van taged chil dren for whom there also ap pear to be no neg a tiveef fectsonbe hav iorthesefnd ingssug geststhatanex pan sionofac cessto crèche may have po ten tial to con trib ute to de creas ing early gaps in child wellbe ing ifqual ityismaintainedandlessadvan tagedpar entsarewill ingtousecrèchecare■ data and methods data we use data from the étude longitudinale française depuis lenfance a pop u la tionbased lon gi tu di nal co hort study fol low ing more than 18000 french children from the time of their birth in 2011 for ward children were born at a ran dom sam ple of 341 ma ter nity units through out con ti nen tal france and were sam pled at four in ter vals with ini tial data col lec tion april 14 2011 followed by june 27july 4 2011 sep tem ber 27oc to ber 4 2011 and no vem ber 28de cem ber 5 2011

proponents of early child hood ed u ca tion and care pro grams cite ev i dence that highqual ity cen terbased childcare has pos i tive im pacts on child de vel op ment par tic u larly for dis ad van taged chil dren however much of this ev i dence stems from ran dom ized eval u a tions of smallscale in ten sive pro grams based in the united states and other an gloen glishspeak ing countries evidence is more mixed with re spect to wide spread or uni ver sal cen terbased childcare pro vi sion in ad di tion most ev i dence is based on childcare ex pe ri ences of 3to 5yearold chil dren less is known about the im pact of cen terbased care in ear lier child hood the french con text is par tic u larly suited to such in ter ro ga tion be cause the ma jor ity of french chil dren who at tend cen terbased care do so in highqual i ty statefunded statereg u lated cen ters known as crèches and be fore age 3 we use data from a large na tion ally rep re sen ta tive french birth co hort the étude longitudinale français depuis lenfance elfe and an in stru men tal var i ables strat egy that le ver ages ex og e nous var i a tion in both birth quar ter and lo cal crèche supply to es ti mate whether crèche at ten dance at age 1 has an im pact on lan guage mo tor skills and child be hav ior at age 2 results in di cate that crèche at ten dance has a posi tive im pact on lan guage skills no im pact on mo tor skills and a neg a tive im pact on be hav ior moreover the pos i tive im pact on lan guage skills is par tic u larly con cen trated among dis ad van taged chil dren this implies that fa cil i tat ing in creased crèche ac cess among dis ad van taged fam i lies may hold po ten tial for de creas ing early so cio eco nomic disparities in lan guage de vel op ment and given the im por tance of early de vel op ment for lat erlife out comes thereby have an im pact on longterm pop u la tion inequalities keywords childcare • crèche • child de vel op ment • early child hood • étude longitudinale français depuis lenfance elfe

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introduction the whole is greater than the sum of its parts 2 this statement by aristotle a philosopher in ancient greece is usually employed in social sciences to address emergent phenomena in groups such as cohesion transactive memory system and so on also called emergent states they are dynamic constructs that characterize properties of the group and that result from the interactions among group members addressing emergent states computationally is an open challenge of humancentered computing a research field aimed at developing computational methods to support and assist human endeavours by studying human interactions through multiple facets 10 this task is made particularly difficult by the multidimensionality of some of these states because dimensions interplay somehow and somewhere over time this paper focuses on cohesion its dimensions and their interplay this emergent state is one of the most commonly studied in social sciences 41 and more recently also in computer science scholars in social sciences provided multiple definitions of cohesion identifying several dimensions despite the scholars disarray on the number and the nature of these dimensions the social and task dimensions are usually retained in most definitions both dimensions indeed play a role in a wide range of situations and are especially relevant for studying taskdriven groups the social dimension refers to the interpersonal bonds that exist between group members while the task dimension corresponds to the group members shared commitment to the task 43 according to theoretical models these dimensions are not orthogonal meaning that they may all influence each other over time for example the development of social bonds and friendships within the group may positively impact task cohesion building on these theoretical models computational studies naturally started to investigate and develop methods for the automated analysis of social and task cohesion to date the focus of computer scientists indeed has been either on predicting the intensity level of cohesion without distinguishing among dimensions or on implementing models predicting the presence and the intensity level of a specific dimension to the best of our knowledge there is however no work on the automatic prediction of cohesion that integrates the interplay between its social and task dimensions over time in this paper we take a first step towards bridging this gap by grounding on social sciences insights more specifically we exploit the role played by the social dimension for creating flexible and constructive relationships leading to the reinforcement of task cohesion concretely we present a deep neural network architecture for predicting the dynamics of cohesion by applying transfer learning this is done to take advantage of the information learnt by a model dedicated to the classification of social cohesions dynamics to predict the task cohesions dynamics 46 dynamics here refers to changes in cohesion this architecture also takes into account temporality by integrating amongst others lstm layers and it models cohesion at both individual and group levels the dnns performances are evaluated against baselines predicting one dimension at a time or predicting both dimensions using traditional machine learning techniques such as multilabel classification background and related work 21 background in the 40s lewin first defined cohesion as a group characteristic that depends on its size organization and intimacy 27 this definition grounds on the force field theory that views peoples activity as affected by forces in their surroundings and environment 28 building upon this work later scholars provided several definitions of cohesion and multidimensional models of it in which the number of dimensions varies from 2 to 5 for example in 6 carron and brawley defined the group integration and the individual attraction to group dimensions to take into account the contributions of both each group member and the group as a whole these 2 dimensions have social and task as their subdimensions according to griffith depending on the presence of hierarchical relationships among the group members cohesion can be also studied at the horizontal level or at the vertical level 17 he differentiated 2 dimensions the instrumental and the affective dimensions bollen and hoyle integrated other dimensions related to the sense of belonging and the feeling of morale associated with membership in the group 5 social and task dimensions always appear in all this plethora of definitions furthermore salas et al conducted a metaanalysis in which they recommend giving priority to social and task cohesion and integrating time when studying cohesion 42 recently severt and estrada proposed a framework of cohesion that gathers all of these efforts to categorize the structural and functional properties of cohesion 43 this framework posits that cohesion serves an affective and an instrumental function the former refers to all the aspects that highlight the emotional impact on a group member and by extension the group as a whole and is structured into the interpersonal and the group pride dimensions the instrumental function corresponds to the aspects that highlight the goaland taskbased activities of the group and is composed of the social and task dimensions finally for each dimension we can distinguish 2 levels this distinction is particularly important as depending on the dimensions and the level at which cohesion is investigated it might emerge and evolve differently in this study we follow severt and estradas framework by specifically focusing on the interplay between the social and task dimensions at horizontal level this level of investigation was chosen as it aligns with the contemporary trends of flattening organizational hierarchies and selfmanaged teams 31 improving the applicability of our findings related work to date computational studies about cohesion focus on analysing its social and task dimensions since they are the easiest to grasp and measure 42 hung and gaticaperez 22 studied the role played by audio visual and audiovisual features on the prediction of cohesion intensity level by binary classifiers their models addressed cohesion as a whole that is without distinguishing between its dimensions nanninga and colleagues extended this work integrating pairwise and group features related to the alignment of paralinguistic speech behavior and addressing social and task dimensions separately 37 they found that their audio features such as synchrony and convergence are more relevant to predict the social dimension rather than the task dimension both these studies show the importance of turntaking and mimicry features for the prediction of cohesion intensity level despite cohesion being inherently temporal these studies unitized interaction in nonoverlapped temporal units which feed models as independent samples this approach cannot catch dynamics that according to 42 is a relevant point to understand cohesion later on researchers started to investigate social and task dimensions of cohesion at a longitudinal level with the use of sociometric badges 51 these badges were used to quantify dyadic interactions and facetoface communications and analyze small group collaborations during longduration missions in confined spaces recently a growing interest in the interplay between the several dimensions of cohesion emerged also in computer science to address this issue a couple of studies developed methods inspired by game theories in 39 the authors investigated the differences between the social and task dimensions using an approach based on evolutionary game theory by promoting the evolution of cooperation in group interactions they reveal that social cohesion is detrimental to the evolution of cooperation while task cohesion facilitates it they explain these results by exploring the effects of the mistake rate on the cooperation of the groups and show that increasing task cohesion would preserve cooperation from mistakes while increasing social cohesion would augment the mistake rate their model however uses randomly generated data and does not consider the reciprocal effect of both dimensions walocha et al proposed a method based on notions from cooperative game theory to assess the importance of motion capturebased features on a random forest model predicting the dynamics of the social and task dimensions of cohesion interplay is faced through a multilabel classification 49 their model however addresses cohesion using a single modality only a social sciences inspired model for integrating social and task interplay in this section we present the transfer between dimensions architecture this is a dnn architecture that integrates the interplay between social and task dimensions of cohesion following social sciences insights takes into account temporality by integrating amongst others lstm layers and models cohesion at both individual and group levels in the following for each of these items we describe the social sciences insights we ground on and how such knowledge is reflected in the architecture concerning carron and brawley question whether and which one of the social and task dimensions is predominant over the other one they argue that social cohesion might particularly impact task cohesion depending on many factors including the context of the interaction the type of group and the stage of formation of the group 6 in 47 the authors claim that social cohesion would likely be more salient in social groups such as group of friends also as suggested by grossman et al 19 social cohesion emerges first in the group before its members shift attention to task cohesion furthermore severt and estrada 43 state that social cohesion may create flexible and constructive relationships and would by extension reinforce task cohesion hence social cohesion is expected to be more salient and to be a driver for task cohesion 1947 for these reasons we decided to implement tbd a transfer learning approach to predict the dynamics of task cohesion based on a pretrained model dedicated to the prediction of social cohesions dynamics in that way the model takes advantage of the social representation of cohesion previously learnt to optimize task cohesion prediction about as cohesion is an emergent state it is by definition a temporal construct changing over time 18 this implies that the relationship between the 2 dimensions develops over time tbd takes into account the temporality into its architecture and also predicts the dynamics of cohesion at multiple points in time finally concerning since cohesion is a grouplevel phenomenon our architecture needs to model both individual and group behaviours simultaneously according to cattell 8 groups can be studied at 3 different levels individual structural and syntality highlighting the need to consider individual and group contributions in tbd this is done both at the feature level and at the architectural level in the following we describe a tbd instance working on a data set explicitly conceived to study cohesion over time and its dimensions data set several data sets of social interactions in groups exist these data sets were either collected to study social interactions in a specific context or to improve group detection or tracking algorithms some of these data sets also offer assessments of specific phenomena such as emotion and leadership provided by the participants or by pools of external observers these assessments however are generally made over time windows defined according to technical constraints or social sciences theories and without a particular focus on the development of the measured phenomenon over time in this study we adopt the gameon data set 32 to the best of our knowledge this is the only publicly available data set specifically designed for the study of social and task cohesion and it provides repeated selfassessments of it over time for each member of the group a slightly modified version of the group environment questionnaire 7 indeed was administered between each pair of tasks geq is a wellestablished questionnaire already used by several studies to measure the social and task dimensions separately moreover this data set was conceived following the theoretical findings of scholars in social sciences such as 47 and 43 gameon is a multimodal data set in which small groups of 3 friends interact in the context of an escape game the data set includes more than 11 hours of interaction involving 15 groups the average duration of a session is 35min and 30s the escape game scenario is structured in 5 tasks explicitly designed to elicit changes in the social and task dimensions of cohesion the first task lasts about 10 minutes while the second task lasts about 9 minutes the third and fourth tasks take 7 minutes and the fifth task 8 minutes table 1 describes the expected variations of cohesion between 2 consecutive tasks for both the social and task dimensions in 32 authors showed that except for the t1t2 and t2t3 transitions of the task dimension the expected changes in cohesion were confirmed by participants answers individual and group features we developed and extracted a set of 84 motion capturebased and audio nonverbal features characterizing social interaction for the sake of brevity and narrative clarity the details of implementation are not given features computed from motion capture data concern proxemics and kinesics for the social and task dimensions as reported in 32 start means the beginning of the recordings body movement and gesture indeed both play an important role in nonverbal communication 21 and is relevant for predicting social and task dynamics of cohesion 49 regarding the audio data we adopt features from the geneva minimalistic acoustic parameter set that is composed of features related to frequency energy spectral balance and temporal features of the voice these features have been successfully used in many affect related prediction tasks such as predicting cohesion or emotions furthermore we included turntaking related features taking inspiration from previous work showing their relevance for the automated detection of cohesion among all the features used in this study some are computed for each group member while others are computed at a group level features were computed over nonoverlapped time windows of 20s according to previous work on group interaction 16 and cohesion perception 9 exploiting a thin slices approach this refers to the process of making very quick inferences about the individual andor group phenomena with a minimal amount of information 1 table 2 summarizes the features we used a ★ indicates that we applied statistical functions instead of using the computed value of the features for sake of clarity some of the names chosen for describing the features concern an ensemble of features related to the same behavior change in cohesion transition social task start t1 decrease ↘ t1 t2 ↘ increase t2 t3 ↗ ↘ t3 t4 ↗ ↗ t4 t5 ↗ ↗ labels based on the selfassessments of cohesion provided with the gameon data set we build labels of social and task cohesion for each pair of consecutive tasks we defined a labeling strategy that formalizes the prediction of the dynamics of cohesion as a binary classification problem in this work we explicitly focused on decreases in cohesion this indeed is an established method in research on affective computing and social signal processing specifically we rank the 6 scores provided by the group members and then compute their mean difference finally we binarize the labels based on their sign a negative label indicates a decrease of cohesion resulting in assigning a value equal to 0 to the label when a label is positive a value of 1 is given overall this strategy led to an imbalanced distribution of the labels for the social dimension and a balanced distribution for the task dimension as displayed by figure 1 the distribution per task is also highly imbalanced for both dimensions overall architecture the tbd architecture consists of 4 modules as mentioned above this model was conceived to take advantage of a pretrained model dedicated to the classification of social cohesions dynamics to predict the task cohesions dynamics using transfer learning hence tbd only focuses on predicting the dynamics for the task dimension the dynamics for the social dimension are predicted during the training phase of the pretrained model 2 in this study features were computed on nonoverlapped time windows of 20s spanning the 2 last minutes of interaction for each of the 5 tasks this results in a total of 30 windows per group the choice to focus on the last 2 minutes was motivated by the use of the selfassessments provided by the group members as reported in several studies carried out in very different contexts selfassessments collected through questionnaires are likely influenced by the last recalled behavior then due to the relatively small size of gameon the module performs data augmentation to create synthetic groups by permuting the order of the group members of the 15 groups in this way the size of the data set is 6 times bigger than initially data augmentation also allows us to prevent the model from learning undesirable patterns related to the order in which the model is processing group members social cohesion this module consists of a pretrained model to predict social cohesion in that way we use the higher representation of the social dimension learnt beforehand to start with a better initialisation point moreover as we are interested in the interplay of social and task cohesion the weights of the pretrained model are modified during the training phase of the tbd so that it also integrates the impact of task cohesion on social cohesion one of the advantages of this pretrained model is that it uses both individual and group features to learn a higher common representation merging individual as well as group representations to predict social cohesion furthermore its structure enables the integration of the temporality between the time windows as it is composed of lstm layers both at individual and group levels the pretrained model also used in 33 consists of 2 components the individual and the group components the former has 3 branches where each one of them is composed of a fully connected layer with 50 units and a relu activation function followed by an lstm layer with 50 units to let the model learn a global representation of an individual each layer of the 3 individual branches is shared following equation 1 y 𝑖 𝜙 𝑛 𝑗1 where 𝑌 𝑖 is the output of layer 𝑖 𝜙 𝑖 the activation function of the layer 𝑖 𝑊 the matrix of parameters common to every group members and 𝑋 𝑗 the input related to group member 𝑗 as groups are composed of 3 persons 𝑛 was here set equal to 3 the group component is aimed at learning the temporal dynamics of cohesion at the group level it takes multiple inputs by concatenating the group features with the outputs of the 3 individual lstm layers from the individual component the group component is made of a first fc layer with 64 units and a relu activation function followed by an lstm layer with 32 units to integrate the group temporality next a dropout layer with a rate of 02 is used to prevent the model from overfitting this layer is followed by another fc layer with 16 units and a relu activation function task cohesion the output of the social cohesion module is used as input of an fc layer with 16 units and a relu activation function in that way the model learns a higher representation of task cohesion before splitting into 5 branches so that each branch learns the task specificity branches are composed of 2 fc layers with 8 and 4 units respectively and a relu activation function 344 output finally this module consists of an fc layer with 1 unit and a sigmoid activation function for each task the resulting outputs are the predictions of the dynamics of task cohesion model evaluation 41 method tbd is evaluated through the following procedure a 3fold nested leaveonegroupout crossvalidation was carried out the hyperparameters here the learning rate and the number of epoch were in 001 0001 00001 and 100 200 300 500 respectively the imbalance in the data was handled by automatically weighting the loss function during training in an inversely proportional way to the class frequencies according to equation 2 this method is inspired by 24 𝑐𝑤 𝑖 𝑛 𝑔 𝑛 𝑐 𝑛 𝑖 where 𝑐𝑤 𝑖 is the class weight used in the loss function during training for the class 𝑖 𝑛 𝑔 the number of groups 𝑛 𝑐 the total number of classes and 𝑛 𝑖 the number of occurrences for the class 𝑖 the models performances are evaluated using the following 2 metrics the f1score per task and the mean of the f1score obtained for the 5 tasks for each dimension these metrics account for the label imbalance and give us insights into the ability of the model to correctly predict underrepresented classes finally according to colas et als guidelines 11 that suggest using a number of seeds ranging from 5 to 25 depending on the data and the algorithms we train our models on 15 different randomly extracted seeds and average the performances to obtain a more robust measure of the architecture performances in this way we aim at providing a reliable assessment of the models performances in this study we first compare 3 baselines between each other to select the most performing one and then we compare it to the tbd model statistical significant differences between the performances of the models were assessed via computationallyintensive randomization tests using 𝛼 005 these are nonparametric tests avoiding the independence assumption between the results being compared and that are suitable for nonlinear measures such as f1score 50 baselines three different models were used as baselines to predict the dynamics of cohesion for the social and task dimensions such baselines range from a simple but consolidated stateoftheart approach to more sophisticated approaches that increasingly address temporality and group contributions each baseline has been implemented in 2 different ways predicting the dynamics of the 2 dimensions of cohesion separately or using a multilabel classification as a first attempt to integrate the interplay between social and task cohesion the latter implies that both dimensions are tightly related to each other since the overall loss is the unweighted sum of the losses from both dimensions and only a final fc layer is differentiating both dimensions for each task for the remainder of the paper the versions of the baselines predicting each dimension separately are mentioned with the sd suffix while the multilabel versions are with the md suffix each model was evaluated following the procedure described in 41 that is by using 3fold nested logo crossvalidation with hyperparameters tuning tree based approach as stated by 48 random forest is one of the most powerful algorithms for solving binary classification problems for this reason we decided to use this classifier as our first baseline to predict the dynamics of cohesion by predicting each of the 20second thin slices since we are using the last 2 minutes of interaction it means that the rfc makes 6 predictions per task and dimension a majority voting is then applied over these 6 predictions to determine the overall prediction of the task for each dimension at each round of the logo crossvalidation a feature selection algorithm based on kolmogorovsmirnov statistic 2544 is applied to reduce the feature set as referred to in 38 the estimated hyperparameters were the number of trees the maximum depth of the tree the minimum number of samples required to split an internal node and the minimum number of samples required to be at a leaf node rfc however does not model the time dependencies between the thin slices nor between the tasks and does not model the group at multiple levels 422 integrating the time dependencies between the thin slices and between the tasks to model the time dependencies between the thin slices and between the tasks we designed the fullinteraction lstm model this dnn architecture integrates the temporality by inputting the features to an lstm layer with 30 units this layer is followed by a dropout layer with a dropout rate of 02 and by 2 fc layers with 16 and 8 units respectively and a relu activation function filstm predicts the dynamics of social andor task cohesion for each of the 5 tasks of an interaction thanks to a final fc layer with 1 unit and a sigmoid activation function for each task as for the rfc filstm still does not integrate into its architecture how a group as well as individuals contribute to cohesion integrating time dependencies and both individuals and group contributions the last baseline is the from individual to group model similarly to filstm this model predicts the social and task cohesions dynamics while integrating the time dependencies between the thin slices and between the tasks in addition it learns individual as well as group representation of the features fitg is used as the pretrained model for predicting social cohesion in the tbd architecture its architecture is described in section 342 the only difference resides in the output of the fitg indeed as for the filstm we added 5 distinct fc layers with 1 unit and a sigmoid activation function results and discussion tbd and each baseline were developed and trained using python 37 and tensorflow 21 on nvidia v100 gpus table 3 summarizes the performances of the 3 baseline algorithms both when they predict the 2 dimensions of cohesion separately and when they predict them using a multilabel approach the results are reported per task and per dimension first we tested whether the initial attempt of using multilabel classification to take into account the interplay of social and task cohesion outperforms the performances obtained by predicting them separately then the best baseline is retained to be tested against tbd comparing the baselines 511 singlelabel vs multilabel rfcmd significantly improves the prediction of the social dimension while it significantly decreases that one of the task dimension concerning the 2 other dnn architectures no significant difference is found for the social dimension multilabel classification however significantly improves the prediction of the task dimension filstmmd achieves 063 ±002 vs 059 ±004 obtained table 3 f1scores obtained for all the baselines predicting a single dimension vs using multilabel classification tables on the left and on the right report the performances for the social and task dimensions respectively results are displayed per task these results show that a simple approach to integrate the interplay of the social and task dimensions partially improves the performances of the models predicting a single dimension in particular improvements mainly concern task cohesion this shows that a multilabel approach has the potential of improving prediction such a kind of approach however neglects the insights from the extensive research in social sciences that we expect to be beneficial for the model as it implies that both dimensions are strongly related to each other and equally contribute to cohesion 512 selecting the best baseline since the models using multilabel classification partially improve the performances of the ones predicting a single dimension we run an extensive analysis on their performances to select the best baseline among the rfcmd the filstmmd and the fitgmd we first compare the performances of the social and task dimensions for each model to analyse whether a dimension is easier to predict or not then we compare each dimension separately across all the baselines for each model the dynamics of social cohesion are significantly better predicted than the ones of task cohesion rfcmd reaches 062 ±002 for the social dimension while it achieves 053 ±002 for the task dimension this difference in the performances is significant filstmmd also obtains significantly better results for the social dimension than for the task dimension with a f1score of 066 ±003 and 063 ±002 respectively similarly the fitgmd achieves a significantly better f1score of 069 ±003 for the social dimension with respect to the task dimension that reaches a f1score of 061 ±003 for every model the performances of the first 2 tasks are particularly mispredicted this could be explained by the fact that social cohesion develops over time and might not manifest during the early stage of the interaction 43 concerning the task dimension the dnn architectures particularly mispredicted task 4 this result could be explained by the nature of this task in which group members had to agree on a solution to solve a quiz in case of disagreements group members might have provided very different cohesion scores for the task dimension resulting in opposite labels within the same group this is a limitation of our labeling strategy that does not integrate the potential disagreements within the group making it harder for the model to predict the dynamics of cohesion for this particular task the rfcmd model achieves on average over the 15 seeds a f1score of 062 ±002 for the social dimension and 053 ±002 for the figure 3 f1scores of the social and task dimensions of cohesion for the rfcmd filstmmd fitgmd and the tbd models pvalues of significant differences are displayed for each dimension and between dimensions for each model task dimension statistical analysis shows that there are significant differences in performances for the rfcmd with respect to the filstmmd and the fitgmd models for both social and task dimensions a posthoc analysis using pairwise permutation ttests was carried out and showed that both the filstmmd and the fitgmd models outperformed the rfcmd for the social and task dimensions indeed for the social dimension the filstmmd model reached on average over the 15 seeds a f1score of 066 ±003 while the fitgmd obtained an averaged f1score of 069 ±003 this improvement of 003 observed for the fitgmd performances is also significant regarding the task dimension the filstmmd achieved an averaged f1score of 063 ±002 and the fitgmd reached 061 ±003 this difference is however not significant to summarize the fitgmd model is the most performing one with a f1score of 069 ±003 and 061 ±003 for the social and task dimensions respectively these results highlight the benefits for a model to integrate temporality and to learn higher representations of both individuals and group to predict the dynamics of cohesion especially for the social dimension indeed for this dimension the fitgmd significantly outperformed the other 2 models confirming the importance of modeling the group at both individual and syntality levels multilabel vs a social sciences inspired approach concerning the dynamics of task dimensions tbd obtains a significant improvement in the performances with respect to the fitgmd indeed it reaches a f1score of 064 ±003 improving the fitgmd performances by 003 such an improvement means that tbd learnt new behavioral patterns that globally improved predictions tbd however does not significantly improve the fitgmd in all the tasks it considerably enhanced task 2 from a f1score of 055 ±011 to 064 ±009 whereas task 5 has a significant decrease in performances passing from a f1score of 078 ±003 to 074 ±004 in task 2 group members had to concentrate on solving problems on their own limiting their movements and interactions while in task 5 they had to collaborate to agree to a solution a possible explanation for this tradeoff in performances is that for a similar label individual and group behaviors are extremely different in these 2 tasks these results confirm that integrating the interplay of social and task dimensions is beneficial for the prediction of the dynamics of task cohesion since both models take into account the dynamics of cohesion and model the group at both individual and syntality levels they differ by the way they integrate the social and task interplay motivated by the social sciences theories claiming that in groups of friends social cohesion is more salient than task cohesion 47 and that the social dimension first emerges 19 and creates a favorable environment to consolidate task cohesion 43 tbd takes advantage of a transfer learning approach to integrate this dimensions interplay such an approach enables tbd to use the social representation of cohesion previously learnt by the pretrained model to optimize the prediction of the task dynamics furthermore by enabling the retraining of the pretrained model during the tbd training phase we also integrate the impact of task cohesion on social cohesion conclusion and future work in this paper we presented an approach to exploit insights from social sciences to build computational models of cohesion taking into account the interplay between its social and task dimensions over time in particular we described tbd a dnn architecture that in addition to that also incorporates temporal dependencies by integrating amongst others lstm layers and models individual as well as collective contributions tbd was evaluated vs 3 baselines modeling cohesion in different ways our architecture allows us to reach a significantly better f1score for task cohesion that as stated in literature is particularly hard to predict cohesion is a complex social phenomenon and this work provides an approach to use some insights from social sciences to improve computational models it is indeed not exhaustive and has some limitations firstly all of the models are predicting the dynamics of cohesion for the whole interaction once all the thin slices are processed in the future we aim to design a model that would predict the dynamics of cohesion at each task relying solely on the thin slices of the previous andor current task instead of the whole interaction such a model would help leaning toward the development of a realtime application furthermore tbd takes advantage of social cohesion to predict task cohesion it would also be interesting to develop a different tbd architecture to explore whether and how task cohesion improves social cohesion prediction although evidence towards this interplay is to the best of our knowledge underinvestigated in social sciences literature it could help to have a better understanding of cohesion in this work dnns were designed to integrate a prefixed number of person here we tested the architectures on groups of 3 adding a new person to a group would imply retraining the models in the future an architecture able to dynamically selfadapt to various sizes of groups should be developed in this paper we focused on the social and task dimensions of cohesion only a new and open challenge will be to build computational models that can also take into account other dimensions and their interplay

emergent states are behavioral cognitive and affective processes appearing among the members of a group when they interact together in the last decade the development of computational approaches received a growing interest in building humancentered systems such a development is particularly difficult because some of these states have several dimensions interplaying somehow and somewhere over time in this paper we focus on cohesion its dimensions and their interplay several definitions of cohesion exist it can be simply defined as the tendency of a group to stick together to pursue goals andor affective needs this plethora of definitions resulted in many different cohesion dimensions social and task dimensions are the most investigated both in social sciences and computer science since they both play an important role in a wide range of contexts and groups to the best of our knowledge however no previous work on the prediction of cohesion dynamics focused on how these 2 dimensions interplay we leverage social sciences to address this issue in particular we take advantage of the importance of social cohesion for creating flexible and constructive relationships to reinforce task cohesion we describe a deep neural network architecture dnn for predicting the dynamics of task cohesion by applying transfer learning from a pretrained model dedicated to the prediction of social cohesion dynamics our architecture is evaluated against several baselines results show that it significantly improves the predictions of the task cohesion dynamics confirming the benefits of integrating social sciences insights into models architectures• humancentered computing → collaborative and social computing • computing methodologies → artificial intelligence

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introduction although the hiv epidemic in latin america remains generally stable hiv transmission continues to occur among persons practicing high risk behaviors such as male sex workers and men who have sex with men in particular those with limited access to hiv prevention interventions and hiv treatment care and support services 12 in peru sex between men continues to represent the main route of hiv transmission 3 the average hiv prevalence among msm from high prevalence cities is 124 with a prevalence in the capital city of lima reaching as high as 223 45 these hiv prevalence levels are substantially higher compared with the 04 prevalence in the general population 3 the prevalence of other sexually transmitted infections among peruvian msm is also high 124 for syphilis and 463 for herpes simplex virus type 2 46 in peru interventions funded by the government and by external sources are based solely on peer education and are not exploring alternative ways to reach msm such as online interventions 7 internet interventions in peru have proven to access highrisk msm who are interested in receiving webbased hiv prevention interventions 78 an online videobased intervention has been effective in motivating behavior change increasing hiv testing among nongayidentified msm 9 understanding the profile of msm who use the internet may improve the tailoring of future online behavioral interventions the aims of this study were to collect demographic characteristics sexual and nonsexual risk behaviors for hiv and stis as well as reasons msm who visit peruvian gay websites have for not getting tested for hiv methods from october 2007 to april 2008 we conducted a crosssectional study whose target population was msm who visited any of seven peruvian gay websites com chicoslimacom and the first five websites were commercial gay websites and the last two were advocacy gay websites we advertised animated banner ads that if clicked redirected the participants to our study website our website included a homepage with information about the objective of the study the content of the questionnaire the optional nature of all the questions and the length of the survey it also included information about risks and benefits of participation and privacy policy information the website also included our email and phone number for the participants to call if they needed more information participants had the alternative to click in a button labeled i want to participate to fill out the online survey or click on i dont want to participate in which case they were asked about reasons for not wanting to participate we did not offer any incentive for study participation the contents of the questionnaire were available in a separate link to anyone visiting the website regardless of their intention to participate thus preventing people from entering the data collection form only to explore its contents the online survey was an open survey designed using limesurvey 10 an open source tool that allows branching recovery of partially completed questionnaires and frontend and backend in spanish we piloted the survey for language workflow and accurate interpretation of question meaning with 20 participants before its launching the survey documented demographic characteristics sexual selfperception sexual orientation sexual role access to hiv prevention interventions sexual and non sexual risk behaviors for stis presence of sti symptoms online sex seeking behavior history of previous hiv testing and reasons for not taking an hiv test the questionnaire design was based on previous studies on hiv and stis conducted in peru 711 and the questions about the reasons for not getting an hiv test were based on previous studies about this topic as well as on two focus groups with each msm subpopulation gay and nongayidentified msm and transvestites 1213 participants were able to review and change their answers before submitting the questionnaire in the questionnaires participants were not asked for any personally identifiable information however they were asked to provide an email address to identify duplicate entries from the same individual we did not use ip addresses to identify duplicate entries because the majority of participants in peru answer online surveys through commercial cybercafe ´s 7 thus it is possible to receive surveys from different participants with the same ip address within a short time period data analysis was conducted using stata 80 software chi square and fishers exact test were performed to assess differences in reported behaviors our proposal and this study were approved by the institutional review board of the university of washington in seattle and the nongovernmental organization via libre in lima peru all enrollees provided a webbased informed consent for the online questionnaire results characteristics of the participants during the five months of the study we received 1481 surveys of these 180 were excluded due to the following reasons 25 had duplicate email addresses 85 reported a foreign residence country 35 were women and 35 were men who reported having sex only with women the study participants were from 24 of the 25 departments of peru and 816 of participants were from lima the median age of the participants was 225 and the majority were in the 1825 year age group 162 of the participants were younger than 18 years old most of the participants had high school education or higher and answered the online survey either at home or at an internet cafe the majority of participants declared themselves as gay followed by bisexual caleta and hombre heterosexual overall 113 participants received inperson hivsti information and 79 received free condoms from a peer educator from the peruvian ministry of health and ngos within the last year 285 participants received inperson hivsti information and 126 received free condoms from a healthcare professional during the last year sexual and nonsexual risk behaviors for hivsti and hiv testing the most common sexual role was moderno followed by pasivo and activo only 392 participants had a stable last sexual partner the remaining had casual anonymous or commercial partners regarding condom use at last intercourse 508 had unprotected anal or vaginal sex nearly half of the participants had never been tested for hiv before of those who tested 414 tested only once and 87 had a positive hiv result regarding the use of the internet during the last three months 537 used it to seek information about hivsti and 850 used it to seek sexual partners among the participants who sought sexual partners 365 also sought hivsti information online and among the participants who did not seek sexual partners 168 sought hivsti information online during the last three months 544 had sex with someone they met over the internet regarding drug consumption during the last sexual intercourse 157 participants reported use of alcohol 10 marijuana 10 cocaine hydrochloride 9 sildenafil 3 crack cocaine 3 anxiolytics 2 inhalants 2 ecstasy 2 intravenous drugs and 1 pain medications no participant used amphetamines reasons for not getting tested for hiv in the analysis of reasons for not getting tested for hiv we included only sexually active participants who never had an hiv positive result and who had not tested for hiv within the last year we divided the participants in two groups according to the type of last sexual partner and use of condoms at last sexual intercourse the lowrisk group included participants whose last sexual partner was stable and participants whose last sexual partner was not stable but who used a condom in their last sexual intercourse the highrisk group included participants who had a nonstable last sexual partner with whom they did not use a condom during their last sexual intercourse the most common two reasons for not getting tested for hiv among participants in the low risk group were i fear the consequences of a positive test result followed by i always use protection the most common two reasons for not getting tested among participants in the highrisk group were i fear the consequences of a positive test result followed by i dont know where i can get tested when comparing differences in the main reasons for not getting tested for hiv among participants in the low and highrisk group we found that participants in the lowrisk group reported at a higher percentage that they have never been at risk for infection and that they always use protection we also found that participants in the highrisk group reported at a higher percentage that they cannot pay for the hiv test and that they dont know where to get tested discussion the internet is a suitable venue to reach at risk msm who have not received any kind of inperson hivprevention interventions during the last year of our sample only 113 received hiv sti information from a peer educator and only 285 received this information from a healthcare professional during the last year for these reasons the different institutions that conduct hivsti prevention activities in peru should consider the internet as an alternative tool to provide behavioral interventions to peruvian msm 78 internet interventions have the ability to reach msm from virtually all urban centers in peru as is the case with our survey nevertheless the majority of online surveys were received from lima a city that contains one third of the population of the country 14 lima is also the city that concentrates most of the hiv infections in the country and has the highest proportion of msm who are hiv positive 414 internet approaches in peru can reach a young msm population the median age of our participants was 225 years and the majority of them were between the ages of 18 to 25 reaching young peruvian msm is very important given that hiv disproportionately affects this population of note it is estimated that the median age of hiv infection for peruvian men is around 20 years old 14 another finding from our study is the ability to reach through gay websites atrisk participants younger than 18 years olda population not targeted by the majority of hiv prevention programs in peru however the internet misses lesseducated msm the majority of our internet participants had high school or university technical education it has been reported that participants with higher education are four times more likely than their lesseducated counterparts to have current access to the internet 15 in a study conducted in china only 78 of the msm population who sent an online survey had attended junior highschool or less 16 in contrast to studies from developed countries where internet access is usually in private settings one of the most common places of internet access in our study was in internet cafes smallscale storefront operations that offer lowcost and reliable connections 8 this phenomenon indicates that the cabinas may constitute an important venue to develop structural interventions to reach msm in lima 8 the most common selfidentifications from our online survey were gay and bisexual similarly in the 2002 sentinel surveillance in lima the largest proportion of participants selfidentified as either homosexualsgays or bisexuals 4 this was most likely due to the fact that in both the online survey and the sentinel surveillance the sampling was done in gay venues in our study few trans and heterosexuallyidentified msm sent online surveys regarding the trans categories a likely reason is the lower level of literacy that these populations have due to stigma and discrimination at school age leading to high rates of dropouts thus the internet may not be a useful tool to reach this population in the case of the heterosexuallyidentified msm group they were not reached in a significant amount because this population likely visit heterosexually oriented websites as opposed to gay websites through the internet we can reach highrisk msm population msm had a high percentage of unprotected sex both at last sexual intercourse and within the last three months the majority of msm did not know the hiv status of their last sexual partner and a substantial percentage experienced condom breakage or slippage or initiated sexual intercourse without wearing a condom however participants from our study who used the internet to engage in highrisk practices also sought hivsti information online future behavioral online interventions in peru should include accurate hivsti information tailored to msm and they should address the correct use of condoms as well as the importance of knowing the hiv status of the sexual partner the majority of msm have not been tested for hiv during the last year a common reason for not getting tested was the fear of the consequences of a positive result fear appeal campaigns were popular at the beginning of the epidemic in peru and although there is still a debate about whether these campaigns produce safer behaviors towards hiv 1718 they seem to have had a counterproductive effect in motivating msm to get tested for hiv although there are programs from the ministry of health and ngo that provide free hiv testing at different venues in lima 14 we found that substantial proportions of msm at highrisk for infection state that they dont know where to get tested and that they cannot pay for the hiv test as main reasons for not getting tested online campaigns that increase awareness of places that offer these services for free are needed our study has some limitations first our sample is not representative of the msm population in lima or peru second given that we did not collect information on view rates and participation rates we do not know if our sample is representative of the msm population who visit the gay websites where we advertised our study third our sampling is likely to be biased in terms of educational background and age fourth it is possible that we misclassified the participants in the low and high risk groups because we only used the last sexual partner and condom use in the last sexual intercourse fifth we may have selfmisrepresentation of some participants leading to misclassification sixth we may have duplicate entries from the same individual although we excluded records for duplicate email addresses we were not able to use cookies or ip addresses to identify potential duplicate entries from the same user study strengths include the fact that no financial incentives were offered for study participation in conclusion a small percentage of peruvian msm who surf the internet are reached by traditional peerbased education programs online interventions should consider the delivery of messages that address the correct use of condoms as well as the importance of getting tested for hiv since highrisk behaviors and absence of hiv testing were common among peruvian msm who responded to our online survey given that fear of a positive result and lack of awareness of where to get tested were the most common reasons reported for not taking an hiv test among highrisk msm interventions aimed at motivating hiv testing in this population should work to reduce fear of testing and increase awareness of venues that offer free hiv testing services the lowrisk group included participants whose last sexual partner was stable and participants whose last sexual partner was not stable but who used a condom in their last sexual intercourse the highrisk group included participants who had a nonstable last sexual partner with whom they did not use a condom during their last sexual intercourse doi101371journalpone0027334t003

background men who have sex with men msm account for the greatest burden of the hiv epidemic in peru given that msm are frequent users of the internet understanding the risk behaviors and the reasons for not getting tested among msm who surf the internet may improve the tailoring of future online behavioral interventions methods from october 2007 to april 2008 we conducted an online survey among users of seven peruvian gay websiteswe received 1481 surveys 1301 of which were included in the analysis the median age of the participants was 225 years range 12 71 67 were homosexual and the remainder was bisexual of survey respondents 494 had never been tested for hiv and only 113 were contacted inperson during the last year by peer health educators from the peruvian ministry of health and ngos additionally 508 had unprotected anal or vaginal sex at last intercourse and a significant percentage reported a condom broken 221 slipped 164 or sexual intercourse initiated without wearing a condom 391 the most common reasons for not getting tested for hiv among highrisk msm were i fear the consequences of a positive test result n 55 344 and i dont know where i can get tested n 50 313 a small percentage of peruvian msm who answered our online survey were reached by traditional peerbased education programs given that among highrisk msm fear of a positive test result and lack of awareness of places where to get tested are the most important reasons for not taking an hiv test internet interventions aimed at motivating hiv testing should work to reduce fear of testing and increase awareness of places that offer free hiv testing services to msm

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with prolonged life expectancy more people are experiencing the myriad changes in both personal functioning and life circumstances associated with aging over a longer period of time than ever before this extended period of life during retirement highlights the necessity of making preparations to deal with these changes although a variety of social welfare programs for older adults exists in most developed countries there are still realms where either individuals are responsible for making their own provisions for their old age or such programs are not sufficient for meeting the needs of the aging individual as might be expected research has demonstrated that preparations for agerelated changes are associated with many benefits for example individuals who engage in planning for their retirement life in advance show better physical and psychological benefits such preparations may foster a sense of security or safety which in turn is positively associated with overall adaptation in later life thus successful planning for old age is an important developmental task for adjustment in later life the present research takes a multidimensional approach to examine preparation for old age focusing on both the characteristics of the individual and the contexts in which preparations take place agerelated changes and domainspecific preparation despite the evidence for the importance of preparation for old age our understanding with respect to the determinants and contexts of preparation is rather limited for the most part research has focused on people approaching retirement or those who have just retired in addition the vast majority of research has focused on financial planning with a major interest in finances for later life this research has concluded that determinants of more preparation are older age being male and having more education which are all related to greater probability of earning a higher income however as planning for the future especially for old age requires a longterm plan people at any point in the lifespan should benefit from any form of preparation for old age a few studies have examined preparations by younger and older adults both of who are often excluded in retirement studies for example anderson li bechhofer mccrone and stewart found that even younger adults report experiences of thinking about planning after retirement though the proportion is rather small relative to other age groups in addition retirees planning for later in life have been shown to be better adjusted in very old age than those not engaging in such planning this highlights the potential importance of beginning preparations in young adulthood and continuing to do so throughout adulthood in addition given the multifaceted nature of change the limited focus across contexts of functioning in studies of preparation fails to provide a complete picture regarding the nature of preparations and the eventual impact on wellbeing some existing research does focus on planning involving activities and interpersonal relationships after retirement but a focus on the full range of retirement preparation is rare one recent study by kornadt and rothermund dealt with both of these limitations by examining preparation within several different life domains using a broad sample of german adults aged 3080 years they found preparation for leisure work fitness and appearance increased to around the age of 65 and then decreased whereas preparation in the domains of emergency situations dependenceindependence housing and finances increased linearly up to the age of 80 these results indicate that preparations for old age are multidimensional and that the focus on specific domains may depend on specific characteristics of the individual such as their age and living conditions highlighting the importance of taking a much broader approach to examine preparations for old age perceived control and preparation for old age whereas age has been shown to be one factor that influences preparations other factors that vary across individuals may also be of interest one potentially important factor that may be linked to individual differences in preparation for old age relates to control beliefs regarding ones capacity to bring about a given outcome that is people with high control may be more likely to engage in preparations for the future some researchers proposed a curvilinear relationship between control beliefs and planning suggesting less engagement in planning in both individuals with a high sense of control due to overconfidence as well as in people with low sense of control due to the assumption that they cannot influence outcomes in later research a positive relationship between control beliefs and futureoriented planning was found although these studies highlight the potential role of control in planning they are limited in terms of the contexts of planning that were studied in addition they also do not take into consideration the domainspecific nature of control beliefs although general views of control may be of interest in certain contexts perceptions of control within particular life domains are likely to be influenced by beliefs knowledge and experiences associated with that domain this suggests that the effects of perceived control on planning in a specific life domain may be best understood by considering perceptions of control within that domain as mentioned previously the research on planning is also somewhat limited in terms of the ages of individuals studied we suggest that the relationship between control and preparation may be further influenced by the age for example control may become increasingly important as the relevance of preparations for old age increases with advancing age with further moderation being dependent on age thus we expected that the relationship between perceived control and preparation for old age within each domain will vary by age with the association generally increasing with age due to the increased salience of preparations futureself view as a mediator in addition to the aforementioned findings and assumptions regarding perceived control the question remains as to how perceived control is tied to preparation for ones old age a first explanation for effects of perceived control on preparation is that individuals with high versus low control differ in their beliefs regarding the capability to execute relevant activities another more indirect influence to help understand potential variability in the impact of perceived control relates to how individuals perceive themselves in old age it is wellestablished that perceived control and selfefficacy are aspects of selfperception thus a sense of control may be closely related to futureself perceptions that is individuals with a high sense of control may have a more positive outlook on their future because they expect that they can shape their lives in accordance with their goals and they are confident that they can successfully prevent or overcome any problems that might occur in later life such a positive outlook on the personal future will eventually manifest itself in positive fsv depicting how the person expects to be like in later life on the other hand perceiving a low sense of control will typically result in anticipating a negative future for oneself thus seeing ones life as being influenced by external or unwanted influences these positive and negative fsv in turn provide an important source of motivation for engaging in activities related to the personal future and old age if ones old age is portrayed as something that one is looking forward to then this facilitates making plans for the future thinking about what is needed to realize these plans and implementing the necessary steps toward reaching these goals negative fsv on the other hand portray old age as a phase in life that is threatening and which is no longer worth living having such a negative outlook on ones future will lead people to avoid thinking about this phase of life and to view it as something that one will have to endure rather than as something that one can actively shape consistent with this perspective kornadt voss and rothermund suggested that fsv involved expectations hopes and fears regarding what the individual would be like in later life that is as preparations involve expectations about what is going to happen in the future futureoriented selfviews could serve as a motivational factor for future goals and preparations supporting this idea longitudinal and crosssectional studies have demonstrated the linkage between fsv and preparation for agerelated changes more positive views of ones own aging are related to increased preparations in addition age is expected to moderate the relationships between control fsv and preparations for old age specifically with increasing age fsv of oneself as an old person reflect more immediate future projections that are close to ones current state rather than characterizing a distant and abstract future because of this aspect of fsv linkages between perceived control and fsv of oneself as an old person should thus become stronger with increasing age likewise effects of fsv on preparation behavior should become stronger in old age due to the increasing relevance of agerelated preparation cultural influences finally preparation for old age does not occur in a contextual vacuum it is not only influenced by individual but also by social and cultural factors above all the associations between futureoriented perspectives and preparation may be influenced by cultural differences in values traditions and social welfare programs across cultures both views of oneself in the future and preparations have been shown to differ across cultures and domains of functioning in a complex manner potentially reflecting these factors in general it might be expected that the association between perceived control fsv and preparations may be buffered by the degree to which social or institutional supports exist within a culture thus for cultures where strong institutional programs are in place within a specific domain of functioning weaker associations would be expected than for cultures without such supports for example the availability of strong public pension programs or comprehensive socialized health care for older adults within a culture may limit the degree of control as well as the necessity of planning within those domains when compared to cultures with less sufficient retirement and health care systems the current study the goal of the present study was to investigate the interrelationships between perceived control views of oneself in later life and preparation for old age we examined these relationships across four different domains of functioning in three different cultures we reasoned that this would allow us to investigate planning in areas that are important to adaptive functioning in later life across cultures that vary in terms of both the available social supports and expectations regarding life in old age we hypothesized that perceived control would be positively associated with preparations with this effect increasing in strength with age we further hypothesized that the impact of control on preparations would be mediated by views of oneself as an older adult with the strength of the mediation effect increasing with age consistent with the foregoing reasoning and our multidimensional perspective we also hypothesized that the strength of these mediation effects would vary across domains of functioning and culture within the domain of social relationships we expected these relationships to be weaker in hong kong where there is a strong tradition of filial piety and thus there may be less emphasis on extrafamilial relationships than in the united states and germany that is a tradition of filial piety in hong kong may lead to expectations of narrow prolonged and cohesive family relationships with less importance assigned to other social relationships in later life on the other hand western cultures affected by christianity hold ideas of more general attitudes or behaviors towards others which are not limited to consanguinity relatively higher levels of geographic dispersions of family in the united states may result in an especially strong emphasis on developing a supportive social network in later life in germany lower rates of homeownership than in other developed countries and governmentsupported finances for retiree communities or apartments since 2013 may lead to increasing preference for moving into those places and the resulting need to develop new relationships with respect to work we hypothesized that the impact of control on preparations would be stronger in the united states than in germany and to a lesser extent hong kong where mandatory retirement policies exist the absence of mandatory retirement and the associated flexibility in employment opportunities would necessitate greater importance being attached to planning with the influence of control and associated perceptions of oneself in the future being elevated we also expected that connections between perceived control fsv and preparations in the financial domain would be weaker in germany than in hong kong and the united states due to differences in the levels of financial support provided by governmentbased pension systems finally within the health domain we predicted that associations involving perceived control fsv and preparations will be strongest in the united states where governmentsupported health care is low and medical expenses are high necessitating greater need for preparation and a potentially stronger impact of perceived control private marketing firms or local registry offices provided the randomly selected lists to meet targeted age and gender distributions data for the present study was obtained based on responses to a questionnaire that was sent to each participant participants received a 25 gift card for participation method household income was assessed on an eightpoint scale with the currency adjusted to each country the scale was recoded into five categories for commensurability indicating higher average income levels in the united states than in hong kong and both were significantly higher than germany f11074 p 001 selfrated general health was assessed with a single item using a fivepoint scale mean ratings on this item were higher in the united states than in other two cultures f 7561 p 001 measures participants completed a paperandpencil questionnaire that contained a short demographic questionnaire as well as several domainspecific and general sets of questions assessing a wide variety of constructs for the present study responses to the following three instruments were of particular interest preparation for the future preparation for agerelated changes was assessed with a questionnaire developed by kornadt and rothermund although nine different life domains were included in the original instrument we only used responses to the four domains of specific interest to the present study and for which responses were available on the other measures social relations finances work and health respondents provided ratings on three items within each domain active preparation thought about it and gathering information participants rated their responses to each item on a fourpoint scale the three items on each domain of preparations seemingly reflect different aspects of preparation proceeding from thinking about preparation to active preparation however preparations have been shown to involve gathering information and thinking as well as doing something in addition confirmatory factor analyses indicated that all three items loaded on the same general preparations factor in each domain perceived control a single item assessed perceptions of control in each of the four target domains participants rated their responses to each item on a fivepoint scale with the option i have no control at all little control some control adequate control and a lot of control higher scores indicated greater perceived control futureself views fsv were assessed within each of the four domains using three to five items for each item participants rated themselves as older persons on an eightpoint scale each item addressed a specific aspect of functioning associated with the domain using two opposing statements participants gave their responses to each item on an eightpoint scale with higher scores indicating more positive views and lower scores indicating more negative views statistical analysis confirmatory factor analyses for fsv and preparations for old age were conducted using mplus the goal was twofold to establish measurement invariance across cultures and age groups in order to determine whether participants from different cultures and age groups interpret these measures in a conceptually similar way and to obtain latent factor scores for fsv and preparation for old age within each domain satisfactory model fits providing evidence of metric invariance were obtained for both measures note that in addition to the domainspecific preparations factors the preparations cfa included two additional methods factors to control for shared variance in items having the same stems across all domains we used the process macro for spss to examine our hypotheses involving moderated mediation the macro used 5000 bootstrap samples at 95 confidence interval to measure direct and indirect effects which has been found to maintain the highest power while controlling for type i error rate the significance of an effect is determined by the 95 ci without zero at p 05 listwise deletion was implemented to remove cases with missing data in the process macro which resulted in the small percentage of missing data in each domain analysis within each culture we ran the moderated mediation models with age as a moderator on all paths for each domain the models were first examined with gender as a covariate however given that gender did not emerge as a significant predictor in predicting preparations it was excluded from further consideration the previously described income and health variables were included as a common covariate across cultures when examined in the domains of finance and health respectively due to their relevance to these specific domains we explored specific agerelated moderation effects at representative points on the age distribution 1 sd above and below the sample mean as shown in figure 1 conditional indirect effects refer to the agemoderated effects of perceived control on preparation through fsv conditional direct effects reflect the agemoderated effect of perceived control on preparations when the same moderator is entered into more than one path that defines an indirect effect the moderated indirect effect becomes a nonlinear function of the moderator in that case the index of moderated mediation as a whole is not available thus our conclusions regarding moderation are based on comparisons of conditional indirect effects and conditional direct effects at each level of the moderator results correlations correlations among all variables are presented in table 1 significant positive correlations between perceived control and both fsv and preparations were found in four domains across three cultures in contrast the associations involving age varied across domains and cultures for example within the us sample positive correlations were found between age and preparations in social relationships finances and health whereas negative associations were observed in work these comparisons suggest that the impetus for preparing for old age at specific points in life varies as a function of domain comparisons within the same domain across cultures may also illuminate similarities or differences in the agegraded expectations associated with behavior in that domain regarding finances for instance positive correlations were observed between age and preparations in the united states and germany with the correlation being particularly strong in the former on the other hand a significant negative association was found in the hong kong sample within the same age range moderated mediation analyses turning to our primary focus we next examined whether fsv mediated the relationship between perceived control and preparations for old age within each domain and culture and the extent to which age moderated each relationship in this model the results are presented for each domain in table 2 as can be seen the impact of age as a moderator was generally greater on the direct effects than on the indirect effects in the following sections variations in the nature and strength of effects across domains and cultures are described in detail social relationships consistent with our hypothesis age moderated the impact of perceived control on preparations with the strength of this relationship increasing with age in each culture despite similar patterns of the moderated direct effects some evidence of cultural differences also existed specifically the strength of moderated mediation involving perceived control and fsv increased with age in germany and the united states but decreased in hong kong in addition the overall strength of effects to account for preparation for social relationships was weaker in hong kong than in germany and the united states supporting our hypothesis of less emphasis on extrafamilial relationships in cultures with a strong tradition of filial piety finances age was a significant moderator of perceived control on preparations with the strength of the direct effect increasing with age in hong kong and the united states but decreasing with age in germany also the overall strength of effects for preparations was weaker in germany than in the other two cultures the differences between germany and both the united states and hong kong supported our hypothesis that the effects regarding finances would be weaker in cultures with relatively strong governmentsupported pension system the form of the moderated indirect effects also varied across cultures but those effects were small and nonsignificant work 1 age moderated the direct effect of perceived control on preparations with the strength of this association increasing with age in all three cultures conditional indirect effects we considered the possibility that retirees in the analysis of work domain might have influenced our results when retirees were eliminated our results remained relatively unaffected thus all participants were included age effects were estimated at mean sample age 1 sd below the mean 1 sd above the mean r 2 114 r 2 059 were rather small but showed increasing trend in hong kong and the united states but not germany inconsistent with our expectations however the overall impact of control fsv and age on preparations was somewhat weaker in the united states than in germany or hong kong health in line with our hypothesis the strength of the direct effect of perceived control on preparations increased with age in all three cultures the conditional indirect effects were somewhat small with the strength of this relationship decreasing with age in the germany and the united states there was no significant conditional indirect effect in hong kong consistent with our hypothesis the overall strength of observed effects involving control fsv and age on preparations was greater in the united states than in germany and hong kong discussion the goal of this study was to investigate the impact of perceived control on preparing for old age and the extent to which this relationship was mediated by views of oneself as an older adult furthermore we tested the hypothesis that age would moderate both the direct and indirect effects of perceived control on preparations with the expectation that both would increase in strength with advancing age we also examined the degree to which the strength of this relationship varied across four domains in three different cultures consistent with past studies we found positive bivariate associations between perceived control fsv and preparations the positive association between perceived control and fsv in our study supports the idea that control is an influential facet of selfperception more importantly our expectations regarding the impact of perceived control on preparations through fsv were also supported suggesting that people who are perceiving high levels of control are more likely to have positive views of themselves in later life which in turn have a positive impact on engagement in preparations for the old age that is perceived control and fsv can be considered positive factors contributing to preparation for old age culture and context as expected we also found that the strength of associations varied across domains of functioning and cultures providing further support for the multidimensionality and domain specificity of agingrelated processes for example consistent with our hypothesis stronger effects in the domain of social relationships were found in the united states and germany than in hong kong this was thought to reflect cultural differences in emphases on preparations for future social relationships government financial support for living in retiree housing and low homeownership in germany as well as geographical dispersion of family with age in the united states were expected to be associated with an emphasis on building new social relationships in later life in contrast the tradition of filial piety in easternasian cultures such as hong kong was expected to result in a greater emphasis on family with reduced focus on building other relationships the stronger associations between perceived control fsv and preparations in germany and the united states compared with hong kong can then be interpreted as a reflection of more selfdirected efforts in preparing for later life cultural differences were also observed in the domain of finances weaker predictive associations were found in germany compared to the united states and hong kong due to a relatively wellprovided statesupported pension system in germany preparations for finances may be less of an issue and thus less affected by individual factors such as perceived control and fsv than in cultures where such systems are less generous for the health domain the expected pattern of stronger effects in the united states than in either germany or hong kong was observed conceivably reflecting low governmentprovided health care and high medical expenses in the united states in addition the youthoriented culture in the united states may also increase the focus on managing and maintaining health on the contrary the necessity of preparations for health may not be perceived as strongly in germany due to a wellprovided universal health care for all individuals similarly lower healthcare expenses in public hospitals and clinics in hong kong may also lessen perceived necessity for preparations age effects we had predicted that age would moderate both the direct and indirect effects of control on preparations whereas consistent moderation was observed in the former case agebased moderation was less evident for the indirect effect the relatively weak age effects on the mediation through fsv are suggestive of stable relationships across adulthood for example young adults with highperceived control still expect their futureself to be positive though perception of futureself as an older adult may be distant or abstract in addition even for young adults positive expectations about their old age may induce those young adults to engage in futurerelated preparations for the work domain the finding of weaker overall impact in the united states than in germany or hong kong was contrary to our hypothesis this was due to weaker age effects and lower impact of perceived control on preparations for work relative to the other two cultures given that mandatory retirement is not policy in the united states individuals regardless of age could be more likely to plan for work however despite their intentions fastchanging job markets and low job security in the united states may lessen the impact of perceived control towards preparations for work potentially accounting for the weaker effect strengths and limitations a strength of the current study is that several domains of preparation for old age were investigated in a sample encompassing much of the adult lifespan comprised of individuals from three different cultures this allowed us to explore both generalities across cultures as well as effects that were specific to particular life contexts whereas there were many commonalities in the nature of the obtained effects the strength of the effects varied across cultures within specific domains of functioning with these variations being meaningfully linked to cultural differences in institutional and traditional social support systems such findings emphasize the importance of considering aging from a contextual perspective as well as the limitations associated with more general approaches to understanding adaptive processes in later life the results of our study also extended recent work by kornadt et al who also examined cultural influences on preparations for old age kornadt and colleagues focused on how psychological variables relating to perceptions of the future influence cultural differences in preparations in contrast our study provides a somewhat different perspective by examining how current personal attributes influence both futurerelated constructs such as views of oneself as an older adult and preparations in each culture consistent with our prior work examining the relationship between personality aging attitudes and life satisfaction the present results suggest that current personal attributes that are not necessarily related to aging may have important outcomes on behavioral and psychological processes that are supportive of aging nevertheless some limitations should also be noted though we identified the impact of perceived control fsv age culture and domains on preparations examination of other potential variables related to preparations would be useful to extend our understanding of planning for old age for example individuals who perceive future time as more expansive may be motivated to engage in greater preparation for the future also although our data were obtained from three cultures more targeted identification of cultures that vary systematically in for example the support systems and views regarding aging would allow more precise identification of determinants of cultural variation moreover as our data are crosssectional we cannot make strong conclusions regarding causality between perceived control fsv and preparations thus for example future longitudinal studies should look at the extent to which perceived control and fsv at time 1 predict preparation at time 2 such a longitudinal study may be beneficial to examine the effects of specific life transitions at the individual level as well as changes in regulations and values at the societal level for example greater financial planning may occur at times in adulthood when more disposable income is available for retirement savings similarly the impact on preparations and perceptions of control associated with the institution of new social programs and within a culture could also be examined as a type of quasiexperiment our conceptual framework and associated models also focused on fsv as predictive of preparations it might be argued that alternative models may be just as viable however the results of longitudinal analyses demonstrating that change in fsv were more predictive of change in preparations than vice versa support the present perspective as a final limitation although perception of high control is related to both positive views of oneself in later life and greater levels of preparation it is still unclear which specific facets of control are operative in each domain for example other research viewed control beliefs in the context of internal versus external shultz and schultz found agerelated changes in internal locus of control with increases until middle age and then decreases in addition to age different effects of locus of control across domains of functioning and cultures might be expected therefore future research using a more extensive measure of control would be necessary to determine which specific control and the extent to which control are important in preparation for the old age conclusion taken together the current study investigated the interrelationships between control beliefs fsv and preparation for old age within different domains of functioning in individuals across adulthood in three cultures we found positive effects of control beliefs through fsv on preparations suggesting that the impact of control may at least partially reflect the extent to which it results in a positive perception of ones future and potentially the perceived benefits of preparation in addition the consistently increasing or decreasing effect size with age in the relationship between control and preparation provides evidence for importance of age salience in preparation research despite the limitations noted above our study expands understanding of how individual perceptions of control and views of oneself as an older adult affect preparations in differentaged adults across domains of functioning and cultures

objectives preparation for agerelated changes has been shown to be beneficial to adjustment in later life however an understanding of the factors that influence such preparations is rather limited this study examines whether perceived control and futureself views fsv influence preparations for old age and if this influence varies across ages domains of functioning and cultures methods assessments of perceived control fsv and preparations for old age in each of four different life domains social relationships finances work and health were obtained from 1813 adults ages 3585 from germany hong kong and the united states results futureself views partially mediated the relationship between perceived control and preparation for old age across both domains of functioning and cultures with one exception the association between perceived control and preparations increased with advancing age across contexts evidence for similar agerelated moderation of the indirect effect of control through fsv was more limited discussion these results suggest that perceived control that is not necessarily related to aging affect fsv which in turn influence preparing for old age further our results indicate that such relationships are contextand agespecific highlighting the importance of considering the salience and diversity of life domains and cultures

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introduction india is rich in heritage and unique for its diverse cultures and alluring landscapes poignantly deeply ingrained gender and caste injustices persist within indian culture and a recent financial crash has afforded certain millionaires an excuse to indulge in a position of authority by limiting minority recourse to vital liberties all of our great preachers have attempted to dismantle caste as a social norm every religion down through buddhism has preached against caste yet each time it has just served to fasten the chains gender is what individuals are evaluated and categorized on their expressions behaviours and gestures based on masculine feminine or neutral gender stereotypes are ingrained in societal and cultural expectations about the acceptable ways to express ones gender often causing harm to individuals who do not conform to the rigid binary gender norms often upheld by these institutions politics and family traditions are important factors for impoverished women social pressures are so strong that they justify the mistreatment of women this is due to the largely patriarchal social systems found in the majority of cultures the caste system has greatly harmed the citizens of our nation even if untouchability was outlawed by legislation in india peoples mental social and traditional outlooks remained unchanged india is not exempt from the class system either caste is what individuals are identified and grouped on their birth classes and social status in which people are assessed through the lens of unchanged family backgrounds srinivas defines caste as caste is a hereditary endogamous usually localised group having traditional association with an occupation and a particular position in the local hierarchy of castes relations between castes are governed among other things by the concept of purity and pollution and generally maximum commensality occurs within the castes untouchability is a repulsive practice of class and castebased discrimination against a group of people highclass individuals avoid making contact with these outcasts because even their slightest touch can contaminate the savarnas additionally there is a notion that persons from higher castes might become impure even if the shadow of an untouchable person touches them in order to restore his cleanliness he must bathe in the gangas sacred waters both the indian novels untouchable of mulk raj anand published in 1935 and the god of small things by arundhati roy published 62 years after the first one display the interconnected and hegemonic nature of caste and gender mulk raj anands novel untouchable narrates the struggles faced by the people under the gendercaste hegemony through the protagonist bakha a dalit boy who is a latrine cleaner and sohini the novel the god of small things by arundhati roy exposes the struggles and oppression faced by the characters under the gendercaste hegemony through veluthas life a paravan who works as an employee in the pickle factory of the ipe family these novels expose societys worst face in which people are evaluated on gender and caste which leads to violence and death making the life of each character victimhood arundhati roys masterpiece the god of small things and mulk raj anands untouchable are among the most renowned works of indian literature that assess themes of vulnerability as caste and gender hegemony they do have a handful of prevalent subjects yet owing to their narrative tactics and their historical contexts being distinct in which they ought to tackle these themes in unique manners this paper analyses the interconnected and hegemonic nature of caste and gender and interrogates how the hegemony leads to victimhood as narrative by the novels untouchable and the god of small things gendercaste hegemony and victimhood the interrelation of the hegemonic nature of gender and caste in both novels is often deeply nuanced outlining complexities of power relationships racial prejudice and the human experience in a particular cultural and historical setting mulk raj anands novels unveil an honest and harsh description of castebased presumptions and their detrimental impact on individuals and arundhati roys novel employs an intricate story arc and analyses comparable subject matters within the context of a family tale both authors shed a glimpse into the complexities and iniquities of indian society anands novel untouchable depict struggles faced by indians under the caste with religious touches of sarcasm on a blunt the grief and despair of the downtrodden and marginalized along with their quest for better lives are concerns covered throughout his initial pieces considering their wickedness apathy and despair he was always conscious of his obligation to assist with bringing a sense of humanity and consciousness to the intangibles villagers slaves the coolies and other persecuted sections of culture he was hailed as indias foremost author known for his politically astute and compassionate portrayals of indias impoverished population through his fiction he vividly exposes the harsh realities of the downtrodden through the novel untouchable he displays a tremendous comprehension of sentimentality and tragedy through the character bakha a sweeper and latrine cleaner an 18yearold untouchable child who gets treated as marginalized by humanity the protagonist of the novel is labelled as an outcast by society solely because his father is a scavenger and his family has been living in a ghetto since he was born he is viewed as filthy impolite and underprivileged therefore his low rank inevitably results in his status as an untouchable the caste system marginalizes the untouchables outside the social ladder since scavenger work is considered to be very filthy the sweeper has a worse situation than a slave because unlike the slave who can change masters and tasks and even gain freedom the sweeper is born into a state from which he cannot flee and is isolated from both social interactions and the consolation of his faith the novel starts with describing the outcastes colony this outcaste colony is for the lower caste people there lived the scavengers the leatherworkers the washermen the barbers the watercarriers the grasscutters and other outcasts from hindu society the 1930s era of hindu culture was the subject of the novels captivating focus on contemporary cultural ideals manners and issues of society notably the calamities of social distinctions and social hierarchies in true form it is an anthropologically cognizant fictive fiction it sheds light on the agony and miseries that hindus of lower socioeconomic strata enacted on marginalized people and the destitute including predators cowhide employees washermen hairdressers water bearers and grass cutters amongst others it expresses a fierce objection to racial bias toward untouchables anand describes a single day in the life of bakha that is marked with realism the novel highlights the harsh realities of untouchability and the specific hardships endured by women in a castebased society that lacks democracy he denounces and disapproves of the hindu caste systems callousness bakhas day starts with a mix of his fathers kind requests and harsh insults along with an encounter with the uppercaste people who disdain him his father lakha who serves as the head of the sweeper community initially mistreats him by sending him outside to clean latrines during the cold early morning hours get up when you bakhiya ohe son of a pig… get up and attend to the latrines or the sepoys will be angry everywhere he goes he receives harsh treatment he is treated like a dog when he is provided with food chapatti is thrown down from the third floor jilebis are also provided in an analogous way to the way a dog is given a piece of meat an indian a packet of cigarettes is thrown at him by the store owner he has been going through numerous instances of terrible beginnings with early encounters whenever a social class guy slaps him he is immensely disgusted for corrupting him hindus of the upper caste persist in mistreatment why dont you call you swine and announce your approach do you know you have touched me and defiled me cockeyed son of a bowlegged scorpion now i will have to go and take a bath to purify myself and it was a new dhoti and shirt i put on this morning the high caste hindus behaviour is typical when they are touched by the untouchable bakha it merely emphasizes the awful predicament of the oppressed anand highlights the entire socioeconomic framework in which members of lower castes feel hopeless about obtaining all opportunities while also exposing the misery and stress of being the underdogs in the meantime the centrality of religion ingrained dogma poverty and an imperial mindset are highlighted to show how the low caste in hindu culture is dominated he also controls the possibility of dripping the untouchability curse instead of encompassing the indian roots at the outset of the novel bakha showcases a greater connection with the british assuming roles and putting oneself like them he possesses an insatiable need to replicate british culture and he is unwilling to relate his mothers demise to the truth of what he sees despite his familys long tenure as untouchables he can disregard his social strata identity unless he endures a day of harassment for being untouchable even though bakha is acutely aware of his status as an untouchable in both the outcastes colony and the army barracks he does not experience social exclusion as intensely there as he does in this town primarily because he is the sole representative of his caste in the entire area anand deliberately takes bakha into the town to directly confront his untouchability which demonstrates anands adept management of the situation anand leads the readers to witness an instance in the life of bakha a young sanitation worker who is a dalit and faces the consequences of discrimination and torture as being a lower caste person social status and labour define his relationship with caste hindus and serve him to identify himself all of them abused abused abused why are we always abused the sanitary inspector that day abused my father they always abuse us because we are sweepers because we touch dung they hate dung i hate it too i am a sweeper sweeperuntouchable i am an untouchable he eloquently reveals the detrimental impacts of the caste system through bakhas experiences shedding light on the inhumane aspects of invincibility ohe bakhya ohe bakhya ohe scoundrel of sweepers son come and clean a latrine for me bakhas suffering and pain are not a result of his mistakes but rather of his birth into a lower social level everywhere he goes in his daily life he encounters a lot of humiliation and abuse and he is always greeted with the phrases defiled and polluted wherever he goes because bakha is inferior to everyone and everything according to society people avoid him wherever he goes calling him unclean and dirty bakha had to endure conflict both inside and outside of society the novel describes the lives of dalit women like bakhas sister sohini highlighting the complex interplay of gendercaste hegemony these women endure a dual form of discrimination facing exclusion based on both their gender and social class sohinis struggle to maintain her dignity and independence in a society marked by a castebased patriarchal society provides an inescapable loop of gendercaste hegemony in which a lowercaste woman is trapped anand is highly conscious of the devastating impact of millennia of tyranny and servitude on the underclasses bakha has an essential grandeur of belief and sensibilities despite the misery he endures on the occasion of the narratives events rendering him despairing he is innately hopeful and sociable he quietly handles individuals for whomever he purifies the washrooms with politeness and good laughter he adores and fiercely guards his sister and he recollects his mother with fondness through the novel readers gain insight into the everyday hardships faced by the untouchables and the constant threat of violence they encounter bakhas interactions with people from various hindu castes especially an incident where he inadvertently touched a woman from a higher caste serve as stark reminders of the deeply ingrained prejudices of that era the caste system seeks solace in religion to maintain its dominance over those with lower socioeconomic status and to rationalize their privileged position this religious faith serves to reinforce their selfjustification bakhas humiliation stems not only from his poverty or the menial labour itself but also from the complete denial of his humanity which reduces him to a subhuman capable of contaminating those of higher caste the hindu social structure hinges on the ideas of cleanliness and contamination wherein any interaction with dirt whether through occupation or otherwise diminishes ones social status greater social status corresponds to greater distance from dirt whereas lower social standing is associated with closer proximity to it if mulk raj anand writes in the preindependent indian context arundhati roy writes in the independent indian context however the gendercaste hegemony is unchanged even after sixty years arundhati roy is widely recognized for her writings that portray the sociopolitical issues and realities of sarcasm faced by the indians under the intersectional disciplines in a poignant manner in her novel the god of small things the female characters undergo perpetual assault abuse and coercion to comply with the stipulations of the patriarchal norms in their families stereotypes regarding gender and expectations have an enormous effect on the daily existence of each character in god of small things ammu the titular protagonist is a victim of the coercive effects of gender bias and social conventions she is socially and economically marginalized challenges the authority of the colonial overlords she rebels against the basic social conventions that make up the syrian christian community in kerala because she feels oppressed by social injustice the basic underpinnings of this society are being challenged by this insurrection the most crucial act she committedhaving a sexual relationship with lowerclass velutha an untouchablecannot be interpreted solely as a sexual trespass the novel portrays the unseen despairs and unjustified sorrows of the women who silently and docilely carry the weight of male dominance throughout their lives ammu mammachi baby kochamma and rahel among other female characters in the novel had a number of difficulties in their daytoday existence their inner selves are impacted by cultural boundaries and family pressure their lives were made wretched by the abuse they all endured at home at the hands of their own these societal norms are jeopardized by her illicit affair with an untouchable man named velutha with disastrous implications the historical narrative explores how caste discrimination affects women as a whole and the way cultural norms are impacted by it although her female characters flee from the norm in society roy expertly utilizes them to point out butlers idea that identity is a rhetorical fabrication veluthas life from struggles to the brutality of death as being an untouchable the paravan is a clear example of victimhood of gendercaste hegemony the novel explains how paravans were treated they were not allowed to touch anything that touches touched … mammachi told estha and rahel that she could remember a time in her girlhood when paravans were expected to crawl backwards with a broom sweeping away their footprints so that brahmins or syrian christians would not defile themselves by accidentally stepping into a paravans footprint the situation was even worse in the case of women since they had to suffer also from gender disparity novels speak about the policemens status as touchable men men who are playing touchable games with touchable cunning as the narrative unfolds it unveils a rigid bureaucracy and concealed power dynamics this connection challenges the established caste hierarchy and the tragic demise of velutha at the hands of law enforcement illustrates the extremes to which the caste dominance is willing to go to preserve its authority according to anuradha dingwaney needham the novel depicts history as a suffocating force that permeates almost every aspect of social and cultural life including close personal and affective interactions society decides and lays down the laws about who should be loved how should be loved and how much should be loved in the context of the relationship between velutha an untouchable and ammu a syrian christian the novel questions this they were not worried about their caste as they valued more their unconditional love they have sex and it shows that they care for each doi 1048165sajssh20234511 other and to make sure their satisfaction is mutual when velutha is brutally beaten and killed in the police station the novel portrays the pain inside ammu caused by her forbidden love with velutha symbolically through the roses she dreams of them together as skin to skin the roses pressing against her skin are not real real roses wilt and rot eventually further representing how the love in this novel does not last velutha becomes the victim of the caste system the novel constructs a scenario in which it becomes evident that veluthas presence in the factory becomes a problem for comrade pillai because according to them paravans were not meant to be carpenters this factory problem is complicated by veluthas active party member status he cannot be recognized and usefully for pillai because he is an untouchable worker yet he cannot be ignored because he is also the only cardholding member at the factory the novel transcends social strata to tackle the most atrocious kind of confinement and dwells on the periphery of indian society the fraternal twins in the novel estha and rahel also break the rule and love laws of having sexual relations at the end as they eventually start with the healing process nevertheless they comprehend how much they care for one another they both lost their innocence at a young age by then estha and rahel had learned how history negotiates its terms and collects its dues from those who break laws they heard its sickening and thud like old roses on a breeze the quote reflects on the fraternal twins loss of innocence another female character in the novel baby kochamma represents pappachis sister who is another victim of the caste disparities her affection towards father mulligan and her attempt to turn into a roman catholic for the sake of her love exposes a womans struggle for love and she fails in that attempt to stay in ayemenem forever in contrast baby kochamma says that she lived her life backwards now she hugged it and it hugged her back thus her affection or the longing for her love comes to an end this novel shows as the characters break the boundaries of love of who should be loved and how much as the narrator says they all broke the rules they all crossed into forbidden territory they all tampered with the laws that lay down who should be loved and how and how much the laws that made the grandmothers grandmothers uncles uncles mothers mothers cousins cousins jam jam and jelly jelly women who fall short of the standard mould of conforming to marital bliss and blending into relatives are not given numerous gratifying options by indian society as a consequence patriarchal panoramas trespass as being in an inadequate ability to upset the natural order even while specific individual actions do have a small impact on societal reactions remain the sole truly severe penalties the multifaceted roots in the novel which possess an embarking in india provide an unconventional viewpoint on indian women which draws attention to westerninfluenced perceptions while at the same time barely capturing indian womens efforts to comprehend themselves a process that wouldnt have been determined by the specific cultural and socioeconomic scenario in the novel indian women who fought against caste traditions are specifically accused of breaching the rigorous patriarchal customs of indian families and are thus doomed to social exclusion or death in extreme cases throughout indian history the caste system segregated the people cruelly and different sections of the division led the people that depicted peoples interactions based on their religious status the narrative subtly promotes an alternative perspective on societal structure highlighting its inherent unfairness to certain individuals what captivates readers in this story is its ability to elevate the ordinary into something sacred revealing the appalling aspects of society in a manner reminiscent of religious revelations conclusion castegender hegemony is portrayed in the two novels as interconnected structures of power that treat vulnerable individuals like slaves these novels act as potent critiques of the inequality and biases that are pervasive in indian society illuminating the intricate ways that hegemonic forces interact and subjugate people who oppose established standards and structures both novels reflect the victimhood of individuals under gendercaste hegemony through the lens of bakha in untouchable and velutha in the god of small things sohini in untouchable becomes the representative of all the victims who face oppression as a dalit woman to uphold her dignity and independence in a society characterised by caste prejudice and patriarchal standards readers are rendered conscious of the enormous exclusion and deplorability the underprivileged go through in bakhas experiences the novel explores how the caste system governs culture and how people from lower castes are often discriminated against the victimhood of all the untouchables is symbolized by bakha and velutha due to his caste identity he suffers daily disgrace brutal treatment and mental anguish his experiences serve as a demonstration of the relentless distress those who are at the bottom of the social hierarchy must suffer velutha being lower caste is unfairly branded as a criminal and ultimately meets his demise at the hands of the police his tragic fate serves as a powerful reminder of caste hegemony even after independence ammus character shows womens bondage in a patriarchal society the novels foreshadow the present worlds daytoday life situations which analyse the relationship of individuals both novels emphasize the lasting impact of castebased discrimination and the limitations imposed by conventional gender expectations they draw attention to the interconnectedness of these problems revealing how people particularly women contend with the compounding effects of various forms of oppression the novels also make substantial contributions to the fields of gendercaste studies they do so by presenting intricate narratives that encourage readers to thoughtfully explore the intricacies of these societal frameworks with their compelling storytelling and rich characterizations these novels effectively serve as valuable resources for comprehending the persistent struggles experienced by marginalized groups in india and the pressing call for social change and fairness and interpreting the nuances of gendercaste hegemony suleman d binti ab rehman f

india is distinctive for its varied cultures enticing landscapes and rich heritage intriguingly caste and gender inequities are still pervasive in indian society and the recent financial crisis has given some millionaires a pretext to abuse their power by denying minority groups access to basic freedoms gender stereotypes are deeply ingrained in cultural and societal expectations frequently harming people who dont fit the strict binary gender norms imposed by these institutions people are classified into castes based on their social standing class and place of birth and their caste status is determined by their largely unchanging familial origins both the indian novels untouchable of mulk raj anand published in 1935 and the god of small things by arundhati roy published 62 years after the first one display the interconnected and hegemonic nature of caste and gender this paper analyses the interconnected and hegemonic nature of caste and gender and interrogates how the hegemony leads to victimhood as narrated by the novels untouchable and the god of small things

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introduction imagine a world in which a singular invention has not only transformed communication but also became the backbone of our global society the internet which was first introduced in the early 20th century as a way to blog and store information has since become a global platform for social interactions connecting people from all over the world the percentage of social media users have increased exponentially in recent years from what it used to be when it first came around today more than 50 of humanity is connected to the internet and social media mostly for social interactions this exponential increase in connectivity raises the question how has this technological miracle affected the very structure of society more specifically how does it affect the realm of islam especially within the domain of social media these questions pave the way for our exploration of the relationship between internet social media and islam as we embark on this journey we will delve into the nuanced ways these technological advancements are shaping islamic discourse from the propagation of religious knowledge to the fostering of online communities and the addressing of challenges posed by digital extremism we aim to unravel the relationship between the social media and the islam tracing the history islamic knowledge transmission and the social media shift as we navigate onto the world shaped by internet and social media its important to explore how islamic knowledge was previously shared during the time of prophet muhammad with a smaller population information primarily spread through oral means the teachings of the prophet were heard directly and this knowledge was meticulously passed down through generations as reflected in hadiths that often begin with narrated by consider this hadith narrated by muhammad ibn bashshar from abu dawood from imran alqattaan from qatadah from yazid ibn abdullahthat prophet muhammad said it illustrates the meticulous transmission of knowledge islamic knowledge was also thrived in halaqas which are communal gatherings where scholars and students convened to share and discuss ideas fostering a vibrant atmosphere of intellectual exchange and community and so social media emerges as a powerful contemporary tool efficiently educating a wide audience about islam teaching the quran with the emergence of the internet and especially social media the message of islam reached many places in a short span of time technology has made it very easy for us to gain any type of knowledge about islam making tasks like teaching the quran spreading alerts sharing hadith and referencing islamic literature for dawah purposes much more accessible uthman ibn afsan said that the messenger of allah said the greatest among you are those who learn the quran and teach it undoubtedly this era dominated by social media presents unparalleled opportunities to attain spiritual excellence in the eyes of allah there are currently many ways for muslims to participate in arabic and tajweed online using various social media platforms the comfort of home has become a great place for people to learn the teachings of the quran in depth spreading of islamic globally in this era of information flow presenting the beauty of islam to the world through the media has become remarkably accessible the holy quran provides insights into global illustrating its principles and significance invite to the way of thy lord with wisdom and beautiful preaching and argue with them in ways that are best and most gracious in the light of this verse it can be said that modern technology can be used in terms of promoting islam the prophet once stated convey my teachings to the people even if it were a single sentence discussion of islam in the media allowed the message to spread rapidly around the world in the past proponents of islam had to put i n a lot of effort to spread the teachings of islam but now it is easier and can be done from the comfort of your home social media is a tool used byprominent islamic scholars to spread the message forexample dr zakir naik mufti monk numan khan bilal phillips and others the dawah efforts of these scholars are so potent that not only do muslims find their beliefs strengthened after watching but nonmuslims also begin to question their own faith and delve into learning about islam the prophet emphasized addeen is sinceritydeen and islam are peoples welfare and so following the islamic principles of inviting others using wellinformed and evidencebacked dialogue can help spread the word better the role of social media influencers the rapid diffusion and widespread adoption of social media platforms in muslimmajority countries such as facebook twitter and youtube have reshaped the digital landscape as reflected in the attached graph the social media landscape in middle eastern countries is undergoing significant growth particularly in the case of facebook which stands out as the dominant platform whatsapp closely follows in popularity this surge in social media activity is fueled in part by the emergence of muslim content creators on platforms like youtube tiktok and instagram these influencers play a pivotal role in disseminating islamic content providing guidance and fostering learning experiences for their audience the educational value of their content encourages sharing among users as the act of sharing itself is considered a form of continuous charity prophet muhammad said the righteous deeds that continue to benefit a believer after his death include the knowledge that he teaches and spreads among others… this ripple effect contributes to the widespread circulation of islamic knowledge within the digital landscape these influencers impact goes beyond the muslim community reaching individuals who are new to islam and seeking information this content on such platforms not only captivates users but also encourages them on open dialogue people can easily ask questions and share problems that they face regarding islam and content creators actively respond creating an interactive space for learning and problem solving crucially these apps are free and easy to download ensuring that every individual regardless of financial background can freely access and benefit from the wealth of islamic knowledge online communities and if he sees any fault in him he tells him to remove it this sense of mutual reflection and improvement demonstrates the multifaceted benefits of online communities beyond education and cultural exchange additionally these virtual platforms play a significant role in promoting unity among muslims fulfilling the quranic injunction in surah alimranand hold firmly to the rope of allah all together and do not become divided the collaborative spirit within these online communities fosters a sense of unity bridging geographical gaps and reinforcing the bond of brotherhood among believers this online community collaboration fosters unity bridging gaps among believers cultural diversity and expression social media provides muslims with an expansive platform to express and showcase the richness of islamic traditions and culture typically muslims share various elements of their cultural heritage including customs attire artwork literature and notable personalities they perceive social media as a virtual stage for presenting their culture increasing awareness about it and educating others muslims actively participate in meaningful conversations delving into discussions about their customs and sharing visual representations of their culture in the online realm this virtual space transforms into a learning environment where individuals elucidate the meaning of diverse cultural customs provide historical backgrounds and foster a more profound environment charity and community support social media serves as a powerful tool for raising awareness about global issues and mobilizing support for those in need the teachings of prophet muhammad emphasize the virtue of giving especially in difficult times as he said give charity o you people of wealth and be assured of ease of heart and the best charity is that which is given when one is still struggling the islamic relief fund committed to alleviating suffering exemplifies this virtue in addressing yemens severe food security crisis over 400000 people face acute malnutrition and the organization provides monthly food aid to two million individuals clean drinking water to over 800000 and has established 167 health facilities this example is just one among the multitude of online charitable organizations the quranic verse serves as a reminder and whoever saves a life it is as if he has saved the lives of all mankind social media particularly instagram amplifies these charitable efforts creating a global community conscious of challenges and actively contributing to positive change the interactive nature of campaigns and realtime updates deepens the connection between individuals and the causes they support promoting crosscultural understanding challenges in navigating social media impact on islam while social media offers numerous advantages it also presents its fair share of challenges the easy and affordable access to the internet has unfortunately given rise to individuals with malicious intent who freely distribute illegal content additionally some people exploit social media platforms to spread misinformation against islam online communities have become susceptible to deceptive activities where individuals especially the youth can be easily misled despite the widespread popularity of these platforms they inherently present challenges users must exercise caution as media can easily become a source of threats and may also be susceptible to exploitation due to its inherent vulnerabilities extremists like many societies worldwide one of the most pressing challenges for the islamic community is extremism on social media islamic extremists exploit the platforms to spread radical ideologies manipulate religious doctrines and advocate for violence rooted in political social or religious motivations these individuals or groups use online spaces to recruit share extremist content and influence vulnerable individual spread of misinformation and negative perception while many utilize social media positively individuals with extreme views exploit these platforms to sow discord among followers of various religions they disseminate biased information and portray an unbalanced perspective of islam influencing public perception western media tends to oversimplify conflicts involving muslims attributing them solely to islam and neglecting similar issues in other religions social media amplifies this by circulating false rumors about islamic leaders fostering misconceptions about muslims regrettably this misrepresentation can lead nonmuslims to perceive muslims as either traitors or terrorists false news on social media the widespread dissemination of false news on social media has resulted in negative perceptions and misinformation about the media social media platforms often feature a substantial amount of misleading content with many blogs lacking proper editing the alarming ease with which rumors can spread during the social media era is particularly concerning conclusion in conclusion social media has profoundly influenced islam facilitating the global dissemination of religious knowledge and the formation of online communities while connectivity transcends geographical boundaries allowing individuals to connect learn and find support it also brings challenges such as the risks of extremism and misinformation muslims must use technology to strengthen not weaken their faith guided by the quran and sunnahs teachings the qurans admonition to fear allah as he should be feared serves as a shield against challenges emphasizing the importance of resilience in the face of negativity the prophets warning about the signs of a hypocritelying breaking promises and betraying trustoffers a roadmap for discerning falsehood by fortifying hearts with sincere faith and adhering to the moderate path of the sunnah believers can navigate the digital landscape resisting extremism and falsehood influential islamic figures content creators and online communities play a pivotal role in addressing these challenges by upholding values of sincerity knowledgesharing and mutual support as we navigate the everchanging digital landscape let us heed the qurans call o you who have believed enter into submission to allah completely and do not follow the footsteps of satan indeed satan to you is a clear enemy may these words serve as a guiding beacon illuminating our path towards unwavering faith and righteous conduct in this digital world where the echoes of truth and falsehood intertwine

this research explores the impact of social media on islam investigating how digital platforms shape religious knowledge community dynamics and cultural expression tracing the evolution from oral traditions to the contemporary digital landscape the study examines social medias role in teaching the quran spreading islamic dawah and fostering online communities while acknowledging the positive contributions the research also addresses challenges including the dissemination of illegal content and the exploitation of platforms by extremists emphasizing the need for vigilance the findings highlight the importance of using technology in accordance with islamic principles the paper concludes with a call to navigate the digital landscape with resilience and adherence to quranic teachings revealing the intricate relationship between technology and spirituality in the modern islamic context

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introduction in any just and equitable society access to justice is a fundamental right that should be afforded to all individuals regardless of their background or circumstances however the reality is that millions of people around the world face significant barriers when it comes to obtaining justice and legal representation this lack of access undermines the principles of fairness and equality perpetuating systemic injustices and leaving marginalized communities further marginalized recognizing the urgency and importance of this issue efforts have been made globally to address the access to justice gap one such initiative is the pathways to justice project a comprehensive approach aimed at expanding access to justice for everyone this project recognizes that achieving justice for all requires a multifaceted approach that encompasses legal social and systemic reforms the pathways to justice project seeks to break down the barriers that prevent individuals from accessing the legal system and empower them to assert their rights it recognizes that access to justice goes beyond merely providing legal aid it involves addressing underlying social and economic inequalities promoting legal literacy and ensuring the availability of affordable and quality legal services this initiative recognizes that marginalized groups including lowincome individuals racial and ethnic minorities persons with disabilities and women face additional obstacles in accessing justice it acknowledges the intersectionality of these barriers and aims to dismantle them through inclusive and targeted strategies through the pathways to justice project innovative approaches are being developed to bridge the gap between those who need legal assistance and the resources available to them technology plays a pivotal role in these efforts with digital platforms and online resources being utilized to provide legal information facilitate communication between individuals and legal professionals and streamline legal processes furthermore the pathways to justice project emphasizes the importance of collaboration among stakeholders including governments civil society organizations legal professionals and community leaders by fostering partnerships and cooperation the project aims to create a coordinated and holistic approach to expanding access to justice ultimately the pathways to justice project strive to create a society where every individual can exercise their rights seek redress for grievances and participate fully in the legal system asian law public policy review by addressing the systemic barriers and promoting inclusivity this initiative aims to build a more equitable and just world in the following sections we will explore the key pillars of the pathways to justice project examining its various components and highlighting examples of successful interventions through these discussions we hope to shed light on the importance of expanding access to justice and inspire further action towards a more inclusive legal system for all meaning of access to justice it refers to a comprehensive approach aimed at ensuring that justice and legal systems are accessible and equitable for all individuals regardless of their background socioeconomic status or other barriers they may face it recognizes that access to justice is a fundamental human right and seeks to address systemic inequalities and challenges that hinder people from fully participating in the legal process i this concept encompasses various dimensions including legal representation legal aid procedural fairness and removing obstacles that prevent marginalized communities from accessing justice it recognizes that individuals should have equal opportunities to navigate the legal system seek redress for grievances and protect their rights expanding access to justice involves implementing measures to make legal services more affordable userfriendly and understandable to the general public ii this may include providing free or lowcost legal assistance simplifying legal procedures and documentation improving language accessibility and utilizing technology to enhance access furthermore it involves addressing underlying social and structural issues that disproportionately affect marginalized communities such as systemic discrimination poverty and unequal power dynamics iii by acknowledging and rectifying these systemic barriers the goal is to create a more inclusive and fair justice system that serve everyone equally overall access to justice promotes the notion that justice should not be limited to a privileged few but should be accessible to all individuals fostering a society where everyone can exercise their rights seek legal remedies and participate in the legal process on equal footing iv asian law public policy review definition and key factors access to justice refers to the principle and practice of ensuring that individuals regardless of their socioeconomic status have the means and ability to effectively and fairly participate in the legal system to seek redress for their grievances protect their rights and obtain a just resolution to their disputes it encompasses both the physical and financial accessibility of the legal system as well as the availability of legal remedies procedures and mechanisms that are fair impartial and affordable v access to justice includes several key elementsphysical accessibility this refers to the availability of courts legal aid offices legal information centers and other legal institutions in geographically convenient locations it also involves ensuring that these facilities are physically accessible to individuals with disabilities accommodating their needs financial accessibility this aspect addresses the affordability of legal services including legal representation court fees and related expenses vi it recognizes that individuals should not be prevented from seeking justice due to their inability to bear the costs associated with legal proceedings legal information and education access to justice requires that individuals have access to clear understandable and relevant legal information as well as legal education programs that empower them to understand their rights and obligations this helps people make informed decisions navigate the legal system and effectively present their cases vii legal representation adequate access to justice often involves having the right to legal representation particularly in complex or highstakes cases this ensures that individuals have the assistance of trained professionals who can advocate for their interests and provide expert guidance throughout the legal process background it is a concept and initiative aimed at promoting equal access to justice for all individuals regardless of their socioeconomic status background or other barriers they may face it recognizes that many people encounter significant challenges in navigating the legal system which can often lead to inequitable outcomes and a lack of trust in the justice system the background of this initiative stems from the recognition that justice should be accessible to everyone not just those with financial resources or connections many individuals particularly those from marginalized communities face barriers such as limited financial means language barriers lack of legal knowledge or geographic constraints which can impede their ability to seek and obtain justice x the concept of pathways to justice involves developing strategies and implementing reforms to ensure that these barriers are addressed and that individuals have meaningful access to the justice system it recognizes that access to justice is a fundamental right and a cornerstone of a fair and inclusive society the specific pathways to justice can vary depending on the jurisdiction and the specific challenges faced by individuals in that context however some common strategies may include ▪ language and cultural accessibility ensuring language interpretation services are readily available to individuals who are nonnative speakers or who have limited proficiency in the dominant language of the legal system this also includes considering cultural sensitivities and adapting legal processes to be more culturally inclusive xiii ▪ collaboration and interdisciplinary approaches encouraging collaboration among legal professionals social workers mental health professionals and other relevant stakeholders to address legal issues comprehensively and holistically asian law public policy review ▪ addressing systemic injustices recognizing and addressing systemic biases and injustices within the legal system that may disproportionately affect marginalized communities xiv by implementing these pathways to justice the aim is to level the playing field and empower individuals to assert their rights resolve disputes and seek redress when they encounter legal issues ultimately the goal is to create a more equitable and accessible justice system that foster trust fairness and equal opportunity for all objectives the objectives of accessing to justice are to promote and ensure equal access to justice for all individuals regardless of their socioeconomic status race gender or any other characteristic the initiative aims to address the systemic barriers and inequalities that exist within the legal system and provide viable pathways for individuals to seek and obtain justice xv promote equal access to justice the primary objective is to ensure that every individual regardless of their socioeconomic background has equal access to justice this includes eliminating barriers that prevent marginalized communities lowincome individuals and other underserved populations from accessing legal resources representation and the justice system asian law public policy review enhance legal education and awareness the initiative aims to improve legal literacy and awareness among the general public particularly those who may be unfamiliar with their legal rights and the available avenues for seeking justice xvi this objective involves developing educational programs resources and campaigns to empower individuals to navigate the legal system effectively expand legal aid services the initiative seeks to expand the availability and reach of legal aid services which provide free or lowcost legal assistance to individuals who cannot afford private representation this includes increasing funding for legal aid organizations promoting pro bono work by lawyers and leveraging technology to facilitate remote access to legal services xvii streamline court processes another objective is to streamline court processes and procedures to make them more accessible efficient and userfriendly this may involve adopting digital technologies to simplify paperwork improve case management systems and reduce delays in legal proceedings foster collaboration and partnerships the initiative aims to foster collaboration among various stakeholders including government agencies legal professionals nonprofit organizations and community groups xviii by establishing partnerships sharing resources and coordinating efforts the objective is to create a more holistic and comprehensive approach to expanding access to justice address systemic issues the initiative recognizes the need to address systemic issues that contribute to barriers in accessing justice this includes addressing biases and inequalities within the legal system identifying xix and rectifying discriminatory practices and promoting reforms that ensure fairness and impartiality in the administration of justice asian law public policy review barriers to accessing justice accessing justice can be hindered by various barriers that individuals may encounter here are some common barriers to accessing justice financial barriers one of the most significant barriers is the cost associated with legal services lawyers and legal representation can be expensive making it difficult for individuals with limited financial resources to afford adequate legal assistance xxi this financial barrier often leads to a lack of representation or individuals representing themselves which can undermine their ability to navigate the legal system effectively geographical barriers geographic location can create barriers to accessing justice particularly in rural or remote areas limited availability of legal services and court facilities can make it challenging for individuals living in these areas to access legal aid attend court hearings or access legal resources xxii language and cultural barriers language and cultural differences can pose significant obstacles to accessing justice limited proficiency in the language used in legal proceedings can make it difficult for individuals to understand their rights navigate the legal system or effectively communicate with legal professionals xxiii cultural differences may also impact individuals understanding of legal processes and their willingness to engage with the justice system asian law public policy review lack of legal awareness and information many people are unaware of their legal rights and the available pathways to justice limited legal literacy can prevent individuals from recognizing when they have a legal issue seeking appropriate legal assistance or understanding the steps involved in resolving their disputes xxiv this lack of awareness and information can further marginalize certain populations and perpetuate disparities in accessing justice systemic and structural barriers systemic and structural barriers such as discriminatory practices or biases within the justice system can disproportionately affect marginalized communities bias based on factors like race gender socioeconomic status or disability can lead to unequal treatment reduced access to legal resources and barriers to fair and impartial resolution of legal issues xxv physical and mental health barriers individuals facing physical disabilities or mental health challenges may encounter barriers in accessing justice physical limitations can hinder their ability to physically navigate court facilities or attend hearings while mental health issues can affect their capacity to engage effectively with legal processes or seek assistance procedural complexity and delays the complexity of legal procedures rules and paperwork can be overwhelming particularly for individuals without legal training navigating through intricate processes understanding court rules and meeting procedural requirements can be daunting and discouraging xxvi lengthy court delays and backlog of cases can also hinder timely access to justice addressing these barriers requires a multifaceted approach that involves legal reforms increased funding for legal aid services public legal education awareness campaigns language interpretation services and efforts to promote inclusivity and diversity within the justice system it is crucial to strive for a more accessible equitable and userfriendly justice system that ensures justice is available to all individuals regardless of their circumstances xxvii by implementing these strategies and fostering a commitment to access to justice societies can create a more equitable and inclusive legal system where individuals can effectively exercise their rights and seek redress for legal issues asian law public policy review case studies and best practices legal aid reform in australia in 2017 the australian government implemented significant reforms to the legal aid system the changes aimed to reduce the budget deficit by restricting eligibility criteria and cutting funding to certain areas of law researchers and advocacy groups conducted studies to assess asian law public policy review virtual courts in rwanda rwanda has implemented virtual courts to increase access to justice particularly in rural areas where physical court infrastructure is limited the use of video conferencing technology enables defendants witnesses and judges to participate remotely reducing the need for expensive travel and minimizing delays in the legal process this initiative has greatly improved access to justice for individuals who would otherwise face significant barriers in accessing the court system xxxvii legal aid clinics in india in india where a large portion of the population faces socioeconomic challenges legal aid mobile courts in bangladesh bangladesh has implemented mobile courts to address legal issues in remote areas with limited access to traditional courts these courts typically held in buses or other mobile facilities travel to different regions to provide prompt and affordable justice they handle a range of cases including civil criminal and administrative matters and aim to ensure that justice is accessible to all citizens regardless of their geographic location asian law public policy review technologydriven dispute resolution in estonia estonia has developed an innovative digital infrastructure for dispute resolution known as the ecourt system this system allows individuals to resolve legal conflicts through online platforms reducing the need for physical court appearances xl by leveraging technology estonia has simplified and expedited the resolution process making justice more accessible and efficient for its citizens xli community mediation in south africa in south africa community mediation centers have been established to resolve disputes at the grassroots level trained mediators facilitate dialogues between parties encouraging peaceful resolutions and reducing the burden on the formal court system xlii these centers cater to the specific needs and cultural contexts of the communities they serve promoting accessible and culturally sensitive justice mechanisms xliii these case studies offer valuable insights into the challenges surrounding access to justice and the potential solutions and approaches that can help address them by analysing realworld examples policymakers researchers and legal practitioners can gain a better understanding of the barriers to justice and work towards creating more inclusive and effective systems legal analysis access to justice refers to the principle that all individuals should have the ability to seek and obtain a fair and effective resolution to their legal issues it encompasses the idea that everyone regardless of their economic or social status should have equal opportunities to use the legal system to protect their rights receive a fair trial and access legal remedies xliv legal analysis on the other hand involves the systematic examination and interpretation of legal principles statutes regulations and case law to understand their implications and apply them to specific factual situations it is a critical component of the legal profession and involves identifying legal issues researching relevant laws xlv assessing the strengths and weaknesses of arguments and providing reasoned opinions or advice based on the analysis asian law public policy review issn 2581 6551 volume 8 2023 © all rights reserved by the law brigade publishers when it comes to access to justice legal analysis plays a crucial role it helps identify the legal rights and remedies available to individuals assess the viability of their claims and determine the most effective strategies for pursuing their cases legal analysis also enables lawyers and legal professionals to evaluate the fairness and equity of laws and legal processes identify areas where reform may be necessary to improve access to justice and advocate for changes in the legal system to ensure equal treatment for all individuals xlvi moreover legal analysis is not limited to the courtroom it extends to various areas such as legal research policymaking legislative drafting and public interest advocacy through legal analysis individuals and organizations can understand the legal implications of their actions make informed decisions and contribute to the development and improvement of laws and regulations xlvii in summary access to justice and legal analysis are interconnected concepts access to justice ensures that individuals have the opportunity to seek legal remedies while legal analysis helps navigate the complexities of the legal system understand rights and obligations and advocate for fair and equitable outcomes together they promote the rule of law and contribute to a just and inclusive society importance of access to justice access to justice is of paramount importance in any society as it ensures that all individuals regardless of their background or circumstances have the ability to seek and obtain a fair and equitable resolution to their legal problems it encompasses the right of individuals to access the legal system participate in legal proceedings and receive a just and impartial outcome xlviii here are some key reasons why access to justice is crucial trust in the legal system when people have access to justice and perceive the legal system as fair and accessible it fosters trust in the judiciary and the legal profession trust in the legal system is crucial for its effective functioning and ensures that individuals are more likely to seek peaceful means to resolve disputes rather than resorting to vigilantism or private retribution protection of human rights asian law public policy review policy recommendations for access to justice policy recommendations for access to justice can vary depending on the specific jurisdiction and legal system in question however here are some general policy recommendations that can help improve access to justice for individuals legal aid and assistance ▪ increase funding for legal aid programs to ensure that lowincome individuals have access to legal representation and advice ▪ expand eligibility criteria for legal aid to include a broader range of income levels and legal issues ▪ establish community legal clinics and pro bono programs to provide free or lowcost legal services to underserved populations liv simplify legal procedures and language ▪ simplify legal processes and procedures to make them more accessible and understandable for individuals without legal training ▪ use plain language in legal documents court forms and information resources to ensure that they are comprehensible to the general public ▪ provide legal education and information programs to help individuals navigate the legal system and understand their rights and responsibilities lv alternative dispute resolution ▪ promote the use of alternative dispute resolution mechanisms such as mediation and arbitration to provide faster and less expensive resolution of legal disputes ▪ develop and support communitybased dispute resolution programs that are culturally sensitive and tailored to the needs of specific populations ▪ encourage the use of online dispute resolution platforms to facilitate access to justice particularly for individuals in remote areas or with mobility limitations lvi technology and innovation ▪ invest in technology and digital infrastructure to improve the efficiency and accessibility of the justice system such as online case filing efiling and virtual hearings asian law public policy review procedural reforms ▪ review and revise procedural rules and requirements to reduce unnecessary complexity delays and costs associated with legal proceedings ▪ implement case management systems to streamline processes prioritize cases based on urgency and allocate resources effectively ▪ explore the use of specialized courts or tribunals for certain types of cases to improve expertise and efficiency in handling specific legal issues lviii public legal education ▪ increase public awareness of legal rights responsibilities and available legal resources through targeted public education campaigns and initiatives ▪ collaborate with educational institutions community organizations and the media to disseminate legal information and promote legal literacy ▪ foster partnerships between legal professionals and community stakeholders to deliver legal education programs and outreach activities lix data collection and monitoring ▪ establish mechanisms to collect data on barriers to access to justice including demographic information types of legal issues and outcomes of legal proceedings ▪ regularly monitor and evaluate the effectiveness of access to justice initiatives and policies to identify areas for improvement and inform evidencebased decisionmaking lx these policy recommendations aim to address various aspects of access to justice including financial barriers procedural complexities lack of legal information and systemic inequalities implementing these recommendations can help promote a more inclusive and equitable justice system asian law public policy review future directions in the future access to justice is expected to evolve and improve in several ways here are some potential future directions technological advancements technology will play a crucial role in enhancing access to justice online platforms artificial intelligence and automation can streamline processes making legal information services and resources more readily available to individuals lxi this includes online dispute resolution mechanisms virtual courtrooms and chatbot assistance to guide people through legal procedures digital legal services with the increasing availability of digital platforms legal services are likely to become more accessible and affordable online legal service providers such as virtual law firms or legal marketplaces can connect clients with lawyers remotely lxii enabling greater convenience and reducing geographical barriers legal aid reforms governments and organizations will continue to focus on improving access to justice for marginalized and disadvantaged individuals this may involve expanding legal aid programs increasing funding and implementing policy changes to address systemic issues that hinder access to justice alternative dispute resolution alternative methods of resolving disputes such as mediation and arbitration will gain prominence these approaches can offer faster more costeffective and less adversarial ways of resolving conflicts reducing the burden on traditional court systems lxiii simplification of legal processes efforts will be made to simplify legal procedures and language making them more understandable and userfriendly clearer legal documentation and standardized forms can empower individuals to navigate the legal system with greater ease proactive legal education there will be a growing emphasis on proactive legal education and awareness campaigns to empower individuals with knowledge about their rights responsibilities and available legal resources lxiv this includes initiatives aimed at promoting legal literacy in schools community outreach programs and online legal education platforms asian law public policy review collaboration and multidisciplinary approaches the legal profession will increasingly collaborate with professionals from other disciplines such as technology experts social workers psychologists and healthcare providers lxv this interdisciplinary approach can offer holistic solutions and address the underlying issues affecting access to justice global cooperation international collaboration will be crucial to addressing access to justice on a global scale lxvi sharing best practices knowledge and resources between countries can help in developing innovative approaches and policies that ensure access to justice for all conclusion finally we say that access to justice represents a crucial step toward achieving a more just and equitable society by addressing the barriers and inequalities that exist within our justice systems we can create pathways that ensure fairness impartiality and equal access to justice for all individuals regardless of their background or circumstances through this comprehensive approach we can work towards building a justice system that is responsive to the needs of the person it serves that promotes trust and confidence and that upholds the fundamental principles of fairness and equality expanding access to justice requires a multifaceted approach that encompasses legal social and systemic reforms it involves improving legal aid services promoting alternative dispute resolution methods investing in legal education and awareness and removing discriminatory practices that disproportionately affect marginalized communities moreover addressing the root causes of injustice such as poverty discrimination and inequality is essential for creating lasting change by tackling these underlying issues we can prevent individuals from becoming entangled in the justice system in the first place and create a more inclusive and just society for everyone however the task of expanding access to justice is not one that can be accomplished by a single entity or organization alone it requires collaboration and partnership among governments legal professionals civil society organizations and communities together we must work to break down the barriers that prevent individuals from accessing justice and build a system that is truly inclusive and equitable while the journey toward achieving universal access to justice may be challenging it is a necessary endeavour if we are to ensure a fair and just society for all by committing to the principles outlined in pathways to justice expanding access for everyone we can move closer to a world where everyone has equal opportunities to seek and obtain justice and where no one is left behind asian law public policy review endnotes

this paper aims to explore and analyse the pathways to justice with a focus on expanding access for everyone access to justice is a fundamental right that ensures equality fairness and the protection of individual and collective rights within a legal framework however many individuals and marginalized communities face significant barriers when attempting to navigate the justice system leading to a lack of access and resulting in systemic inequalities this paper examines the challenges faced by different groups such as lowincome individuals minorities and persons with disabilities and explores strategies to expand access to justice and promote inclusivity within the legal system it analyses various approaches including legal aid programs technologyenabled solutions communitybased initiatives and policy reforms that have the potential to bridge the justice gap and enhance access for all

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introduction financial literacy and quality of life have been researched in many countries with reference to different consumer contexts the relationship between financial literacy and how it does affect peoples behaviours is a critically import matter in terms of social economic and psychological perspectives empirical studies highlight the need to investigate the financial literacy of people affected by different social physical and psychological unrests based on the depth of its association with human life sri lanka is a country which is driven by acceptable levels of social indexes including education and health compared to regional countries however increasing issues are reported in terms of noncommunicable diseases like cancers the overall impact of such patients and their families has been less examined other than health factor studies which have led to a knowledge gap for social and economic policy to be made for such communities studies are highlighting how such people suffering from illnesses like cancer would make holistic issues to their close communities including family members due to economic and social pressures the quality of life of patients is an important matter other than the health treatments there are challenges faced by such cancer patients due to expensive treatment costs mental pressures and social issues which lead to many social issues the issues faced by cancer patients in sri lanka should be closely examined other than healthrelated matters to find avenues for improving the quality of life patients and their families become clueless about other regular matters related to life when a family member gets affected by such diseases the lack of knowledge of financial literacy may lead to many issues by intensifying the issues faced by cancer patients which creates unrest for families the social and welfare aspects of cancer patients need to be carefully managed to maintain the psychological wellbeing of them and their family members the empirical gaps have been found mentioning the need of investigating how financial literacy and quality of life are interconnected concerning people affected by different personal social and community issues the factors related to quality of life have been investigated by previous authors with different scales and measures it finds special attention made to how financial literacy affects on quality of life amongst cancer patients depending on the level of mental pressures economic pressures and social pressures bared by patients and their family members in todays world financial literacy is considered a critical life skill however many people all around the world lack opportunities for acquiring this essential knowledge the national foundation for educational research defines financial literacy as the ability to make effective decisions regarding the use and management of money financial literacy is a broad concept about a wide range of topics from understanding novel and sophisticated financial products to managing basic everyday economic decisions a growing body of research has demonstrated that financial literacy is linked to life satisfaction physical and psychological wellbeing as well as quality of life in contemporary health literature and oncology research wellbeing is defined as quality of life among cancer patients qol is a selfassessed subjective wellbeing based on the individuals perception of their ability to cope with the personal social and financial burden of their disease thus given the increasing global cancer incidence it seems critical to identify how financial literacy could potentially improve the patients qol moreover direct and indirect cancer treatment expenses would be a type of financial burden for the patients and their families therefore it expects that financial literacy allows individuals to allocate their income to appropriate financial tools that can be utilized in times of need problem statement most cancer survivors and their caregivers report that cancer care providers have failed to address patients psychological needs and their quality of life has tremendously diminished upon receiving a cancer diagnosis patients and their families experience a great amount of stress and worry permanent health impairment inability to function in social roles or perform daily activities as well as high cost of medical treatment inflict emotional distress often resulting in mental health problems which can lead to social issues and even job loss therefore it is important to minimize the negative outcomes caused by cancers including quality of liferelated issues moreover cancer treatment incurs significant direct and indirect expenses for the patients direct medical costs are expenses related to health services such as doctors visits medicines as well as inpatient and outpatient surveillance indirect costs on the other hand include expenses related to travel to health centres as well as loss of longterm employment both of which would be a type of financial burden for the patients and their families in addition social support is another main variable attributed to the behaviour of patience social support could generate perceived satisfaction for the quality of life when a patient receives social care with emotional support there is a set of managerial implications and research requirements mentioning the role of social support in making the quality of liferelated experience for patience financial literacy allows individuals to allocate their income to appropriate financial tools that can be utilized in times of need although there is a need for research on factors affecting cancer patients quality of life to the best of the authors knowledge the role of financial literacy and financial burden in this context has rarely been studied it is said that cancer patients need a holistic treatment atmosphere including drugs clinical treatments social support and financial support when they feel unformattable with their lifestyle accordingly studies mentioned that the quality of life of patients including cancer patients could not be established based on treatments alone but they should be carried with financial assistance over financial toxicity and social support over mental pressure they experience the relationships between financial distress and quality of life and the interlink between social support and quality of life had been found in previous studies as very valuable investigations within the cancer patients context however it still claims further investigation with reference to different country contexts and lifestyle situations sri lanka is a claimed research context in examining how cancer patients quality of life should be improved via social and psychological aspects whilst the role of family members is also a considered matter but as per available empirical evidence fewer or no comprehensive studies are being carried out to investigate how financial literacy and the quality of life of cancer patients are interrelated within sri lankan context this research addresses foresaid empirical issues and countryspecific issues implications of this research could contribute to policymakers and even business firms to predict and respond with strategies to penetrate the needs and wants of cancer patients in line with their financial literacy and uplifting quality of life findings may also help health advisory services to direct their social and family consultancy services to help the quality of life of the patients and their relatives in the scope of financial wellbeing alongside this this study also addresses the issues and knowledge gaps found in financial literacy amongst cancer patients in sri lanka whilst examining how it affects the quality of life the author believes this study is one of the inputs for the policymakers and health sector professionals to extend their services on the quality of life of patients overall in addition respective officials could approach extended services to uplift the quality of life of patients and their families by educating financial literacy as one of the important matters to mitigate the pressures affecting their lives literature review and hypotheses financial distress social support and quality of life the quality of life is only a reflection of the general state of affairs in every social community as well as on the planet as a whole as far as nature and physicality are concerned it is normal for someone living in the modern world to have a much busier schedule than someone from a tribal society or any other era in our evolutionary history however it is not normal for them to be more stressed out and overworked than ever before with no time for living their lives as required more people are unsatisfied and stressed when they miss the quality of life for many reasons including health conditions not only do people expect considerably more from life in general but specific expectations are there to satisfy the quality of life financial distress of people including the situations faced by patients feel uncomfortable conditions including physical and mental health conditions it refers to the fact that financial wellbeing may impact the quality of life due to direct and indirect influences on the other hand positive financial habits like good savings and supportive arms could create a good quality of life for people facing health issues some studies mentioned that financial distress may create negative quality of life resulting in emotional and physical health issues this type of investigation is deemed to be monitored with situational variances the degree of the seriousness of the health issues and the social perception of the health issues may differently influence patience to feel distressed for instance patience becomes uncomfortable when they feel they are not secure enough with social protection and financial strength some studies argue that the relationship between financial distress and the quality of life of people pr consumers should be studied in terms of the nature of the diseases and their perception of how general society reacts to them the financial distress faced by cancer patients has been viewed in different terms like financial toxicity and financial hardships in general it is a known fact that cancer patients have to shoulder the high price challenges of cancer drugs treatment methods and even clinical services that usually create financial distress or are similarly known as financial toxicity as per some studies the said financial distress has been attributed to related aspects like gender the stage of cancer availability of insurance facilities accessibility to the treatment centres and threat of loss of income therefore the financial distress of cancer patients seems a more connected notion and studies are further required to investigate how it affects the quality of life in different societies and countries the research context of sri lanka is also a significant matter to be investigated since there are centers to provide services to cancer patients including supportive services to mitigate the financial distress of the patience and the guardians too previous studies mentioned that people become motivated or managed their liferelated issues particularly when they feel no good due to illness provided they are being facilitated with remedies for financial distress the rigour of the financial distress is attributed to a snowballing effect on quality of life once the cancer patient or his or her family members face financial issues it has to limit their budget for activities that directly impact on qualityoflife people may reduce their leisure activities and the amount of money spent on food clothing and even do longer hours of working this type of lifestyle change will hurt the overall quality of life in the end thus many studies have proved the link between financial distress and quality of life with different explanations whilst proposing further studies to revalidate the interrelationship between financial distress and quality of life accordingly having good financial conditions could impact to make positive health conditions for patience to spend a quality of life accordingly this study hypothesized the direct relationship between financial distress and quality of lifebased on the empirical evidence mentioned by recently held studies h1 financial distress has a significant impact on the quality of life of cancer patients in addition current society is in a period where access to affordable highquality healthcare has decreased large financial resources are needed for health care services to treat patients therefore it is crucial to have the financial expertise and knowledge that can make it possible to raise enough money to cover these basic requirements the link between proper financial knowledge and behaviour shows whether someone is aware of the expense of maintaining his health and whether they are financially responsible many researchers in the social sciences typically hold that residents socioeconomic position and health are closely associated the socioeconomic status element of income has a strong positive impact on health and highincome individuals typically have better health because they have access to more resources the impact of variables like education and racial discrimination on health has been explored by academics additionally social support given for patience has been viewed on immediate and distance factors as per some studies patients need to have family support and closet chats to discuss their issues and problems related to their quality io life and diseaserelated matters thus it is important to notice that the influence that could be made by the social parties including family members is a pivotal matter to provide a required environment to care the cancer patients as per the study carried out by colloca colloca social support for a cancer patient could be arranged via counselling the spouse family members and immediate friends of the victimized person such a social role could provide good mental relief for the cancer patient to feel good and make a base for a quality of life therefore it is important to have formal programs organized through community centres or clinical centres to educate the social role of the patients family members and friends in addition to the issues of physical conditions and financial distress studies have investigated and emphasized the critical importance of social factors or social needs for cancer patients as an important inclusion for them to feel good overall the social support given to cancer patients could enhance their mental condition to retain their love and social contact the role of spouses and family members is very decisive for cancer patients to manage their health condition besides the regular treatments accordingly it is said that social need satisfaction has a direct link with mental relief for patience and eventually the quality of life and most countries and clinical centres had initiated programs including sri lanka to execute social services and educating programs to help family members to understand their role to assist to cancer patients to experience relief for a better life this reflects that cancer patients need holistic caring other than the regular drugs and treatments to experience recovery with the support of social needs other than financial support some studies directly addressed how residents financial literacy affects their health based on this this study linked financial literacy with personal health status to investigate if financial literacy affects personal health status social support has been researched as another main force to determine the quality of life in healthcare sector studies financial literacy has been viewed in different ways by authors depending on the context being considered in general sri lanka reports a controversial level of financial literacy compared to its higher level of general literacy alongside cancer patients are reported as having less financial literacy or no proper focus on the financial scenario of their families to keep their living standards at an acceptable level some studies deeply examined this matter since cancer patients suffer from diseases and they neglect the essential components of family members and their quality of life including her quality of life the research requirements regarding different countries and patient categories have been claimed by previous authors addressing knowledge gaps prevail this study also considered the role of social support as one of the investigating areas to contribute new knowledge for practicerelated requirements accordingly it made the undermentioned hypothesis on social support and quality of lifebased on the empirical evidence h2 social support has a significant impact on the quality of life of cancer patients methodology this study followed a deductive research approach as per the nature of the problem statement and key investigation areas hypotheses were developed based on the empirical evidence followed by a literature review accompanied by contextrelated rationales the sample was selected based on the cancer clinic centres available in sri lanka followed by the prior approval of the necessary parties data collection was assisted by a questionnaire and all the enumerators were educated about the technicality of the question contents whilst approaching responsible employees of the hospital management service to reach the respondents it distributed 285 questionnaires but the final analysis was limited to 187 as it received only 206 questionnaires out of which 19 questionnaires were removed due to incompletion of information it followed the normality test for the data set by using the spss23 version and the reliability test was carried out with the cronbach alpha test this study followed the cbsem model to test the hypotheses after satisfying the initial assumption tests and model fit indices alongside structural equation modeling technique was used since it meets the minimum sample size of 200 to support model fit covariancebased sem was the opted method since it satisfies the quantitative assessment considering convergent and discriminant validity measures of the study financial literacy has been viewed in terms of how the respondents feel financial distress thus the main independent variable of financial literacy was operationalized on financial distress to measure perceived financial distress a comprehensive score for financial toxicity measure developed by de souza et al was used the 11item scale consists of one financial item two resources items and eight affect items each item was measured on a fivepoint likert scale ranging from 1 to 5 quality of life was measured by using seven items scale proposed by cella et al to measure physical wellbeing social support was measured based on the eleven items scale mentioned by gündüz yılmaz karabulutlu and akça talaz çınar data analysis profile of the sample the survey was limited to 285 respondents who obtained the treatment from government clinic centres the questionnaire was executed subject to ethical conditions and institutional norms of the treatment centres the data collection work was assisted by 5 fieldwork enumerators including one health sector administrative officer for the necessary coordination and official permissions finally 187 questionnaires were considered for the final analysis due to the incompletion of the information and rejections of respondents to answer questions related to quality of life accordingly it has presented the summary of the sample profile in the undermentioned table it has inquired about the basic information about the health level of cancer patients subject to ethical limitations the summary of the information is given in the undermentioned table it has done the reliability analysis based on the output of the spss21 statistical package all the variables found an acceptable level of reliability with the respective items used to measure the observed variables the following table presents the output of the reliability analysis it has done the normality test before running the final test for testing hypotheses accordingly kurtosis and skewness tests were done by using the spss21 all the variables were found within the acceptable thresholds of both kurtosis and skewness a data set is named normal if the skewness or kurtosis of the data is ranged between 1 and 1 accordingly financial distress reported skewness and kurtosis values as 0598 and 0412 respectively where the shapirowilk test value was 0714 social support measured by using eleven items reported the skewness and kurtosis as 0317 and 0398 respectively whilst its shapirowilk test value was 0832 the skewness and kurtosis values of quality of life were 0617 and 0562 and the shapirowilk test value was 0472 indicating an acceptable zone for normality test of hypotheses and discussions the hypotheses testing process was executed after confirming the sample adequacy accordingly it reported kaisermeyerolkin as 0839 whilst the pvalue was found to be less than 005 justifying the required scope to do a factor analysis it executed an exploratory factor analysis and all the items had factor loadings greater than 05 confirming its convergent validity in addition average variance extraction and construct reliability values justified the convergent validity of the constructs since the ave values were higher than 05 and cr values were found greater than 07 accordingly it was able to execute the confirmatory factor analysis as validity measurements were within the acceptable zone it executed the cfa to confirm model fit before testing the two direct paths as mentioned in the hypotheses the measurement model indicated the normed chisquire as 257 whilst the root mean square error of approximation was found to be 0053 in addition it reported the incremental fit indices and goodness of fit index as 0807 and 0912 respectively for the improved model the improved model was reported with a pvalue below 005 accordingly the amossem outputs were used to test the hypotheses and report the outcomes the output statistics produced by the regression weights made by amossem were used to test the hypotheses this study hypothesized only two hypotheses as direct path hypotheses the summarized statistical estimates have been stated in table 3 alongside the findings reported it could verify that the financial distress faced by cancer patients had made a significant impact on their quality of life thus it is wise to pay serious attention to maintaining the needful environment and emotional rest for cancer patients in terms of financial issues to make them comfortable with the quality of life the financial literacy of the patient and his guardians could provide some sort of relief to make the patient feel good about the quality of life in addition social support was found as another important force to make the quality of life a better one for cancer patients the results revealed that social support that remains around the patient could facilitate his or their experience of a quality of life therefore the guardians caretakers and health sector officials need to guide the patient to associate the social support given by immediate parties around him or her life such social interactions could provide mental relief for cancer patients as proved in this study as well additionally the notion of caring for cancer patients with indirect mechanisms like financial support to mitigate the distress and social support to make them experience relief had been proved with the tested hypotheses this provides a managerial note for cancer treatment centres to come up with social programs to educate family members and friends to identify their roles to support the patients the overall outcome of the treatment methods will be intensified if financial distress and social supportrelated measures are arranged for patients thus caring for cancer patients needs a strategy combined with different stakeholders other than the medicare staff and patients for instance clinical centres attached to hospitals could provide lecture facilities to patients guardians and be supposed to recognize their roles to make the patient mentally fit to experience a better recovery the behaviour communication quality and relationship role of the social groups connected with the cancer patients could provide a valuable contribution to make sure quality of life for cancer patients the notion of financial distress or financial toxicity has also been proved to have a direct link with the quality of life as the hypothesis tested in this study accordingly the future implications have to be arranged to make the life of cancer patients a quality one with some remedial actions it is practically known factor that treatment costs including the prices of drugs are beyond the controllability of patients and their facilities thus it can educate the family members of the cancer patients on the financial sources available for economically vulnerable cancer patients so that financial distress can be mitigated in addition personal financial literacy could be improved with some formal educational activities for family members to avoid the mental distress caused by financial issues so that they can pay proper attention to cancer patients to play their social role conclusion and further research areas this research attempted to examine how the quality of life of cancer patients is influenced by financial distress as reflected within the scope of financial literacy additionally the role of social support was researched to evaluate how it does impact to maintain the quality of life of cancer patients addressing knowledge gaps and practice issues found within the context of sri lanka previous studies have proven the relationships between financial distress social support and some other social and psychological forces that affect the quality of life of different people suffering from diseases however it found a knowledge gap in sri lanka to examine the behaviour of cancer patients in social and psychological aspects accordingly this study examined the hypotheses on how financial distress and social support influence the quality of life of cancer patients the results proved a significant impact of both financial distress and social support on the quality of life of cancer patients thus it could propose to have policies and managerial implications to initiate formal education for guardians and patients to manage the financial aspects and social support to make the quality of life apart from the medical treatments taken for cure it is even good that health sector professionals and supportive staff initiate more programs to educate cancer patients on how to manage the social and personal factors as a part of their recovery process for a quality of life apart from the said this finding provides a direction to business perspective too the consumer behaviour of cancer patients and their immediate families could be considered a significant context for businesses since it counts for a significant amount in numbers countries could evaluate the size population of the cancer patients and their immediate family members to come up with marketing approaches to improve their quality of life supported by consumer experience for instance welfare products supported by relevant marketing mix elements could be implemented to motivate cancer patients and their families to have a better consumer life in addition it is recommended to extend further studies targeting some communities that have been seriously affected by diseases like kidney disabilities and diabetics so that some significant outcomes could be found to contribute inputs for policymaking perspectives and social welfare decisions alongside this further studies could be extended to examine how patients suffering from noncommunicable diseases face challenges in their regular consumption behaviour due to financial distress and lack of social support this could provide insights to have decisional knowledge for business communities to rethink on marketing model attributed to welfare inclusions to penetrate such affected communities to ensure better consumption life conflict of interest the author declared no competing interests the work explained in this research paper is original work and hasnt been presented nor did the work was accepted elsewhere

purpose the quality of life has been widely examined by social science researchers with reference to different lifestylerelated issues of people across the world it has made an eyeopening contribution by many authors educating the importance of quality of life for patients suffering from different diseases including cancers as one of the critical scopes alongside this this study aimed to examine how financial literacy and social support could impact the quality of life of cancer patients in sri lanka with a rationale for its social and community impacts designmethodologyapproach the variable of financial distress was considered the main independent variable within the scope of financial literacy to examine its influence on the quality of life of cancer patients additionally this study investigated how social support influences the quality of life of cancer patients supported by empirical evidence it followed a quantitative research method in line with the required inclusions for an acceptable methodology respondents were selected for the survey with a questionnaire followed by a convenient sampling method the final analysis was limited to 187 respondents due to the incompletion of the questionnaires filled in by the sample units the hypotheses were tested by using the cbsem model supported by amos23 software and the descriptive analysis was executed by using the spss21 packagethe main findings of the study were discussed in the article in line with the two hypotheses tested in brief results proved that financial distress fd has a significant impact on the quality of life qol of cancer patients additionally it has tested the hypotheses related to how social support ss impacts on quality of life qol of cancer patients the results verified that social support experienced by cancer patients significantly influences the quality of life of cancer patientsthe cancer patients in sri lanka should be supported by a holistic approach besides the treatments alongside this this paper contributes new knowledge of examining how the quality of life of cancer patients has been influenced by financial distress and social support in line with the empirical and practice gaps noticed in addition this study contributes to the main scopes mentioned by sustainable development goals sdg with reference to the local context as it provides new knowledge for social and communityrelated issuesthe findings of the study could be used by the health sector authorities and social welfare service organizations to come up with policies and programs to make life better for cancer patients in terms of financial and social aspects

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according to the department for education in the uk 69540 children were in the care of local authorities on 31st march 2015 with 75 of these children living with foster carers with numbers of children being taken into care increasing and social care being faced with a growing shortage of foster carers the need to recruit and retain foster carers is essential research shows that foster carers report high levels of stress related to their role the typical stressors faced by foster carers include placement disruptions allegations difficulties with social services and contact with birth families high levels of strain are associated with a foster carers overall job satisfaction and intention to quit in addition a recent review highlights the impact of carerwellbeing on overall placement stability limited training feeling unsupported and low selfefficacy also appear to contribute to a foster carers likelihood of leaving the profession whilst placement stability is a priority for social care research exploring the overall wellbeing of foster carers remains extremely limited the reasons children are placed in the care of a local authority are often related to potentially traumatising experiences of abuse and neglect given the adverse circumstances usually associated with a child being taken into care looked after children often present with high rates of behavioural difficulties and emotional distress it is well established that looked after children in the care of a local authority experience higher rates of psychiatric disorders and increased rates of behavioural difficulties than children living with their biological parents with this in mind the impact of caring for children presenting with a history of complex trauma as well as behavioural and emotional difficulties understandably puts a strain on the foster carers with whom they are placed psychological impact of working with traumatised individuals a number of terms have been used to describe the psychological impact of working with traumatised individuals including burnout secondary trauma and compassion fatigue • compassion fatigue is considered to be an overarching term used to describe the emotional impact of working with traumatised individuals including secondary trauma and burnout • secondary trauma is characterised by tension and preoccupation with the suffering of others as a result of working in trauma related contexts secondary trauma symptoms are similar to symptoms of posttraumatic stress disorder and include heightened states of arousal intrusive thoughts or images and avoidance of thoughts or reminders of the persons traumatic experiences • burnout is the response that occurs as a result of prolonged exposure to demanding interpersonal situations and is characterised by emotional and physical exhaustion depersonalisation and reduced personal accomplishment the symptoms of burnout tend to develop gradually over time but if ignored can progressively worsen • compassion satisfaction is described as the positive emotional response that results from helping others including positive feelings about colleagues contributions to the work setting and doing something good for society compassion satisfaction has been found to mitigate the effects of burnout and secondary trauma the presence of compassion fatigue has been widely reported in various professionals working with traumatised individuals including nurses trauma counsellors domestic violence staff and social workers of adult trauma victims there have been fewer studies investigating the impact of working with traumatised children however there are indications of similar experiences of compassion fatigue in child protection workers forensic interviewers of abused children and paediatric healthcare providers the emotional impact of working with children may occur directly as a result of the challenges of managing behavioural difficulties or indirectly through hearing about a childs traumatic history avoidance and trauma avoidance of trauma related thoughts and memories is central to the definition of compassion fatigue and specifically secondary trauma more broadly avoidant coping has been found to be common in a range of psychological problems including depression and anxiety disorders as such this exploratory study aims to investigate the relationship of avoidant coping with compassion fatigue two cognitive processes that have been described as highly related to avoidance are psychological inflexibility and thought suppression psychological flexibility is described as the ability to fully contact the present moment and the thoughts and feelings it contains without needless defence thought suppression is the conscious attempt to stop thinking about a particular thought research indicates a paradoxical effect of thought suppression and avoidance of unwanted internal experiences with continued avoidance over time actually causing maintenance or increased frequency of the unwanted experiences the present study this is a proof of concept study that aims to examine whether the model of compassion fatigue described in other professionals applies to this population the study draws similarities from previous unpublished work by mclain and a recent study by ottaway and selwyn who investigated compassion fatigue in foster carers this study expands on previous work by also considering the potential relationship with job retention and satisfaction as well as underlying avoidant mechanisms the study examined the association between secondary trauma burnout and compassion satisfaction on intent to continue fostering and overall job satisfaction two outcomes that will have significant practical implications finally the study explored the association of compassion fatigue with two cognitive processes psychological inflexibility and thought suppression which are known to be related to symptoms of avoidance in trauma method measures professional quality of life questionnaire the proqol is a 30 item 6point likert scale based on experiences in the last 30 days measuring three components compassion satisfaction burnout and compassion fatigue with each score measuring distinct theoretical concepts this measure has good psychometric properties from a range of populations including social work and the proqol was scored using the method outlined in the proqol manual which includes cutoffs for high and low scores based on a databank of 1289 cases created from multiple studies across various helping professions for this study cronbachs alpha indicates good internal reliability for all subtests secondary trauma burnout and compassion satisfaction secondary trauma stress scale the stss is a 17item5point likert scale designed to assess the frequency of intrusion avoidance and arousal symptoms over the past 7 days a score of 38 or higher indicates secondary trauma the stss has demonstrated good validity and reliability in studies of social workers in relation to this study the total stss score showed good internal reliability as did the subtests of intrusions avoidance and arousal intent to continue and job satisfaction were measured using two items from a previous study investigating foster carer satisfaction and intent to continue the first item all in all how satisfied are you as a foster parent consisted of a fourpoint scale to create binary categories not at all satisfied and somewhat dissatisfied were combined and somewhat satisfied and very satisfied to create binary categories of low and high satisfaction the second item how likely is it that a year from now you will still be working as a foster carer consisted of a threelevel scale of not at all likely somewhat likely or very likely the latter two scores were combined to create a high intent to continue score acceptance and action questionnaire the aaqii consists of 7 items on a 7point likert scale the scale reflects the single domain of psychological inflexibility with higher scores indicating greater psychological inflexibility the psychometric properties of this measure are well documented in nonclinical samples in this study internal reliability for this scale was high the white bear suppression inventory the wbsi is a 15 item measure on a 5point likert scale measuring a persons tendency to supress thoughts this measure has been found to have good reliability and validity and the internal consistency in this study was high procedure foster carers were contacted via local authorities in and around london as well as the voluntary sector organisation tact the uks largest fostering and adoption charity following consent from gatekeepers foster carers were sent an email invitation to participate in the study containing the information sheet and a link to the online survey consent was implied by participants completing the survey once the survey had been completed participants were given an opportunity to contact the researcher via email to claim a £5 voucher participants were able to remain anonymous and not claim the voucher should they wish both the information sheet and the exit page of the survey contained information for accessing further support for participants who experienced any anxiety or distress as a result of completing the survey the research was approved by kings college london research ethics committee and consent forms and information sheets were available via the online survey data collection was conducted between and october 2015 to january 2016 data analysis plan the data from the survey was exported from the bristol online survey into ibm spss statistics 22 where it was then coded and analysed due to data not being normally distributed the bootstrap function was used to generate more accurate standard errors confidence intervals and pvalues the bootstrap function on independent sample ttests do not use the tdistribution and degrees of freedom to derive the pvalue and confidence intervals and so these are not provided effect sizes for ttests were defined as weak moderate or large as recommended by for bivariate analyses correlations were defined as weak moderate or strong based on recommendations by results descriptive statistics the majority of participants were females over 40 years old married and had their own children 435 of the sample were white british and 496 had obtained higher education or professional qualifications the majority of participants reported they were very likely to continue fostering and either somewhat or very satisfied in their jobs table 1 here overall 252 of participants reported high levels of secondary trauma and 305 reported high levels of burnout 183 of participants rated themselves as high for compassion satisfaction table 2 here the mean scores and standard deviations for the stss can be found in table 3 the stss provides a specific clinical cut of off 38 and this study found that 198 of participants were above the clinical cut off for secondary trauma table 3 here in line with the hypothesis there was evidence supporting the presence of secondary trauma and burnout in foster carers further analysis indicated significant correlations between the two measures of secondary trauma furthermore and in line with previous findings compassion satisfaction was negatively associated with secondary trauma and burnout scales table 4 here intent to continue fostering was significantly associated with secondary trauma burnout and compassion satisfaction participants with low intent to continue fostering had significantly higher secondary trauma and burnout scores and significant lower compassion fatigue scores than those with high intent to continue fostering figure 1 here low job satisfaction was significantly associated with secondary trauma burnout and compassion satisfaction participants with low job satisfaction had significantly higher secondary trauma and burnout scores and significantly lower compassion satisfaction scores figure 2 here results indicate that psychological inflexibility was significantly and positively correlated to secondary trauma and burnout thought suppression as measured by the wbsi was also positively associated with secondary trauma as well as burnout as predicted higher levels of psychological inflexibility and increased thought suppression are related to higher secondary trauma and burnout scores table 5 here discussion this study investigated the experiences of compassion fatigue in foster carers working in the uk a sample of 131 foster carers completed an online survey to measure compassion fatigue and several related variables the primary aim of the study was to establish whether the concept of compassion fatigue the overarching term to describe the effects of secondary trauma and burnout occurs within this population this study also examined the impact of compassion fatigue on risk factors related to intent to continue fostering and job satisfaction this study also examined the associations between compassion fatigue and avoidant cognitive styles of psychological inflexibility and thought suppression results indicate that 198 of participants were above the clinical cut off for secondary trauma based on the stss and 252 presented as high risk for secondary trauma and 305 for burnout on the proqol whilst stss scores appear somewhat lower than previous studies on nurses the results remain concerning additionally results from the proqol appear to be consistent with previous work with foster carers as well as other professionals working with trauma victims compassion satisfaction was found to be negatively associated with compassion fatigue in line with stamms model supporting the idea that potential for mitigating effects of compassion satisfaction on compassion fatigue whilst similarities can be drawn from studies examining other caring professions it should be noted here that fostering vulnerable children is unique and complex work unlike any other profession and requires incredible emotional commitment as such all references to fostering as a job does not intend to simplify this important and at times complicated role with this in mind this study focuses primarily on compassion fatigue but acknowledges there are range of stressors related to this role that have not been measured in this study which may also impact a carers job satisfaction and intent to continue fostering local authorities are currently facing a significant challenge in recruiting and retaining sufficient numbers of foster carers to take on the growing numbers of looked after children in the uk the high rates of mental health difficulties and behavioural challenges in looked after children are well documented and these are known to contribute to the success of a placement however the experience of the foster carer themselves is under researched and this study aimed to explore the relationship between compassion fatigue with job satisfaction and foster carers intent to continue fostering foster carers with lower job satisfaction and intent to continue had significantly higher compassion fatigue scores and this could be a target for intervention as discussed below additionally compassion satisfaction scores were higher for foster carers with higher intent to continue and job satisfaction the report of physical harm at 48 appears high and may well contribute to the level of secondary trauma in this sample however the data was collected as a single item as part of the demographic data and as such we would not claim that it is necessarily a precise representation bivariate analyses found strong correlations between compassion fatigue and psychological inflexibility and thought suppression given the paradoxical effect of avoidant cognitive styles foster carers with higher psychological inflexibility and a tendency to suppress thoughts may be at increased risk for compassion fatigue similarly the negative emotional impact of their work may be exacerbated by a predisposition to engage in avoidant styles ie be bidirectional this is an initial study to establish proof of concept and the relation to some key variables as such the sample is relatively small and diverse in terms of the type of foster placement and recruitment centring in and around one major urban region all of which may impact the representativeness one potential limitation is that the content of the survey may have influenced the type of respondent and affected the return rate one possibility is that those experiencing higher strain and possibly at greater risk of compassion fatigue did not feel able to take the time to complete the survey and the current results underestimate the overall levels of compassion fatigue amongst foster carers on the other hand the survey content may have appealed to those experiencing high levels of strain as a means of reflecting experiences qualitative studies may be more able to investigate the potential influences driving participation and responses as a cross sectional study we are unable to describe the direction of effects further research should be conducted to examine the direct effect compassion fatigue may have on intention to leave additionally the outcomes for job retention and satisfaction were measured as binaries derived from ordinal scales and although this has been done in other studies the relationships between satisfaction and retention are likely to be more nuanced than captured in these binary constructs future studies would benefit from more in depth investigation of these constructs especially if there was an aim to predict risk of leaving the profession based on current satisfaction conducting a longitudinal study with repeated measures of compassion fatigue may be particularly valuable in assessing the trajectory of foster carers job retention in relation to their compassion fatigue levels in terms of the risk factors investigated in this study the relationship between compassion fatigue and other variables may well be bidirectional clinical implications the current study provides important evidence of the presence of compassion fatigue in foster carers which is relevant to those managing and supporting the foster carers in their work the association between compassion fatigue and job satisfaction and intent to continue provides further support for increased awareness and support for foster carers as symptoms may have negatively implications to placement stability and overall retention formal training on compassion fatigue and related risk factors as well as encouraging services to screen for symptoms may be beneficial this study has shown the proqol and stss are two reliable measures that could be used for screening symptoms of compassion fatigue in addition the associations between avoidant cognitive styles and compassion fatigue have implications on further interventions that aim to reduce thought suppression and increase psychological flexibility as a way to target possible mechanisms underlying compassion fatigue acceptance and commitment therapy is a psychological therapy that promotes a nonjudgmental willingness to experience aversive events whilst simultaneously moving toward valued life goals and an intervention incorporating an act framework could be useful for foster carers interventions incorporating mindfulness may also be worth consideration although further research is required to explore their efficacy in relation to compassion fatigue conclusions this study is the first to describe rates of compassion fatigue in foster carers with approximately one quarter of participants reporting high levels of secondary trauma and burnout this study also replicates previous findings of the association between compassion satisfaction and compassion fatigue higher levels of compassion fatigue were also associated with lower job satisfaction and lower intent to continue fostering in order to promote placement

background with the number of children being placed in the care of local authorities increasing the need to recruit and retain foster carers is essential compassion fatigue is recognised as a negative effect for professionals working with adults and children who have experienced trauma this study aims to confirm the proof of concept within foster carers and to explore the potential risks associated with intent to continue fostering overall job satisfaction and psychological factors avoidant coping that could be targets for interventions methods 131 foster carers completed an online survey including selfreport measures of compassion fatigue and associated risk factors results results confirm the existence of compassion fatigue amongst foster carers with rates in line with previous studies on other professionals working with children high compassion fatigue was associated with lower intent to continue fostering and lower job satisfaction avoidant cognitive styles of psychological inflexibility and thought suppression were associated with compassion fatigue conclusions the confirmation of compassion fatigue amongst foster carers and the potential risks to job retention are important findings for social care the associations with avoidant cognitive styles have clinical implications for potential interventions recommendations for further research and the limitations of this study are also discussed

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background the effectiveness of intermittent preventive treatment of malaria among pregnant women with sulfadoxinepyrimethamine has been established 1 2 3 4 5 6 since 2012 the who recommended that sp should be given at each scheduled anc visit except during the first trimester subsequently sp can be given every month until the time of delivery with doses given at least one month apart this is to ensure that a high proportion of women receive at least three doses of sp during pregnancy 78 consequently most malaria endemic subsaharan african countries have adopted the world health organizations recommendation of iptpsp as one of the key interventions 1 9 10 11 12 13 14 15 16 17 several studies have been carried out over the years to evaluate implementation success of iptpsp in the sub region 1 9 10 1315 18 19 some of the studies reported that failure to inform women of additional doses of iptpsp and to offer them additional doses on subsequent anc visits contributed to low uptake 1920 hill dellicours 19 study has contributed to understanding health worker interaction with anc clients in the process of offering iptpsp service through reported experiences thus this current study leverages on their study to report on observed interactions between health care providers and women in the anc during the provision of iptpsp also studies have reported that possible causes of low uptake could be poor health provider supervision and lack of enforcement of the direct observation therapy in the administration of iptpsp 918 other challenges that have been noted are stockouts of sp confusion over number of doses that should be provided and poor dissemination of focused anc guidelines 101321 additionally late booking for anc poor staff attitudes and motivation and iptpsp intervention not systematically being enforced like other interventions have been reported 101321 ghana instituted a nationwide feefree maternal healthcare policy intervention in 2004 22 23 24 and subsequently integrated the whos iptpsp intervention 17 25 26 27 ghana later revised the policy by extending the minimum number of doses to 5 and maximum 7 doses in 2014 28 the country recorded 97 of women attending anc in 2014 29 and 98 in 2017 30 also the number of women in ghana who reported that they attended anc at least four times increased from 78 in 2008 to 87 in 2014 2931 and to 98 in 2017 30 this has made the integrated antenatal care service delivery an ideal platform for the implementation of iptpsp in ghana so it is expected that anc attendants should be able to obtain the minimum 5 doses as some of the factors that have been reported to determine adherence to iptpsp uptake are the number of anc visits and knowledge of malaria 13 32 33 34 yet the national malaria control programme 22 reported that in 2017 683 of anc registrants received the first dose of sp compared to 640 in 2016 and 578 took the second would be provided upon reasonable request from the ethics committee contact information for ethics committee is as follows mr fidelis anumu university of health and allied sciences research ethics committee administrator email edugh dose compared to 512 in 2016 iptp3 uptake was 430 in 2017 compared to 367 in 2016 in 2017 221 received iptp4 and 89 received iptp5 22 these reports raise concerns that despite the policy change and progress made in implementation the gap between high anc attendance and iptpsp uptake remains significant 17 additionally ghana still experiences malaria and anemia in pregnancy low birth weight among others 35 36 37 these developments are worrying as they suggest that the investment in policy and resources to attain the minimum of 5 doses or more for all pregnant women are only achieving marginal gains over the years the questions are how effective is the anc in delivering iptpsp how are sociocultural factors influencing iptpsp uptake and how can the anc and communities be supported to ensure that the countrys investment in iptpsp yields the desired results at a much faster rate the causes of low iptpsp uptake have been attributed to frequent stockouts of sp due to procurement and supply chain challenges resulting in delays in getting sp into the country especially during 20122014 17 additionally the countrys central medical stores was gutted by a fire that destroyed the national sp stock in january 2015 17 other studies have suggested that unemployment resulting in some womens inability to afford the cost of maternal healthcare service and late first anc visit accounted for the low coverage of subsequent doses 1323338 this current study is part of the first authors postdoctoral research study on health system and sociocultural factors influencing knowledge attitudes and acceptance of malaria interventions among pregnant women in ghana 39 an earlier paper from the said research study abereseako magnussen 38 reported that healthcare managers dealt with stockouts governments failure to reimburse facilities for the cost of feefree maternal healthcare and to supply health facilities with health products such as maternity record booklets by charging fees and rationing sp to women such managerial decisions contributed to the increasing price of sp and the general cost of anc services so women devised coping strategies such as skipping scheduled anc appointments and laboratory tests which compromised with quality health care provision this current ethnographic study contributes to literature by exploring and describing factors that influenced uptake of iptpsp in healthcare facilities in ghana by focusing on the daily interactions between healthcare providers and women as well as the sociocultural context of healthcare provision methods study design the study design was ethnographic it included nonparticipant observations case studies informal conversations and in depth interviews to obtain data from healthcare providers healthcare managers pregnant women and community members informal conversation in this study is defined as an unplanned and unanticipated interaction between an interviewer and a respondent that occurs naturally during the course of fieldwork observation it is the most openended form of interviewing 40 idis were more formal compared to informal conversations as research assistants used semistructured interview guides written with probes transitions and followup questions which provided more data direction and control than the informal conversations 41224 data were collected from april 2018 to march 2019 the research team comprised of a female medical anthropologist and 9 graduate research assistants three of the ras were females and six were males who could also speak the indigenous language of their assigned study areas the twi language for ras who were recruited in the ashanti region and the ewe language for those who were recruited in the volta region ras observed and documented anc care provision in the 8 study facilities and 8 communities to prevent a hawthorne effect observations were conducted intermittently in the eight facilities and 8 communities 42 ma trained ras on observations and writing observation notes in accordance with emerson fretz 43 they were also trained to carry out community entry to conduct informal conversations and idis prior to data collection and during the data collection process selection of research area the study was conducted in five districts three in the ashanti region and two in the volta region of ghana eight health facilities and 8 communities were chosen for the study ashanti region was selected to represent the middle belt of the country while volta region was selected to represent the southernmost belt of ghana the two regions are linguistically different twi is spoken in the ashanti region and ewe is spoken in the volta region ashanti region reported the second highest percentage of women receiving anc care from skilled providers in 2014 while the volta region reported the second lowest percentage of women receiving anc from skilled providers 29 the district hospitals in the five districts qualified automatically to participate in the study also interactions and interviews with pregnant women in some of the study communities revealed that they preferred to visit particular health facilities for anc services three of such facilities which are faithbased were included in the study thus a total of 8 health facilities were selected for the study some women preferred the three facilities because they were closer to their communities than the district hospitals the womens assertion of nearness to facilities was further confirmed when the study team conducted transect walk in all the study communities to confirm the location of health facilities 38 the study team visited the 8 health facilities and went through anc records and maternity admission records for malaria in pregnancy cases the total number of mip cases from january 2015 to march 2018 for the different ownership of facility government owned 2 3 mission owned 2 1 communities 4 4 � study facilities in the ashanti region have been given the following pseudonyms asf01 asf02 asf03 and asf04 study communities in the ashanti region have been given the following pseudonyms asc01 asc02 asc03 and asc04 study facilities in the volta region have been given the following pseudonyms vrf01 vrf02 vrf03 and vrf04 study communities in the volta region have been given the following pseudonyms vrc01 vrc02 vrc03 and vrc04 communities that access the services of each facility were tallied the community with the highest total number of malaria in pregnancy cases in each facility was chosen to participate in the study the average population for each study community was 10000 inhabitants the study team conducted community entry activities such as visiting assembly members and chiefs and holding meetings with a cross section of opinion leaders to inform and to seek their permission to conduct the study in their communities selection of study participants a research assistant was assigned to one health facility to carry out nonparticipant observation and to interact with health providers and pregnant women attending anc convenience sampling was used to select pregnant women for conversations 4127 ras took the phone number of any pregnant woman who was attending anc and was willing to participate in an idi the woman was contacted later on and arrangement was made to meet her at her preferred venue for an in depth interview the snowball method was also used to recruit pregnant women from the 8 study communities 40115 the first pregnant woman who was recruited helped the ra to identify other pregnant women in the community the study was explained to them and those who were interested were recruited to participate in idis after a written consent had been obtained opinion leaders such as assembly members mothers and mothers inlaw of pregnant women were invited to participate in idis case studies were purposively selected from women who regularly attended anc every month and those who were irregular or skipped anc appointments a total of 12 case studies were followed throughout the study period they were visited several times at home where ras observed how they took their medications whether they honoured their anc appointments their experiences from their previous anc visits especially on being offered sp and whether they were using llins also their maternity record booklets were reviewed to confirm the information health providers mostly midwives and nurses providing anc service who had one year or more work experience in a health facility were selected to participate in the study anc unit managers facility managers such as senior medical officers physician assistants and administrators were interviewed to help understand managerial and administrative issues the study team carried out followup informal conversations and interviews with procurement officers laboratory personnel and officials at the district health directorate the aim was to clarify some of the issues raised in idis and conversations with health providers and health managers details of the different category of study participants and the methods used for data collection are presented in table 2 data collection techniques and data collection process an ra spent several months in a facility observing anc procedures interactions between healthcare providers and women who were attending anc ras first observed women and health workers during the following anc activities registration of women checking of womens blood pressure and protein in their urine women being attended to in the anc consulting room women visiting the laboratory and the pharmacy in order to understand and experience the various processes that the women went through ras also selected anc attendants at random and accompanied them throughout the anc process the ras obtained permission from the health providers to interact with the women and they also sought verbal consent from such women to accompany them through the anc procedures the ras talked to the women who they chose at random to clarify actions and activities that were observed ras wrote down notes on the conversations that they had with the anc clients and the health workers and later typed them out observations and conversations with women focused on womens knowledge on sp knowledge on mip their intention to take sp among others conversations with health providers centred on sp policies sp availability information offered to women before and after offering them sp conversations and idis that were conducted with pregnant women and community members were in the ewe language for those in the volta region and the twi language for those in the ashanti region the idis centred on knowledge attitudes beliefs and practices on malaria in pregnancy interventions and sociocultural practices ras conducted idis with healthcare providers and healthcare managers in english and they focused on maternal and mip policies and service provision challenges and facilitators idis were recorded using digital recorders and they were transcribed verbatim to preserve interviewees original messages and experiences interviews in ewe and twi were transcribed into english to enable easy analysis and comparison the study used english language to conduct idis and conversations with healthcare providers and nhis officials because english is the official language of ghana also ras obtained permission from the women to go through their maternity booklets to confirm iptpsp uptake data analysis idi transcripts observation notes and notes from conversations were uploaded onto qualitative analysis software nvivo version 11 to support the analysis the data was triangulated and a coding list on common themes that arose from the data was generated ma and ed independently coded the data thematically the analysis aimed at identifying similarities patterns differences and contradictions in the information observed or presented by study participants 44 main themes that were identified from the analysis formed the basis for interpreting and reporting on study findings this manuscript is part of the larger study mentioned in the introduction so some of the findings have been reported in the earlier paper 38 ethics statement ethical clearance was obtained from the university of health and allied sciences research ethics committee uhasrecai ul 1718 written consent was obtained from all interview participants verbal consent was obtained from study participants that informal conversations were held with and for observations while written consent is recommended for study participants verbal consent can be used in situations where time is of the essence as was the case with the informal conversations that the study team conducted with some of the clients attending anc who did not have time to participate in idis 45 in this study women who were attending anc were invited to participate in conversations and interviews those who had ample time for an interview were given time to reflect and their phone numbers were taken by the ras they were called at a later date by the ras and if they consented the ras followed up to their homes for interviews after they had obtained written consent from them however ras conversed with women who were willing to participate in the study but did not have enough time to participant in idis for such study participants ras first sought permission from anc department heads and subsequently from the clients who granted verbal consent to participate in the study a few of those who were approached declined to be interviewed only one study participant was 16 years old and permission was sought from her mother prior to her inclusion in the study permission to conduct the study was sought from district directors of health of participating districts facility managers of the eight study facilities department managers and chiefs and assembly members in the study communities besides actual country and region names pseudonyms have been used for districts individuals and facilities names to protect informants identity health facility pseudonyms beginning with asf refer to study facilities in the ashanti region and asc refer to study communities in the ashanti region while the prefix vrf refer to facilities in the volta region and vrc refer to study communities in the volta region pseudonyms of respondents are thus predicated by the prefix of the facility or community that the observation conversation and idi was conducted respectively results findings from the study reveal that all the health facilities observed dot however most women did not take the optimum number of iptpsp doses during pregnancy three groups of factors that contributed to women completing 5 doses of iptpsp5 were health system sociocultural and individual the details of these three group of factors are discussed in subsequent sections health system factors health system factors such as how anc services were organized strategies employed by health workers to administer sp and high trust in the healthcare system facilitated uptake of the first dose of iptpsp however healthcare providers providing inadequate information to anc clients facilities experiencing occasional stockouts and charging fees for sp and other anc services reduced uptake and adherence to subsequent iptpsp doses organisational arrangement facilitating iptpsp3 uptake interviews and conversations with health providers at anc clinics revealed that they knew that the first dose of sp is to be given to women at 16 weeks of pregnancy however respondents presented varying opinions on the number of doses that a pregnant woman should receive during pregnancy three in five health providers said that the guideline indicated that women should receive 5 doses of sp given monthly with the first dose at 16 weeks of pregnancy and the last at 36 weeks nevertheless 2 in 5 health providers said that sp can be extended beyond 36 weeks so a woman could be given 6 or 7 doses prior to delivery all eight facilities mostly practiced focused anc and implemented the whos recommendation of administering iptpsp under dot in most facilities anc procedures started with checking womens blood pressure and testing for protein in urine in an open space in six facilities the next set of procedures were conducted in a consulting room the women were examined to confirm that their gestational age was 16 weeks or more either through a scan or through physical examination they were offered seats opposite to the midwives position which enabled midwives and clients to have a facetoface interaction midwives usually kept a box of sp on the consulting table they removed a pack ripped the three tablets from the package placed them in the right palm of the women and watched them chew or swallow them afterwards the healthcare providers recorded the uptake into the womens maternity booklet before returning it to them each facility had an anc outpatient department where all the pregnant women converged to be called one at a time into an anc consulting room usually when the women appeared for anc each woman placed her booklet on a table located in front of the anc opd a nurse or a ward aid went through the booklets to determine those who were due for sp the booklets were then given back to the women after the vitals had been checked and recorded the study team observed that in the anc consulting room a health providers first approach was to take the booklet from the anc attendee to read her records to know her history of sp uptake and other treatment to guide the health provider in clinical decision making all the pregnant women that were observed in the 8 facilities had a copy of the maternity booklet or were in the process of receiving one each pregnant woman was given one copy of the maternity booklet when she visited the anc for the first time and tested positive for pregnancy all the different components of care given to her including the issuing of each dose of iptpsp was recorded in the maternity booklet she was required to carry the booklet along with her on each visit the health provider referred to the book on each visit to determine the womans healthcare history and whether she was eligible for the next sp a midwife explained that the booklet is accepted in all facilities nationwide so women carry it even when they travel outside their catchment areas in order to enable them access anc at any other facility in the country prior to the start of anc procedures in vrf01 a health provider called out names of all women who were due to take sp on that day in asf03 and vrf01 a midwife provided sp in the open to all women who qualified to take sp she first offered them a seat and then she offered them three tablets of sp and watched them swallow or chew it facility asf02 and vrf02 provided water to anc clients while asf01 and vrf04 sold water to them in facilities that did not provide water to clients health providers took the womens maternity booklets asked the clients to go out to get water and return to take the sp tablets in front of them the health providers then recorded the intake in the womens maternity booklets and the women left to continue with the rest of the anc procedures most health providers explained that sp was strong so they ensured that women ate before taking it as a way of addressing complaints from women that they experienced sideeffects of themes reponses obtained on the different themes from pregnant women whether women were offered sp during their last visit to the anc yes medicine for malaria sp and you drink it at the hospital they wont allow you to bring it home because it is very difficult to drink it i nearly vomit after drinking it and we are also given some 3 white tablets to chew in their presence when i went they gave me that threethree sp they made me take it in front of them we take it in front of the nurses some people when they bring it home they wont take it and they will throw it away it is very difficult to take it so they will tell you to take it there we are given a certain malaria drug that we take inside the consulting room before getting out sp health providers considered food such as porridge or tea as too light so women who mentioned that they had eaten such foods were asked to find heavy food such as banku kenkey to eat before returning to take sp in depth interviews with pregnant women and health providers conversations and observations in anc clinics revealed that one in two women were not given information on the relevance of sp the number of doses that they were supposed to take during pregnancy and when to return for the next dose however it was observed that health workers usually wrote the date of the next scheduled anc visit in each clients maternity booklet health providers were observed to give detailed information on sp to clients who were refusing to take sp and in most cases they were successful in convincing them however health providers reported that education was critical for adherence so they gave the women ample education nevertheless a few health workers admitted that they failed to give some of the women relevant information on sp because of the heavy client load that they had to cope with sometimes women who were due for sp were diagnosed of having malaria parasites which was usually confirmed after a laboratory test was conducted such a clinical decision was taken because some women appeared at the anc with complaints akin to malaria infection in some instances women who were taking sp for the first time were made to undertake a test for malaria even if they did not show or complain of any symptoms those who tested positive were treated for malaria but were not offered sp such women were informed that they would receive sp on their next visit to the health facility if the malaria parasites were cleared in some facilities such clients were asked to visit the laboratory to test for malaria parasites on the next anc visit and if they tested negative they were given sp it was observed that in asf03 clients who were previously treated for malaria were given sp on their next scheduled visit without being tested for malaria parasites a health worker explained we assume that the person has been treated after a month so we start giving them the sp community health nurses role in sp uptake facility vrf02 reported that in order to increase uptake of sp among women community health nurses provided information on itns and sp to community members and households during community outreach programmes in the district this initiative was to help to create awareness among community members and to encourage women to attend anc in order to access itn and iptpsp additionally some of the community health nurses administered subsequent doses of sp to women during community outreach programmes the community health workers were guided by documentation of the first dose of sp in the womens maternity booklets the practice was to ensure that the first dose of sp was always administered at the anc clinic and recorded in the patients maternity booklet so that anywhere she went within ghana a health provider could refer to the booklet to make informed clinical decisions including offering her subsequent doses of sp thus the subsequent doses could then be offered in the communities by the community health workers who visited the communities frequently for health outreach programmes this ensured that women who were reluctant to honour subsequent anc appointments those who did not have money to visit the anc and those who complained of long distance to the anc could still get sp trust in the health care system and belief that taking sp was compulsory influenced uptake clients trust in the health care system and health providers motivated them to take iptpsp it was observed that anc clients trusted health providers so they took in sp that was given to them by the providers even when they were not given information they believed that health providers were concerned and interested in their welfare so they will not mislead or harm them additionally health providers continued to tell women that sp was compulsory thus some women believed the health workers claim and felt that they had no choice but to take sp even though some were not told by the health workers the reason why it was compulsory some women were motivated to attend anc regularly because they had high interest in protecting themselves and their babies and they trusted that the health care system could facility code observations in 8 facilities ashanti region asf01 client 01 the midwife told her she was going to take medication which will protect her and the pregnancy from malaria the midwife brought out sp and gave it to her together with water and the woman took in the medication client 02 the midwife asked her if she had any complaints the woman said she had none the midwife asked her if she had eaten before coming and the woman said yes she had the midwife gave her sp it was her 3 rd dose of sp she was asked to return in a months time asf02 client 01 the midwife told her she was going to take medication the midwife brought the sp out and gave it to her together with water and the woman took in the medication client 02 the midwife asked her if she had eaten the woman replied that she hadnt so the midwife asked her to go and eat because she will take medication she went and came back in some few minutes and the midwife took the sp out and gave it to her together with water after the woman had taken the medication the midwife asked the woman to go and her next visit was scheduled for 28 th september 2018 asf03 client 01 is seven months pregnant after bringing her urine for testing she was given sp which she was given sachet water to take in the full glare of everybody client 02 a seven months pregnant woman gave her urine to the incharge for proteinglucose test after the test she was given sp to take client 01 kept the sp in her hand bag the nurse who gave it to her realizing that screamed at her to bring the sp out and added when you go to the house you wont take it client 01 replied i will take it just that i feel dizzy when i take it one of the nurses gave a sachet of water to client 01 and she took the sp there in front of the nurses client 03 is sixteen years old this happens to be first pregnancy when she took the seat the nurse took her vital statistics tested her urine and asked her have you eaten she said no the nurse then told her to take the drug and after that go and find something to eat she gave the drug to client 03 and she peeled it out of the pack and took it with water client 04 the midwife told client 03 that she needed to do some labs for her to ascertain how she is doing after the treatment given to her by the doctor the midwife asked her to go and buy water and come for the sp she came after a short while with the water and took the sp in the presence of the midwife asf04 client 01 went back to the maternity ward where she was given sp it was observed that water was not provided for her so she went to the entrance of the facility bought water and returned to the anc and took the sp in the presence of the midwife incharge she paid three cedis for the sp client 02 sp was served on dot but no education was given because it is her third dose of sp the client paid 3cedis for the sp served volta region vrf01 before sp was given to a woman she was asked whether she had eaten if she responded in the affirmative they asked her to bring water to take the drug in their presence if she responded in the negative she was told to go and eat get some water and come back for the drug some chewed and drank water afterwards others swallowed the three tablets one after the other with water while others swallowed the three tablets at once with water client 01 at the sp table client 01 pleaded that her sp be given to her to send outside get water and take it there at once but the nurses refused she made all efforts to convince them to trust her but to no avail so she had to leave her maternity booklet on the anc table and go to get water she returned with water to take the drug in the presence of the nurses vrf02 there was a big veronica bucket with water and several drinking cups placed on top each client was told to fetch water in a cup and come for the sp client 01 after client 01 took the sp in the consulting room she was then directed to the pharmacy for her routine drugs client 02 left the anc consulting room to the lab and came back in an hour with the result in her anc booklet indicating no malaria parasites the midwife then asked her to fetch water and come for the sp she fetched water from the veronica bucket and went to take the sp from the midwife and took it in the presence of the midwife vrf03 client 01 came into the consulting room the midwife asked her if she had any issue for today client 01 stated that sometimes she felt abdominal pains the midwife explained the reason for the abdominal pain and after a series of interactions the midwife told her that they had a malaria drug that they give to pregnant women starting from the fourth month of pregnancy and it protects the mother against malaria aside sleeping under the bed net the midwife asked client 02 to go and buy water and come for the sp client 02 went out and returned after a short while with water the midwife gave her sp which she took in the consulting room vrf04 the midwife at the anc had a bag of water so when pregnant women came for anc and were given sp they were told to buy water at 20 ghana pesewas to take the sp provide them such protection such women trusted all the information given to them at anc and were always willing to comply with directives including fulfilling all the scheduled anc visits and taking iptpsp the following quotations illustrate experiences of clients some of the medicine sp we take it there some people dont take it when they bring it home so they give you water and tell you to take it some people dont like taking medicines and if you do that you are causing harm to your child they health providers want the best for you so that everything will be okay for you and your child there are some people who will collect it sp but will not go and take it so they are also responsible for protecting us against malaria and for preventing the child from getting it so they ensure that we take it in their presence effect of stockouts on iptpsp3 uptake occasional stockouts of sp in health facilities affected uptake of optimum doses of iptpsp some facilities dealt with stockouts by prescribing sp for anc clients to buy from private pharmacies sometimes womens maternity booklets were seized and only given back when they returned to the facility to take the medicine under dot because they take the sp under direct observed therapy when we dont have the sp in the hospital we write it and give it to the pregnant women to buy the sp outside the hospital after they have bought the sp they will then bring it to the facility to be taken in our midwives presence we seize their anc booklets so after they have bought the sp outside the hospital and have taken the sp in our presence then we give their anc booklets back to them three facilities asf02 asf03 and asf04 had regular supply of sp because they the solved stockout problem by purchasing sp and selling it to clients they sold it as a package with routine drugs or haematenics at 3gh₵ however some clients could not afford the price of the package of drugs so sometimes they skipped scheduled anc appointments and missed some doses of sp a woman who was nine months pregnant and attended anc in facility asf04 indicated that sp was beneficial to pregnant women yet she had taken it only once she failed to take the subsequent four doses because she could not pay for the drug as the interaction between her and a research assistant illustrates ra have you ever been given this drug showed her the sp before respondent yes they have given me this drug sp before and i took it at the hospital they said i will take it five times before giving birth but i have only taken it once ra have you asked the nurses why they havent given you the malaria drug again respondent no i havent asked them one other thing is that the government does not cover it and even if the government covers it he does not pay all so you have to buy it yourself and it costs 3gh₵ if you dont have money they will not give it to you ra you mean they sell the sp at the hospital respondent yes the first day i took it i bought it for 3gh₵ 0 6 so if you dont have money to buy it they wont give it to you in some circumstances when facility asf04 had limited quantity of sp in stock it rationed sp to clients as a healthcare manager revealed with the iptpsp that is the malaria prophylaxis that they give to the pregnant women which is supposed to be taken monthlythat is after 16 weeks of pregnancy it is not readily available so in theory the iptpsp is given monthly after quickening but practically the midwives are still using the old system where they give it to the pregnant women in two months interval instead of one month interval and then stop giving it to the pregnant women at 36 weeks of pregnancy it will be good if the sp could be made readily available so that the pregnant women can take it monthly facility vrf02 addressed stockout of sp by borrowing sp from sister facilities for clients a second strategy that facility vrf02 used to address stockouts which was also practiced by facility vrf04 was to ask clients to return at a later date for sp clients returned when sp was available to get their regular dose sociocultural factors influencing iptpsp uptake sociocultural factors such as women being encouraged by family members and friends facilitated initial and continued uptake of iptpsp however womens inability to afford the cost of sp social commitment and household decision making on anc attendance hampered continued uptake of iptpsp for young unmarried women health system and sociocultural factors influenced their use of anc services which affected uptake of iptpsp interpersonal relations social commitment and ability to afford sp influenced iptpsp uptake a husbands ability to pay for the cost of anc care and to advise or force his wife to attend anc influenced anc attendance an opinion leader stated we also tell them husbands to force their wives to go for anc friends family members such as sisters mothers and mothers inlaw encouraged women to attend anc and to take sp which contributed to uptake in some cases family members especially mothers and mothersinlaw decided on when a woman should begin anc for instance a husband who accompanied his wife who was 4 months pregnant to the anc explained that his mother and his mother inlaw decided that his wife should attend anc at 4 months this is because his mother and his mother inlaw had a history of attending anc in their fourth and fifth months of pregnancy respectively others on the other hand were encouraged to attend anc by their friends some pregnant women were discouraged by friends and female relatives to go for anc early as they were told that they would have to pay fees some women combined anc visits with taking herbs visiting herbalists and pastors for health care which affected adherence to anc directives including taking sp in community asc02 three in four pregnant women combined medicine given at the anc with herbs when they discovered that they were pregnant they first went to an herbalist and delayed visits to the anc which affected early uptake of sp they explained that the herbs helped to prevent the unborn child from getting asiram hydrocephalus they believed unborn babies are exposed to spiritual and physical attacks by enemies also there were instances that pastors decided on when church members could start attending anc and when they should eat during pregnancy a midwife shared an experience with a client who was refusing to take sp a pregnant woman came here last time take the drug i am fasting the pastor said i should fast so i told her that i am osofo mame wife of a pastor or a female pastor but i wont ask a pregnant woman to fast so she went and ate and came and took the medicine sp in community asc04 it was common for women to relocate from their husbands or their own residences to their mothers places mostly their mothers lived in different communities to deliver anc providers could not document whether such women completed 5 or more doses of sp prior to delivery the following quotation illustrates the challenges health workers face in such circumstances about 60 of the pregnant women who come here for their anc service complete the first second and third doses some of the pregnant women when they are about to deliver they go to their mothers houses mostly outside asc04 so they usually take the fourth and fifth doses at different hospitals that is if their parents stay outside asc04 so we are unable to capture fully the number of pregnant women who take the fourth and fifth doses women were encouraged by health providers to carry their anc booklets whenever they travelled so that they could attend anc on their scheduled dates at the closest health facility some women skipped scheduled anc appointments due to social commitments such as funerals having to go to the market on their scheduled anc dates and family responsibilities such as going to the farm thus missing out on the monthly intake of sp nevertheless it was observed in anc clinics that some midwives encouraged clients to carry their anc booklets along whenever they traveled out of town this was to enable women attend anc clinics that were deemed closer during travels anc providers also encouraged clients to explain to their family members to allow them to attend anc on their scheduled anc appointment dates if family members wanted them to engage in other activities on such days health system and sociocultural factors influencing young womens access and uptake of iptpsp majority of the unmarried young women between the ages of 1824 years old who the study team interacted with were unemployed or had recently dropped out of school because they had become pregnant and were not receiving support from their partners for most of them the pregnancy was unplanned and unwanted which affected their attitude towards utilizing anc and mip services including the uptake of iptpsp some of them were brought to the anc by their mothers or grandmothers sometimes in their sixth seventh eighth and even ninth month so they did not receive the minimum 5 doses of sp table 5 presents interviews and observations of young women who sought anc services most of the cases were observed in facility asf02 in the ashanti region which was the only facility that devoted one day in a week to conduct adolescent anc clinic facility asf02 addressed the challenge of getting adolescents to utilize anc services by devoting one anc day to adolescents they served soda drinks to welcome them to the anc and this motivated them to attend anc this practice ensured that adolescents attended anc which facilitated uptake of iptpsp facility asf01 reported that one day in a week was devoted to adolescents so the team visited the facility on two occasions on the reported allotted day and time to observe the adolescents clinic however the team did not find any adolescents so the team questioned the staff and no explanation was offered thus our observations suggested that no day was actually set up for adolescent anc in facility vrf01 the study team observed on one occasion an adolescent who was attending anc being reprimanded for mistakenly placing her urine bottle on an anc table other pregnant women who made similar mistakes were not reprimanded also a case study who was 17 yearold told the research team that she was unwilling to attend anc at the nearest health centre which happens to be vrf02 but rather travelled to a distant lower level facility a communitybased health planning and services compound because she believed that the nurses did not treat her with respect at vrf02 she admitted that sometimes she could not afford the cost of transport to the distant facility so she had skipped her latest anc appointment as at the time of the teams visit to her home individual factors influencing iptpsp uptake individual factors such as womens knowledge of the relevance of sp womens desire to protect themselves and their unborn babies motivated them to take sp but some women refused to take sp others skipped scheduled anc appointments and some women started anc late which made it difficult for them to complete the recommended optimum doses of iptpsp individual factors contributing to low uptake of iptpsp interviews and conversations with study participants revealed that there were instances that women declined to take sp even when they were eligible some complained of vomiting and nausea but others did not table 5 young womens experiences in seeking anc care and iptpsp uptake young womens experiences at the anc some pregnant women they can stay at home for a very long time and report with the pregnancy very late for example one girl adolescent came today the pregnancy was already six months she was not even having health insurance so she had to go and get the nhis card and return people like that are not able to take all the 5 doses before delivery adolescent client 01 was brought in for anc for the first time in the ninth month of pregnancy by her mother she was not given sp as the midwives explained that she was due to deliver so it was too late to start her on sp adolescent client 02 a 23 year old second year pharmacy student was seven months pregnant she started attending anc in her sixth month she indicated that she would never take sp because she did not like the smell and it causes her to vomit she also admitted that she was not sleeping under a bed net and that she was not taking her routine anc drugs she lamented that the man who made her pregnant had absconded and her parents were peeved she said if she had detected the pregnancy early she would have aborted it however she only detected it in her fourth month so she was afraid that if she aborted it she would die from all indications she was not enthused about the pregnancy so she had a negative attitude towards protecting herself from malaria and its negative consequences on the pregnancy adolescent client 3 was a 16 year old who had stopped attending school after junior high school she was impregnated by a boy who was in the senior high school she was about seven months pregnant when the research team visited her at home for the first times she had never attended anc so she had never taken sp she explained that the boy did not have money to support her and her mother did not also have money to support her that was why she had not started attending anc have any tangible reason for declining to take sp in both regions most refusals came from professional teachers it was noted that health workers made efforts to persuade such women to take sp but they were not successful teachers they think they know they read the wikipedia thing so they will come and challenge you so they normally refuse it sp i had two cases they said that thing sp any time i take it i vomit the whole day i wont take it i talked talked talked i had to refer them to my second colleague to advise them but they refused so i wrote it boldly there in their maternity booklets refused almost all my clients take the sp i have a client who is a teacher so far she is the only one who is refusing to take sp so what i did was i recorded it in my book that she is refusing to take sp her lab test shows that she can take the sp but she refused to take it like the saying goes patients right she is a teacher so i assume she knows the right thing but if she says she wont take it i cant force her nevertheless lack of appropriate information and lack of experience in taking sp contributed to refusal an ra interacted with a woman who had completed junior high school and was four months pregnant with her second child her responses suggested that she had never taken sp as the excerpts illustrate and they say what does that drug do respondent i havent asked that intentionally ok when i got pregnant with my first child i never took it they said it was unavailable so when i went yesterday they said they were going to give me some sp however i told them i had not eaten so i was going to take some food and return but i didnt take it ra okay so how did you manage to avoid taking it such that they also didnt realize that you had not taken it respondent i didnt use any means i just told her health provider that i had not eaten she said she was not letting me off the hook simply because i had not eaten she said from her estimation my time had not advanced that much and that i would eventually take some so i should go and return later thus i just went for my medications and left i didnt take it several pregnant women reported that they started attending anc late because they did not have money to pay for anc services others started anc early but skipped some of their scheduled anc appointments as a way of coping with the cost which was confirmed by a health care provider this reduced their chances of obtaining the monthly required doses in order to attain 5 or more doses by the time they delivered late attendance to anc contributed to late initiation of iptpsp and women not being able to complete optimum doses of sp also after the third dose some women defaulted and only returned to the facility to deliver while others came to register for anc received a dose of sp and did not return until they were due to deliver health workers shared their experiences some of the pregnant women dont complete all the 5 doses before delivery because some of them dont visit the facility at the early stage of the pregnancy they stay at home for long so some of the women sometimes take only three doses of the sp before delivery the uptake is okay it is encouraging only that the fourth and fifth doses are not encouraging because they dont register early others also default clients who took sp without being observed by health providers during the study period only three women were observed or reported that they took sp without being observed by a health worker in asf04 it was observed that an anc client who was pregnant for the first time took her first dose of sp outside the anc consulting room unsupervised when she was asked why she explained that the midwife asked her to take the sp on her own as the midwife had other issues to attend to an anc client who was nine months pregnant in asf03 reported that she took some of her sp doses at home unsupervised she said she experienced dizziness and nausea when she took her first and second doses under dot so on her third visit the health providers agreed that she could take the subsequent doses at home another respondent in community vrc03 reported that she bought her second dose of sp from a private pharmacy and took it unsupervised she said she made the decision because she wanted to protect herself from getting malaria womens knowledge on when to start taking sp number of doses and willingness to take sp in future most women knew that they were supposed to take sp including those who were not due for sp however majority of women were not sure when they were supposed to start taking sp and some said they had no idea of the number of times that they were supposed to take sp because they were not told they told me the time to take it is not due i didnt ask them but here they have a specific time that you take it i am just 4 months pregnant i havent reached far for that one number of times to take sp we were not told so we know nothing about it whenever you go and you are told to take medicine then you go for it so we do not know how many times it should be taken women gave various responses on the number of doses of sp that they were required to take during the period of pregnancy most women indicated three a few mentioned two four and five while some said they were not told when they asked the midwives the quotations below testify to the different responses the last time i asked they only told me i was supposed to take it four times they did not give me any reason i was only told it is four times i should not talk much and that it is my duty to take it i have drunk it 2 times and it is left with 1 to drink i will finish drinking mine this month there were these 2 clients when i was giving them the 4th dose they said they had finished i said oh it was first that you take only three doses now you have to take 5 doses yes they have given me this drug an ra showed her the sp before and i took it at the hospital they said i will take it five times before delivery but i have only taken it once and my date of delivery is almost due all women who the study team interacted with including those who complained of sideeffects such as feeling dizzy and weakness said that they were willing to take sp in the near future only one woman said she was not willing to take future doses recommendations for promoting iptpsp uptake healthcare providers provided recommendations on how iptpsp uptake can be improved recommendations included giving health education such as encouraging women to start anc early stressing the importance of sp to women and motivating them to take it some health providers suggested that sp should be made readily available at health facilities an anc manager stated the government should provide the sp and it should be given to us frequently they should not let us experience stockouts of sp healthcare providers in facility vrf02 recommended that community health nurses should be encouraged to include community education on regular anc attendance and sp uptake during outreach programmes also community health nurses should be encouraged to administer subsequent doses of sp to women who are due in communities this will save the women time and the inconvenience of having to travel to a health facility for subsequent doses anc clients recommended that they should be given adequate information on how to prepare well before taking sp and on the sideeffects a case study who the study team visited at home said that she prefers that it is put in liquid form opinion leaders such as mother inlaws assembly members and community elders recommended community education and husbands involvement in encouraging their wives to attend anc and to adhere to all treatment offered discussion this study used ethnographic research methods to explore how health system factors such as organisational arrangements health workers strategic approach to enforcing dot and trust in health facilities facilitated initial uptake of sp other factors such as interpersonal individual and sociocultural factors that influenced uptake of iptpsp were explored organisational arrangement such as assigning a health provider to provide sp and facetoface interaction between health providers and anc clients created an enabling environment for women to take sp these arrangements facilitated uptake of the first dose of sp therefore it is not surprising that iptpsp1 uptake in ghana has been increasing over the years 2829 similarly maheugiroux and castro 46 found that facilities that reported that iptpsp was routinely offered as part of anc services were more successful in getting women to receive optimum doses of sp also onyangoouma okuonzi 47 in a study in kenya found that the most sustainable and effective way to implement iptpsp was by integrating it into anc service delivery all hospitals and healthcare centres enforced dot which was effective as it contributed to adherence and a high uptake of iptpsp1 similarly other studies reported that women who attended health facilities where dot was practiced were more likely to receive at least one dose of iptpsp 48 49 50 other studies have found that poor supervision of sp intake by health providers contributed to low adherence and uptake of iptpsp among pregnant women 918 another study also found that delivering iptp through anc was ineffective especially in higher level facilities the two intermediate steps that were noted to be ineffective in the delivery of iptp at that level were women attending anc being given any sp and being given iptp by dot 51 another health system factor that promoted iptpsp uptake was recording the monthly uptake of sp in the clients maternity booklet this ensured that healthcare providers could quickly refer to womens history on iptpsp such as women who were eligible for iptpsp and those who were due to take sp during an anc visit which facilitated quick clinical decision to offer such women iptpsp even women who traveled out of their original place of residence were able to continue with their monthly uptake of sp seamlessly in other health facilities they only needed to present their maternity booklets in their second facilities and the healthcare provider referred to the booklets to know their history to facilitate clinical decision making a study in south africa equally found that a new individual maternity case record card introduced in maternal healthcare delivery greatly improved the referral process and contributed to quality health service delivery however it increased the workload of midwives 52 study participants who were unwilling to take sp for fear of sideeffects were influenced to take it after healthcare providers convinced them by providing them with information women in one facility visited herbalists or took herbs while several women in all the study communities visited prayer camps and followed pastors directives such attitudes contributed to women skipping scheduled anc visits or starting anc late which contributed to low uptake of sp similarly a study noted that when women are counseled and given information on malaria and iptpsp it increases uptake of sp 20 other studies have also reported on alternative sources of care that women use which hampers their ability to utilize maternal health care services optimally 5354 health providers appeared to have devised simple but effective ways of dealing with individual sociocultural and interpersonal challenges that pregnant women navigate through in their daily interactions strategies that facilitated sp uptake included insisting that women ate before taking sp and that women brought water as well as informing clients to carry along water to take sp in subsequent anc visits another strategy was encouraging women to negotiate with family members to postpone or forgo responsibilities that could cause them to miss scheduled anc visits health workers also discouraged women from obeying pastors who directed pregnant women to fast health workers approach helped to dispel misconceptions superstitious beliefs about pregnancy and cultural practices which discouraged women from accessing sp this ensured that most women who attended anc took sp whenever available similarly previous studies found that perceptions that sp should not be taken without eating and lack of clean water and cups in anc clinics hindered the effective implementation of dot in health facilities 95556 a study in southern tanzania found that women who had previously taken sp on empty stomachs and reacted badly such as vomiting and becoming weak refused to take it unless it was given under dot 57 hill hoyt 11 and webster kayentao 58 reported that side effects of sp contributed to ineffective delivery in mali studies in tanzania also reported that some pregnant women avoided and postponed anc attendance because of the fear of sideeffects of sp on the foetus 59 nevertheless a study in uganda reported the contrary 60 the study found that most women considered sp to be safe and were willing to take it again in future without supervision despite experiencing unwanted effects of sp on previous occasions 60 doku zankawahs 56 study found that anc staff had limited knowledge on the dropout rate in their catchment area and poor attitudes of some health workers contributed to low uptake of iptpsp3 this study found that stockouts of sp in health facilities affected regular uptake of iptpsp in some facilities this is worrying because most anc providers were willing and effective in administering sp under dot abereseako magnussen in their earlier study found that some facilities dealt with stockouts by compelling women to buy sp from private pharmacies others sold sp to clients while one facility rationed sp to clients such decisions were borne out of health facility managers decisions to address stockouts by charging fees and rationing sp which was reported in the earlier paper 38 abereseako magnussen 38 also reported that other facilities were reluctant to buy sp from the open market because of a directive from the ghana health service which mandated them to buy drugs from the cms they could buy drugs from the open market only when the cms did not have the required drug other facilities did not have money to buy sp from the open market so they depended heavily on the cms the decision to charge fees contributed to women who could not afford to pay for anc services skipping scheduled visits and others skipping some of the anc procedures also some of the study participants who attended anc regularly did not complete the recommended 57 doses of sp due to stockouts of sp at the central medical stores and the rationing of sp 38 similarly other studies have reported that shortages of sp in anc clinics reduced uptake of sp 9465356 another study has attributed low uptake of sp to lack of services and lack of sufficient staff to implement the iptpsp policy 61 similarly studies in other parts of subsaharan africa reported that high cost of anc services and mip interventions including sp demotivated women from accessing anc which affected access to sp 576263 some women in this current study could not afford the cost of anc services such as paying for laboratory test buying the maternity booklet and buying sp such women sometimes skipped some of the anc procedures especially laboratory tests delayed initiating anc and skipped their anc scheduled appointments which contributed to low uptake of sp similarly studies conducted in uganda and mali found that cost of accessing anc and sp at health facilities in both public and private facilities hampered utilization of anc services including iptpsp uptake 64 65 66 also studies have found that early and frequent anc visits increased uptake of iptsp3 among married women while early anc attendance contributed to iptpsp3 uptake among rural women 6768 another study in ghana noted that women who began anc in the third trimester of pregnancy were not likely to meet the 3 doses required while those who initiated anc in the first and second trimesters were more likely to meet the required 3 doses of sp at the time of delivery 32 while health workers indicated in interviews that they gave anc clients ample information on sp observations in anc consulting rooms and idis with women revealed that one in two anc clients did not receive information so they did not know when they were supposed to start taking sp why they were taking sp and the optimum doses recommended for the duration of a pregnancy nonetheless some healthcare providers admitted that one in two women were not given ample information because of heavy workload also some health workers were unclear about the recommended optimum doses of iptpsp and how long women were allowed to take it so it is not surprising that women did not also know this gap in information affected early uptake and regular intake of sp as women were not motivated to return to facilities after the first dose it also explains why many women lacked information on the change in policy from 3 to 5 or more doses of sp which may have accounted for the default another factor could be the volume of clients who attended anc most facilities had two to three midwives attending to an average of 60 women in a day this was quite tasking and time consuming because the facilities practiced focused anc which required that each patient was given integrated services and should have ample interaction with the healthcare provider the healthcare provider was also required to document some of the processes such as recording iptpsp uptake among others such challenges are not uncommon in lower and middle income countries where health facilities and patienthealth provider ratio tend to be very high 69 70 71 aburayya alshuridehs 70 study in dubai and bradley kamwendos 71 study in malawi found that few health care facilities coupled with too few staff and too many patients contributed to poor quality service delivery and health worker burnout in advanced countries like the united kingdom it has also been found that communities that had a right balance of healthcare facilities healthcare providers and fewer patients experienced lower levels of mortality compared to communities that had fewer facilities and healthcare providers but high patient load 69 other studies in ghana and tanzania found that a good number of pregnant women did not know why they were given sp 572 some studies reported that pregnant women who were attending private and public clinics lacked correct knowledge on the effect of malaria in pregnancy and the benefits of sp in pregnancy 6073 consequently studies have concluded that womens lack of understanding and correct knowledge of iptpsp contributed to low uptake and adherence 53546074 refusing to access iptpsp without any justification affected uptake interestingly most of those who refused to take sp were teachers who are welleducated this is probably because being educated they were aware of their right to refuse and for that matter the health workers could not compel them to take sp also the educated appeared to rely on information sources such as information from the internet that discouraged them from taking sp such an attitude contributed to low uptake of sp despite high anc attendance in ghana 2930 similarly a study reported that well educated anc clients such as teachers expressed fear of sp and were reluctant to take sp they were equally influenced by media reports on side effects of sp 59 rassi graham 74 reported that reluctance to take in medication served as a barrier to iptpsp uptake marchant nathan 75 on the other hand found no evidence of individual factors affecting second dose coverage beyond living in an urban area exavery mbaruku 20 and okethwangu opigo 76 reported the contrary that women with secondary or higher education compared to the less educated were more likely to take optimal doses of sp during pregnancy high trust in health facilities and health care providers influenced initial and regular uptake of iptpsp even women who lacked knowledge on the reasons why they were taking sp were motivated to take it due to their firm belief that health providers meant well anc clients trust in health providers and the healthcare system is crucial for building an effective health providerclient relationship 77 such a relationship facilitates clients adherence to treatment satisfaction with care received and clients returning to health facilities for maternal health care services including completing the recommended 5 or more doses of sp 38 77 78 79 similarly studies in nigeria southern mozambique and uganda found that women who trusted health providers were highly motivated so they willingly took in drugs such as sp which were prescribed by health providers 49537480 trust has been noted as crucial in the emotional and interpersonal aspects of the patienthealth provider relationship and ensures effective therapeutic encounters it affects a host of important patient behaviours and attitudes relating to care including seeking care patient disclosure of critical medical information complying with treatment and patient satisfaction with care 81 yevoo agyepong 82 reported that anc clients lack of trust in health providers resulted in clients lying to healthcare providers about their reproductive history which affected clinical decisions studies on healthcare provision in south africa have also reported on the critical role trust plays in clienthealthcare provider encounters and its influence on adherence to treatment 7783 in uganda on the other hand it was found that a change in healthcare policies resulting in a drop in government subvention to healthcare facilities contributed to the introduction of user fees for service this development resulted in distrust of healthcare facilities and a rise in selfmedication 84 women whose husbands other family members and friends supported them with funds or encouraged them to attend anc and to take iptpsp completed 5 doses of iptpsp those who were discouraged from attending anc did not complete the optimum doses of iptpsp this suggests that interpersonal relations influence womens health seeking behaviour and thus should be considered in future interventions other studies corroborate this finding 536685 the different studies noted husbands encouragement financial support and reminder to wives to take their drugs influenced uptake of iptpsp and adherence to other maternal healthcare demands also extended family members and neighbors influenced pregnant womens utilization of anc and sp services 536685 the influence of interpersonal relations in facilitating acceptance of healthcare interventions has also been reported in interventions on long lasting insecticide treated bed nets 8687 other studies in subsaharan africa attest to the crucial role of male involvement in hiv treatment and prevention 88 maternal and child health services 89 as well as in family planning decision making 90 only one facility reported that community health workers were encouraged to provide sp to women who were continuing iptpsp in communities this approach ensured that women who experienced challenges with distance anc charges and family commitments could still access iptpsp similarly other studies have noted the importance of using community health workers in the administration of iptpsp in africa 9192 mbonye hansen 92 found that using community health workers to deliver iptpsp and other maternal health services in communities was effective in ghana community health officers are trained health professionals who carry out outreach programmes in communities this gives them access to communities and for that matter they are in a good position to reach out to women who fail to honor anc visits the volta regional health directorate in its efforts to promote uptake of iptpsp has recently rolled out an intervention that seeks to use the chps programme to deliver iptpsp service in communities this involves midwives working with community health officers to improve access to iptpsp service through anc outreaches home visits defaulter tracing and followups 93 unmarried young women and adolescents initiated iptpsp late and thus could not complete 5 or more doses most of them were brought to the anc by their mothers and grandmothers which suggests that they were probably forced to attend anc and they lacked funds to access anc independently besides most of them did not receive support from the men responsible for the pregnancies this is worrying because most of them were experiencing pregnancy for the first time yet they were likely not to have access to nutritious meals and were more likely to suffer from negative consequences of malaria in pregnancy such as abortions and still births 9495 facility asf02s strategy of dedicating one day in a week to offering anc services to adolescents and giving them a drink as an incentive is commendable there is ample evidence to suggest that adolescents are reluctant in accessing key interventions which is not surprising 96 97 98 factors such as lack of money shame in sharing space with their parents cultural norms that place them in subordinate positions sociocultural taboos among others affect their willingness to access even interventions like sexual and reproductive health services 96 97 98 similarly other studies revealed that adolescents were the least likely to complete at least three anc visits resultantly they were less likely to adhere to iptpsp uptake 6199100 this is a result of structural constraints such as their low position in society most of them being unmarried sometimes they feel embarrassed to use anc services with older women and they also fear that others will gossip about them 116199100 the contrary was found in a study in tanzania which reported that despite most adolescents being single they attended anc with older women 61 the study found that sociocultural factors such as late recognition of pregnancy and not being supported by the husband or partner influenced late antenatal care enrolment 61 another study reported the contrary that the proportion of women making more anc visits decreased with increasing parity 54 this study is limited in its ability to generalize the findings as data was collected in only eight health facilities however the findings compare with previous studies that have been carried out in other context additionally the study is subject to researchers biases in using the observation data collection method because researchers could misinterpret interactions between healthcare providers and patients in order to minimize this bias multiple data collection methods were used which were later triangulated also revisits were conducted to selected study participants to seek clarification over incidents that were difficult for the researchers to interpret conclusion this study found that multiple factors such as how healthcare is organized and health providers approach to administering iptpsp individual and sociocultural factors influenced iptpsp uptake in two ghanaian regions consequently interventions that seek to address iptpsp uptake need to involve the healthcare system anc clients and the community the findings suggest that while integrating iptpsp into the health care delivery system influences initial uptake of iptpsp it does not necessarily ensure that women take optimum doses of iptpsp health providers approach to dealing with individual interpersonal and sociocultural barriers to iptpsp uptake is commendable and should be replicated in other settings this will help to address individual and sociocultural challenges in administering iptpsp however health providers failure to provide clients with adequate information on sp is worrying providing women with the right information before or after the first dose of sp is one of the key factors that motivate women to return for subsequent doses consequently health facilities need to encourage health providers to provide anc clients with relevant information on malaria and iptpsp some womens willingness to buy sp suggest that if women are well informed of the relevance of sp some would be motivated to prioritize buying and taking iptpsp unsupervised health facilities and health workers can only be effective in facilitating iptpsp uptake if facilities are regularly provided with sp at no cost thus systemic challenges such as stockouts need to be addressed the ghanaian government through the moh should resume the supply of maternity record booklets and other medical essentials to both public and faithbased facilities for onward distribution to women free of charge this would help to defray the cost of anc services and thus encourage women to partonise them in addition to this initiative the effective implementation of the feefree maternal health delivery service will promote early and regular attendance to the anc which will go a long way to ensure that women receive optimum doses of iptpsp health facilities would also be able to facilitate iptpsp uptake by involving community health workers and volunteers to carry out followup visits in communities the decision of the volta regional health directorate to extend iptp services through the chps programme is commendable and it is hoped that other regions in ghana would one day adopt the intervention additionally health providers and the state with the support of the media need to encourage early initiation of anc among pregnant women early initiation of anc could contribute to women being able to complete 5 or more doses of iptpsp it will help to enforce uptake of maximum doses of iptpsp because women who are not able to honor scheduled anc visits will be able to receive sp in communities adolescents are a critical group that need ample attention and care both public and faithbased facilities need to dedicate one anc day each week to adolescents as one of the facilities in the ashanti region has done which is commendable the study team observed more adolescents patronizing anc service in the facility than in the other 7 this suggest that if a day is dedicated to them they will be motivated to utilize anc services since the fear of stigmatization shame will be less and they will also enjoy some privacy additionally maternity fees need to be waived for them since most of them are unemployed and cannot afford to pay which is one of the deterrents to their utilization of anc services such interventions will facilitate early and consistent anc attendance which will facilitate iptpsp uptake among young women and adolescents

intermittent preventive treatment of malaria among pregnant women with sulfadoxinepyrimethamine iptpsp is one of the three recommended interventions for the prevention of malaria in pregnancy mip in subsahara africa the world health organisation recommended in 2012 that sp be given at each scheduled anc visit except during the first trimester and can be given a dose every month until the time of delivery to ensure that a high proportion of women receive at least three doses of sp during pregnancy despite implementation of this policy ghana did not attain the target of 100 access to iptpsp by 2015 additionally negative outcomes of malaria infection in pregnancy are still recurring this ethnographic study explored how health system individual and sociocultural factors influence iptpsp uptake in two ghanaian regionsthe study design was ethnographic employing nonparticipant observation case studies and in depth interviews in 8 health facilities and 8 communities from april 2018 to march 2019 in two ghanaian regions recommended ethical procedures were observedhealth system factors such as organization of antenatal care anc services and strategies employed by health workers to administer sp contributed to initial uptake womens trust in the health care system contributed to continued uptake inadequate information provided to women accessing anc stockouts and fees charged for anc services reduced access to iptpsp sociocultural factor such as encouragement from social networks influenced

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introduction sports have been an indispensable part of peoples lives since ancient times and with the development of the times holding sports events has become an important form and method for developing the sports industry many cities have developed the hosting of sports events into an important symbol and milestone of the city and have become the embodiment of the competitiveness of urban development sports events have expanded from simply strengthening the body and enriching life to an industry with wide influence that promotes the characteristics of the city at the end of 2022 the national bureau of statistics released that the total scale of the national sports industry in 2021 was 31175 billion yuan and the added value was 12245 billion yuan compared to 2020 the total output of the sports industry increased by onetenth 1 historians refer to ancient greece as the oldest birthplace of the international olympic movement according to records the worlds first tournament was a grand and meaningful event held to commemorate the warriors of petchollers after the event was successfully held the local people made it an important part of the future celebration major sports events to see the construction of sports facilities as the entire development plan was indians in 1970 it was he who suggested that the city host the major sporting event as an opportunity to rebuild the host citys economic society his successful use of major sporting events to rebuild the declining urban centers of host cities has attracted the attention of many cities and governments and more cities want to use this method to revitalize development the success of largescale sports events hinges on robust local support these events have a global reach and offer several advantages not only showcasing a citys unique characteristics but also significantly impacting its economic development and the entire country largescale sports events attract tourists and investments bolstering local industries such as hotels restaurants and transportation which in turn create job opportunities and boost economic income additionally they foster social cohesion and cultural exchange providing residents with spiritual enjoyment and entertainment ultimately enhancing overall wellbeing and happiness however its crucial to acknowledge the potential risks and drawbacks associated with such events one of the primary concerns is the substantial capital investment required if not meticulously organized and planned these events can lead to financial burdens furthermore they can disrupt residents daily lives causing issues like overcrowding noise pollution and traffic congestion another significant consideration is the environmental impact and resource consumption largescale sporting events demand substantial energy and water resources for venues lighting heating and more they can also result in environmental challenges including waste generation and sewage moreover the impact on the lives of nonprofit groups within the city and the utilization of venues and facilities after the games require thorough examination while successful largescale sporting events can elevate a host citys reputation and offer opportunities for local economic and urban development there has been limited research on the various costs and noneconomic social impacts associated with such events taking the 2022 qatar world cup as an example its unfortunate that there have been unprecedented numbers of deaths and exploitative practices during the events preparation with an estimated 4000 workers losing their lives in qatar in conclusion largescale sports events bring significant benefits but also pose considerable challenges and ethical concerns comprehensive research and planning are necessary to strike a balance between the positive impacts and potential drawbacks ensuring that these events contribute positively to host cities and their residents through research this paper points out that there are many aspects of social impact of sports events on host cities including economic benefits economic costs city honor urban development transportation facilities and security pressures this research can help governments or sports organizations better understand peoples perceptions and concerns about hosting sporting events and how to avoid them reasons for qatars successful bid for the world cup qatars economy booms in recent years more and more countries and cities have begun to compete for the right to host major sports events which can promote tourism marketing and the wide dissemination of national characteristics since 1995 qatars massive oil and gas exports have accelerated the countrys rapid development making qatars citizens one of the richest in the world with a personal gdp of 140000 in 2013 the situation in qatar has provided financial support for its bid to host the world cup however there are also concerns that qatar is too dependent on a limited supply of hydrocarbons so it launched the vision 2030 policy in 2008 to diversify its economy in the letter of intent included in the report on hosting the world cup in qatar there is a commitment to zero carbon emissions the development goal is to transform qatar into an economic and commercial hub by 2030 with a significant political economic and sociocultural status tourism contributes to the diversification of the economy and integrates sports tourism with the worlds biggest sporting event 3 complete facilities in qatar in addition international competitions are characterized by a short period from bidding to hosting and high preparation pressure which has certain challenges this requires builders to strengthen fair and transparent processes increase public participation and make efficient use of decisionmaking resources for comprehensive international events the host city needs to build multiple stadiums and supporting facilities at the same time and the location and layout of the new venue the planning and infrastructure construction of its surrounding urban areas are all issues that require special attention another characteristic of international competitions is their great influence which can often guide the regions history and culture folk customs economic development and scientific and technological progress therefore the venue design under international competitions should be innovative dare to break through and promote new processes new materials and new products 4 the legal risk is low in qatar the modular design of qatar stadium allows the stadium to be freely dismantled after the world cup and then rebuilt in poor developing countries therefore fifa determined that the legal risk of qatar hosting the world cup was low qatar in order to have the capacity to provide appropriate equipment and infrastructure aviation and other resources these advantages are due to the strong support of the national government the concentration of power in the hands of a ruling family and the rapid formulation and implementation of policies unlike the democratic systems in western countries which played a crucial role in qatars bid to host the world cup the hosting of the world cup is about the country and the world and naturally there are many setbacks as mentioned above the workers needed to build the world cup facilities in qatar are mainly from poor south asian countries and foreign workers account for a huge proportion in qatar with qataris accounting for only about 12 the urban construction industry owes its prosperity to overseas labor they are poorly paid but they have to endure long hours live in substandard dormitories have their passports confiscated have no freedom and the law often fails to protect their health and safety and their labour is exploited this situation continues to play out in other gulf states and asian countries but the world cup highlights the unfair treatment of labor in qatar risk analysis during the preparation and holding of the qatar world cup however the most important thing is the 2022 qatar world cup a small country with an area of only more than 11000 square kilometers and a population of only 168 million which is watched by more than 1 billion people in the world cup and the event lasts for up to 1 month with a cost of more than 220 billion us dollars the qatar world cup entered the global vision with the most magnificent world cup marketed the national image enhanced its international status and took a key step towards the 2030 national visionpaving the way for national transformation and highquality development in the postoil era 6 the world cup in qatar also made a name known to the world lussell the main stadium of the 2022 world cup is called lucerde stadium with repeated focus on global television cameras lusail stadium has become one of the most recognizable landmarks of this world cup and will become qatars city of the future lucerneville will also have the worlds largest cooling system a natural gas pipeline network that connects the entire city as well as smart metering smart grid and integrated traffic management systems covering the entire city the qatar world cup not only aims to create an open modern and friendly international image in front of the world attract more investment and tourism opportunities but also promote the overall infrastructure speed and quality with the help of the event and eventually become one of the most important scientific cultural and trade hubs in the middle east and even the world 7 however the qatar world cup on such a large scale has the highest number of deaths in history with about 15000 of all foreigners dying within its borders 8 this is mainly due to three points accountability for workers rights first the qatari government has historically held little accountability for workers rights and the number of workrelated deaths in qatar is increasing despite reforms such as the socalled workers charter aimed at raising wages workers are trapped in the kafala system which is unique to the middle east known as the guarantor system which is essentially modern slavery which stipulates the employer keeps the workers passport and cannot leave the country without the employers approval workers are not allowed to change jobs without the approval of the employer they must not join trade unions and cannot enter labor dispute procedures it is a crime etc to leave the workplace without permission labor is subject to the kafala system more like disposable goods 9 since qatar won the right to host the 2022 world cup about 1200 migrant workers from india and nepal have died it is estimated that in the eight years leading up to the world cup 4000 workers in qatar will die in world cuprelated accidents some in stadiums and some while building other facilities qatar has said it will work to reduce the number of deaths qatars laws are imperfect second after the world cup it was estimated that about 6750 workers lost their lives due to extreme working conditions lack of proper safety measures and medical care this number may be higher but it is difficult to determine the exact number due to the lack of transparency by the qatari government the international labour organization the united nations body believes that this is an underestimation of the real situation qatar does not classify cases of heart attacks and deaths from respiratory failure as workrelatedin fact these are frequent symptoms of heat stroke because the highest temperature in qatar is 50 degrees foreign workers who come to qatar to work in the heat every day work in harsh construction sites and water in the desert is so precious that most employers do not provide free drinking water to workers to further reduce costs in addition some workers died of heart failure after 148 days of continuous work however according to local law the deceased is treated as a natural death if it is not an autopsy but only criminal cases are eligible for free autopsy so workers are judged to die of natural causes 10 the lack of site facilities thirdly construction risk primarily pertains to the challenges associated with venue and infrastructure development encompassing design technology construction environmental considerations and more in the case of qatar hosting the 2022 world cup the country faces the ambitious task of constructing nine new stadiums while renovating three existing ones while qatar boasts substantial financial resources due to its oil wealth it confronts a unique challenge the region experiences scorching summer temperatures with surface temperatures reaching nearly 50 degrees celsius rendering it unsuitable for players and spectators to address this issue qatar is employing cuttingedge technology to build stadiums equipped with airconditioning systems ensuring that the temperature inside the stadiums remains a comfortable 20 degrees celsius the qatari government has also committed to ensuring that these stadium airconditioning systems meet zero carbon emissions standards despite achieving this remarkable feat in creating showcase stadiums with advanced cooling systems the construction risk remains substantial particularly when building massive stadiums capable of accommodating up to 50000 spectators 11 qatars means of avoiding the risk of hosting the event setting the kafala policy the government of qatar which had received complaints from the population was developing a comprehensive training course on dispute resolution with plans to design standard operating procedures and monitor the efficiency of grievance mechanisms in addition to developing the skills of mediators workers representation and social dialogue are the ilos top priorities when negotiating reforms with the qatari government social dialogue took various forms and new legislation led to the establishment of joint committees for workers management at the enterprise level an ilo study is exploring the feasibility of making joint commissions mandatory for companies of a certain size the authors propose that the ilo should create more sectoral bodies to support the goal of broader social dialogue at the sector level since 2019 the qatari government has established 14 qatar visa application centers to provide appropriate information to migrants in 6 countries and reduce opportunities for contract fraud qatari law states that workers should not pay recruitment fees but a recent survey conducted by the qatar institute of social and economic survey found that 54 percent of lowwage workers come to qatar for a fee illustrating qatars inadequate policies and the resulting debt often leaving workers vulnerable to exploitation or abuse 12 ensure the authenticity of labor contract second according to qatari state media the qatari cabinet has announced changes to the regulations on the administration of the entry and exit of foreigners this week employers can no longer decide whether workers should be granted exit visas but instead leave it to government committees to decide 13 the author argues that qatar should introduce a minimum wage system as soon as possible so that foreign workers can be treated as a signed labor contract so as not to be lowered by their employers upon arrival so as to ensure the authenticity of the contract apply more funds to improve for construction risks the government should establish a reasonable financial budget and supervision mechanism control capital investment and risks ensure the sustainability and economic benefits of the event and apply more funds to invest in design technology construction environmental protection etc environmental protection and resource conservation should also be strengthened such as the use of clean energy watersaving measures and garbage disposal and sewage treatment with the development of the times the world cup should be guided by the construction of the smart fire protection system through the largescale event security remote monitoring system comprehensive use of big data cloud computing internet of things mobile internet and other new technologies venues hotels and surrounding key areas to carry out fire protection facilities internet of things transformation conclusion the economic sociocultural political and environmental spheres are closely linked to the sports industry the benefits of hosting the world cup are very attractive to potential host cities in this situation but the cost of hosting the world cup is huge and it is likely to exacerbate existing inequalities in the social system this article is only a personal point of view there are still some shortcomings mainly including several aspects 1 the research scope is limited as a result the reliability and authenticity of the research have been limited 2 there are some defects in the research method although the various research methods used in this study can explore the research problem from different angles there may be some defects in the specific operation process for example literature reviews may be insufficiently informative therefore it is necessary to further improve the research methods and improve the reliability and scientific of the research in the future 3 there are some limitations in the research conclusions due to the particularity and complexity of the research object the conclusions of this study have certain limitations and may not be fully applicable to other fields or problems therefore it is necessary to further expand the research objects and explore related issues in the future research so as to improve the universality and feasibility of the research conclusions this study has some advantages and disadvantages which need to be further improved and optimized in the future research it is hoped that this study can provide some reference and reference for the research and practice in related fields and make certain contribution to the development and progress of this field

the full name of the world cup is the fifa world cup which is participated by the worlds national football teams symbolizing the highest level of football the highest honor and the greatest influence if a country wants to host the world cup it first needs to be a member of international football the second is to submit an application to the national fifa which can be hosted by two or even three countries and then voted by all fifa member states so the world cup venue is very strict because the world cup has always been a significant sporting event which will bring many benefits to the local area of course there are many disadvantages this paper analyzes the bidding experience and risk assessment of hosting the world cup over the years analyzes and puts forward relevant risks by identifying the qatar world cup summarizes the hidden dangers and problems existing after the world cup provides effective concepts and solutions for the construction of risk response strategies and puts forward specific measures for future world cups for the problems raised

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introduction there are several reasons to analyse socioeconomic inequalities in the lack of access to childrens dental care services first oral health status may have an impact on healthrelated quality of life 1 in fact lack of appropriate oral health can lead not only to aesthetic problems related to appearance like those generated by obesity or baldness 2 but also to functional problems in adulthood like chewing eating and having social relationships it can even contribute to the development of some severe illnesses like coronary heart diseases or atherosclerosis second oral diseases have a high prevalence and incidence in all regions of the world with the greatest burden of oral diseases being on disadvantaged and socially marginalized populations 6 third adult oral health is predicted by oral health in childhood as well as by childhood socioeconomic advantages or disadvantages 7 there is evidence of a relationship between socioeconomic conditions and early childhood caries as this condition is more frequently found in children that live in poor economic conditions in addition one of the most common chronic diseases in childhood is early childhood caries 10 fourth prevention improves oral health in childhood and substantial cost savings can be derived from this 11 prevention involves a combination of community individual and professional measures regarding the latter it consists of visiting the dentist at least once a year despite having no symptoms at all in order to prevent dental pathologies and to educate children about how to take care their teeth fifth treatment of oral disease is very costly to the extent that it is the fourth most expensive disease to treat in most industrialized countries 12 therefore the importance of socioeconomic level as a potential driver of both oral health and access to dental care has led us to analyse the inequalities in the lack of access to dental care services by socioeconomic groups our research is undertaken in the spanish context and for a sufficiently long period on the basis that rather than identifying the extent of inequality in the lack of access at a particular point in time it is more informative and relevant to analyse whether such a situation remains or whether there is a trend in the access pattern over time spain has a national health care system characterised by universal coverage and tax funding responsibility for healthcare provision lies with each of the seventeen comunidades autónomas these regions are a consequence of the progressive political decentralisation process undertaken since the seventies a remarkable objective of the spanish national health service has been to achieve a wider coverage in dental care services for children however the time and way in which this aim has been undertaken has varied among regions in the early 90s pais vasco and navarra were the first two regions that developed the so called childrens dental care programme padi such programmes widened the provision of dental care with new services and improved childrens access possibilities through agreements with private dental clinics patients could choose between the corresponding public centre or the nearest private dentist enrolled in the programme the final aim of the padis programmes was to promote the utilisation of dental care services during the following years the padis programmes were progressively generalised across other regions andalucía in 2002 murcia in 2003 aragón baleares y extremadura in 2005 and canarias in 2008 castillaleon and castillala mancha in 2003 and 2004 respectively and madrid in 2010 chose a mixed model public in the first instance but susceptible to being referred to the private sector for particular dental treatments the remaining regions just maintained the conventional public model not having additional dental care services for children 13 therefore the progressive implementation of different dental care programmes across spain had as their main objective to achieve greater access to dental care services for children irrespective of the socioeconomic level of their households in line with this cortés and llodra 14 indicate first the need to guarantee free of charge access to preventive and treatment dental services for children between 6 and 15 years old as a strategy to achieve good levels of oral health in maturity second the report suggests introducing reforms that would reduce inequalities in access to dental services irrespective of characteristics like socioeconomic level or the geographical area of residence a crucial question is therefore whether in the past twenty five years there has been an improvement in access to dental care services and whether it is independent of the socioeconomic characteristics of childrens households some studies have tackled the analysis of inequality in access to dental care services in spain considering the use of dental care services across socioeconomic groups normally in a crosssectional setting stoyanova 15 finds that both incomeinequality and incomeinequity exist in dental care using an adult sample from 1997 tapiasledesma et al 16 in a study of children aged 315 for 2001 conclude that children in households with a lower family income and parents with the lowest educational level register a significantly lower use of dental services the year previous to the survey other studies have also considered the effect of contextual variables such as the type of dental care model offered in different regions in use of dental care services for instance garcíagómez 17 shows evidence that indicates that the infant oral care programme promoted in the país vasco region is associated with an increase in the probability of children visiting the dentist pinilla and gonzález 18 analyse the impact on equity in the long run of different infant oral care programmes they estimate the probability of visiting the dentist together with the number of visits aiming to compare regions with the programme and regions without the programme they conclude that in comparison with regions without infant oral care programmes those regions that do have it the probability of using it is greater and independent of household income also barriuso and sanz 19 analyse the individual and contextual variables associated with the use of oral health services by a population aged 6 to 15 and adjusted by need which is approached by different measures of dental disease they conclude that the use of oral health services is lower than recommended and is positively correlated with socioeconomic level and with living in regions having an infant oral care programme of 10 or more years standing to our knowledge there have not been any studies that analyse this topic for a sufficiently long period to ascertain whether any inequalities in access persist therefore the aim of this research is to analyse inequalities in the lack of access to dental care for children in spain by socioeconomic groups over the period 19872011 methods data sources data at the individual level comes from eight editions of the spanish national health survey conducted in spain in 1987spain in 1993spain in 1995spain in 1997spain in 2001spain in 2003spain in 2006spain in and 2011 these repeated crosssectional surveys were specifically established to collect data on adult and child health indicators that are representative at the national state level the snhs contemplates a sample of noninstitutionalized children aged from 0 to 15 years old with the exception of 2011 when the sample was from 0 to 14 distributed throughout the 17 regions of spain ceuta and melilla were excluded from the analysis as information on children was not gathered from 19871997 due to their relatively small sample size data from the 1995 and 1997 surveys were analysed jointly details of the methodology sample design sample size and sampling procedure together with the anonymous microdata of the eight national health survey editions are publicly available 21 regional rate of dentists per 100000 inhabitants data come from the spanish national statistics institute 22 after a generational classification of individuals based on reported age and year of the survey we have combined the microdata of the eight published editions of the snhs the combined file contains common variables across all of the snhss which provides us with a sufficiently homogenous series to undertake pooled analysis an average effective sample of 89 households has been obtained from the initials dwellings selected for all years 19872011 after eliminating cases with missing data a final analytical sample of 24689 was obtained across the eight surveys measures of inequality in access to dental services the approach used to measure lack of access to dental care is based on a dummy variable which takes a value of 1 for children who report having never gone to the dentist and 0 otherwise our analysis is undertaken for children aged between 6 and 14 the target population for preventive dental care programmes that was common to all regions covariates as explanatory variables we have considered demographic socioeconomic and contextual variables for which there is information across the different snhss particularly regarding sociodemographic variables we have considered age and sex with respect to socioeconomic variables we have just considered occupational social class of the head of the household regarding education level its inclusion together with social class gave problems of multicollinearity so we finally decided to use social class of the head of the household as proxy for socioeconomic status regarding contextual variables for each of the regions we have considered ratio of dentists per 100000 population and whether there existed a padi programme at the corresponding year specifically we considered the following covariates in our analyses age group in 3year intervals and sex family social class region of residence ratio of dentists per 100000 population at the year of the survey by region and finally a variable to take into account existing special childrens padi programme by region survey year was also included using one indicator variable each for the eight surveys social class variable is based on the occupation of the principal wage earner in the household following regidor et al 23 we have assigned each of the occupation categories shown in the different snhs to one of the following four social classes upperlevel nonmanual workers lowerlevel nonmanual workers skilled manual workers and unskilled manual workers for the majority of snhs the occupation categories were assigned as follows upperlevel nonmanual workers lowerlevel nonmanual workers skilled manual workers and unskilled manual workers for the rest of years there were slight variants particularly for 2003 2006 and 2011 the categories were similar to those mentioned above but the cutoff number for employees was ten instead of six regarding 2001 a more thorough assignments was undertaken given the much wider information on occupation provided by this particular snhs analysis we estimated pooled logistics regression models to analyse the binary outcomes associated with having never been to the dentist we estimated our models with regions specified as random effects and as fixed effects in separate models while the former has the advantage of being more efficient the latter is often considered to be less biased as all observed and unobserved characteristics of the region that are timeconstant are accounted for 24 models included interaction terms for time and social class the first model m 1 is our fixed effect logistic the second model m 2 is the mixedeffect logistic regression containing both fixed effects and random effects at intercept the results of fixed effects were shown as odds ratios with their 95 confidence intervals measures of random effects in mixedlogit included an intracluster correlation the icc was calculated by the linear threshold according to the formula used by snijders and bosker 25 regression diagnostics were used to judge the goodnessoffit of the model they included the akaikes information criterion and bayesian information criterion the statistical significance of covariates was calculated using the wald test all significance tests were twotailed and statistical significance was defined at the 5 alpha level results figure 1 shows the proportion of children who had never visited the dentist decreased from 495 in 1987 to 84 in 2011 indicating an improvement in childrens access to dental care services as measured in this paper table 1 presents the summary statistics of the variables considered in our analysis for the seven years of the analysed period given the dichotomous nature of most of the variables mean proportions are presented in such a way that the variability in the distribution of the characteristics that explain the probability of not having ever visited the dentist can be appreciated apart from the considerable reduction in the proportion of children who had never visited the dentist already noted in figure 1 table 1 shows that the demographic characteristics apart from some particular peaks do not significantly change during the period analysed regarding the socioeconomic level of the spanish population it can be observed on the one hand that for the period between 1987 and 2006 there is a relative increase in the weight of the two intermediate social classes to the detriment of the upper nonmanual and unskilled manual this pattern have a change in 2011 when there is a relative increase in the proportion of uppernon manual and unskilledskilled manual to the detriment of lower nonmanual social class in part probably due to the effects of the economic crisis the results of logistic regressions are shown in table 2 both fixed effect and mixed effect models present very similar results and statistical significance estimated coefficients for the interactions between time and social class and regional dummies in m 1 and the interactions in m 2 have been omitted in order to reduce the size of the table and make it clearer both m 1 and m 2 models present very similar global significance and goodness of fit according to the aic criteria m 1 would be slightly better than m 2 whilst according to the bic criteria m 2 would be slightly better than m 1 however it can be observed that in the fixedrandom effects model m 2 the percentage of observed variability in the dependent variable having never visited the dentist attributable to being resident in a particular region is very low icc 18 this leads us to consider fixed effects in the variable region of residence and choose the simplest model m 1 when interpreting the interactions between time and social class variables girls are significantly less likely to have never visited the dentist showing an odds ratio of 091 one explanation that should be further investigated is that girls might be more likely to be flirty than boys and therefore they might go earlier to the dentist regarding age compared with children aged 68 those children aged 911 and 1214 are also less likely to have never visited the dentist with odds ratios of 043 and 033 respectively these results seem reasonable as with age it is more likely to have oral health problems and therefore it is more likely to attend the dentist the number of dentists per 100000 inhabitants in the region of residence is significant when explaining the probability of having never visited the dentist indicating that a greater availability of dentists per inhabitants facilitates childrens access to the dentist in addition living in a region with a padi programme significantly reduces the probability of having never visited the dentist compared to those children who live in regions without this sort of programme in other words having padis programmes also improves the probability of access to dental care services finally the trend of the odds ratio of survey year indicators is consistent with the one observed in the descriptive analysis the probability of never having visited the dentist decreases over time figure 2 shows the odds ratios by regions over the course of this eleven year period the regions where children have a lower probability of having never visited the dentist are navarra país vasco cantabria galicia aragón castillaleón y valencia on the other hand extremadura canarias and andalucía have a higher probability indicating a worse access to dentist care services in these regions we are also interested in estimating time trends of inequalities in the lack of access to dentists among children between 1987 and 2011 beta parameters for time dummy variables tell us about the starting place of the time trajectory however we have a special interest in estimating the changes in the slope related to the family social class variable during this trajectory we therefore compared the odds of not visiting the dentist for each social class level compared to visiting the dentist stratified by year the estimates are presented in figure 3 as line graphs showing the proportion of the population experiencing the outcome of interest within each social class level in 1987 the probability of not having ever gone to the dentist is more than two times higher for children in the unskilled manual social class than for those in the upper nonmanual social class and this difference is not reduced significantly throughout the period analysed rather it increases as in 1993 in 199597 in 2001 in 2003 and in 2006 to end in 2011 slightly below than in 1987 the latter might be due to the marginal effect of the last two regional padi programmes launched in canarias and extremadura so despite the mean probability of not having ever gone to the dentist falls considerably discussion the results reported in this paper show evidence of a reduction in childrens lack of access to dentists in spain over the period 19872011 however this reduction has not corrected the socioeconomic inequalities in childrens access to dentists in spain in line with other previous studies like barriuso and sanz 26 or tapiasledesma et al 16 we have found a lower access of children belonging to households with low socioeconomic status in addition unlike most previous studies we have done a longitudinal study which has allowed us to show that far from being reduced the inequality has remained or even widened over the years regarding our dependent variable having never visited the dentist it clearly indicates a lack of access to dental care services to some extent this represents an advantage with respect to other measures of access that would require a dental care need adjustment any child over 5 years old should have visited the dentist for preventive reasons 27 in other words every single child is in need of these types of services irrespective of her oral health state therefore not having visited the dentist before by the time of the surveycorresponds to a lack of access not having to adjust for dental care need is a methodological advantage first it skips the controversial task of measuring dental care need second it avoids the potential problems of endogeneity of a need variable present in models of utilisation unlike other health care services a high proportion of dental visits are preventive and if they are effective then a childs current oral health heavily depends on past use of services 28 however adhoc information of need would be relevant to complete our analysis if childrens oral health need ie inequalities in lack of access that favour higher socioeconomic groups evidenced in our research are accompanied with inequalities in the distribution of need then there would be evidence of the inverse care law that has been proven elsewhere for childrens dental care for instance jones 31 analysed the association between the british national health service dental registration and deprivation the system worked as follows children got free dental treatment under a capitation scheme with an nhs dentist but if children did not attend within 24 months their registration lapsed and were deleted from the capitation list he found that registration and lapse rates were significantly associated with social deprivation it is also true that having visited the dentist at least once does not guarantee an appropriate access to these services in order to further discriminate among those who have visited the dentist additional information on use of dental care services in a given period adjusted by dental care need would give a more thorough view of access to dental care however this information was not available for the period analysed the main policy change related to childrens dental care in the period analysed has been the implementation of the different regional padi programmes however the extent to which the results obtained in this research are attributable to such programmes or to changes in other demand and supply factors is something that cannot be answered in this paper in addition given the heterogeneity in the services provided in different regions it is likely that there may be different effects among those regions with the infant oral care programmes for instance garciagomez 17 in a study of the país vasco concludes that such programmes have not had a differential effect on the proportion of those who have never visited the dentist with respect to regions that did not have it rather the reduction of this proportion is attributable to a general trend in spain pinilla and gonzález 18 conclude that in comparison with regions without padis the probability of using dental services is greater and independent of household income in those regions with padi programme additionally barriuso and sanz 19 conclude that the use of oral health services is lower than recommended and is positively correlated with the socioeconomic level and with living in regions having a padi of 10 or more years running in our longitudinal study it has been shown that children living in regions with the padi programme have greater access to dental care services and this condition has improved over time an analysis that takes into account not only the time but also the geographical dimension in the application of the padis would have been desirable to analyse to what extent the reduction in the proportion of children who have never visited the dentist is due to the effect of the infant oral care programmes or to changes in other factors the ultimate aim of childrens dental care is to improve oral health elsewhere it has been shown that the padi has been effective in improving childrens oral health 32 however it would also be desirable to know whether this improvement is also concentrated among those households with higher socioeconomic level as expected given the results obtained in our research in addition it is interesting to note that the differences in access by regions found in our research are also in line with regional differences in oral health found by cortesmartinicorena 13 according to the childrens dental caries prevalence país vasco and navarra show lower prevalence whilst andalucía canarias and extremadura show higher prevalence just the same distribution that we have had for access in our paper if the final aim of a health care policy is to provide health services that can be used by the whole society including all population groups 33 then the results obtained in this research particularly those that evidence the persistence of socioeconomic inequalities in the access to dental care services should be taken into account by health authorities when designing childrens dental health programmes it might be of help to analyse first the reasons why those children belonging to lower socioeconomic levels experience a greater lack of access to dental care services that is whether this inequality it is driven by demand factors by supply factors or by a combination of both nevertheless any reference to the policy implications from the equity point of view must take into account that the aim of our study was to analyse socioeconomic inequalities in the lack of access to any type of childrens dental care rather than a study of equity in access to childrens dental care services published and have agreed to be accountable for all aspects of the research related to accuracy and integrity of any part of the work the three authors read and approved the final manuscript competing interests the authors declare that they have no competing interests authors contributions jp mn and ia discussed the motivation and design of the research specifically jp has contributed to the conception and motivation of the study and to the collection and preparation of the data mn has contributed to the design of the research jp and mn have contributed to the estimation process and the interpretation of results ia has contributed to the motivation of the study selection of contents and elaboration of the discussion the three authors have also been involved in drafting and revising the manuscript have given final approval to the version to be

introduction adult oral health is predicted by oral health in childhood prevention improves oral health in childhood and consequently in adulthood so substantial cost savings can be derived from prevention the burden of oral disease is particularly high for disadvantaged and poor population groups in both developing and developed countries therefore an appropriate and egalitarian access to dental care becomes a desirable objective if childrens dental health is to be promoted irrespective of socioeconomic status the aim of this research is to analyse inequalities in the lack of access to dental care services for children in the spanish national health system by socioeconomic group over the period 19872011 methods pooled data from eight editions of the spanish national health survey for the years 19872011 as well as contextual data on state dental programmes are used logistic regressions are used to examine the related factors to the probability of not having ever visited the dentist among children between 6 and 14 years old our lack of access variable pays particular attention to the socioeconomic level of childrens household results the mean probability of having never been to the dentist falls considerably from 495 in 1987 to 84 in 2011 analysis by socioeconomic level indicates that in 1987 the probability of not having ever gone to the dentist is more than two times higher for children in the unskilled manual social class than for those in the upper nonmanual social class odds ratio 235 and this difference is not reduced significantly throughout the period analysed rather it increases as in 1993 odds of 239 and 2006 odds of 303 to end in 2011 slightly below than in 1987 odds ratio 180 conclusion there has been a reduction in childrens lack of access to dentists in spain over the period 19872011 however this reduction has not corrected the socioeconomic inequalities in childrens access to dentists in spain

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introduction a properly structured life insurance plan can be a powerful part of a familys financial plan it is especially useful in managing tax liabilities unexpected expenses lost income and household services after the death of a family member however this basic observation is not a truism for all parts of american society in particular the existing literature suggests a very diverse usage of life insurance ownership among households in different ethnic and racial groups if these suggestions are correct financial planners may face special challenges when constructing plans for clients who are in a group that tends to underutilize life insurance products alternatively it may be that the decision to use life insurance may be a function of family size rather than ethnicity studies on family support networks suggest that the presence of strong family support networks are important in determining how families manage household resources could family support networks be perceived by clients as a substitute for a properly designed life insurance program this is an important distinction for financial planners because it could suggest a focus on family size rather than cultural background when deciding how to educate clients about insurance products this study investigates how family support systems affect life insurance purchasing decisions across various ethnic groups by performing this analysis we are able to help distinguish whether possible underinsurance tends to result from strong family support networks accompanying larger family size or whether it tends to be a function of ethnic background or whether it is an interaction between the two specifically we focus on the effects of household size and ethnicity on the face value of insurance policies purchased according to data from the 19922010 survey of consumer finances the results of this study have practical value for financial planners by providing insight into minority households predilections regarding life insurance products and the perceived need for such tools in their financial plans by recognizing minority households inclinations towards life insurance when crafting a financial plan advisors can reinforce their relationships and longterm impact on their clients financial wellbeing literature review insurance provides an effective way for individuals to protect against a severe downturn in consumption by pooling and sharing risks beneficiaries will receive their insurance payouts when a covered death occurs this is an example of smoothing consumption over time a primary goal of financial planning on the other hand households with extended familial ties may plan to rely on the safety net provided by family members to offset the financial loss after the death of a household earner illustrated in part by the increase since 1990 in the number of older individuals who live in multigenerational households there is evidence of interdependence and strong family support networks among minority households minority households also receive greater financial assistance from family members compared with white households white households have relatively higher rates of insurance coverage compared to black households large family support systems could be used as a substitute for life insurance ownership as earnings produced by the lost family member may be replaced by other household members findings indicate that black hispanic and asian households utilize adaptive strategies of strong extended family networks and collectivism and also exhibit group loyalty these adaptive strategies foster childrearing goals of socialization for interdependence when comparing black and hispanic households black families have larger support systems studies on family support networks suggest they are important in determining how families manage household resources tienda and angel analyze hispanic black and white families to determine whether extended household structure moderates the impact of labor market disadvantages they report the following hispanic and black households are similar in their dependence on extended household support whereas white households are less likely to rely on extended family support nonimmediate members in black and hispanic households contribute significantly to total household income nonimmediate members in white households do not appear to participate contribute significantly to total household income mutran finds that when controlling for socioeconomic status elderly black parents are more likely than elderly white parents to provide financial assistance to adult children padgett uses the 1988 national survey on families and households to assess the extent of network involvement and its relationship with household labor when just examining married couples approximately half of black couples receive tangible assistance related to household production most commercial transactions include some element of trust if we define trust as the likelihood an individual attributes to the possibility of being cheated we may better understand the greater dependence of minorities on their families in contrast to a product sold by an insurance salesman within a principalagent theoretical framework an individuals level of trust may affect financial decisions including the decision to purchase life insurance exchange systems involve a series of individual actions based on assymetric information trust helps to manage responses to the innate uncertainty of exchange relationships brehm and rahn argue that experiences with discrimination may explain the pervasiveness of low trust among black households discriminatory practices from agents within the financial and capital markets combined with a history of restricted access to these markets may lead to a negative perception by minority families of all agents and the products they sell for example in the early part of the 20th century major life insurance companies excluded black customers or set discriminatory rates as a result blackowned insurance companies began selling cash value burial policies to provide affordable life insurance coverage for working class black families data we use the 1992 1995 1998 2001 2004 2007 and 2010 scf for our analysis the scf is a triennial crosssectional survey that provides detailed financial information on us households it contains the most detailed balance sheet information of any publicly available nationally representative dataset it is sponsored by the united states federal reserve board in conjunction with the department of the treasury and other governmental agencies since the scf oversamples wealthy households the descriptive statistics in our analysis are weighted to generalize to a nationally representative population the total sample size over the time period was 32371 there are several factors that have been found to influence the decision to purchase life insurance the presence of a spouse may increase the demand for life insurance as the purpose of life insurance is human capital replacement for an individual with insurable interest truett and truett find age income and education level affect the demand for life insurance because human capital declines with age age should be negatively associated with the likelihood of owning life insurance a bachelors degree is a human capital signal that proxies for a steeper earnings path that should increase the likelihood of owning life insurance there is evidence that the demand for life insurance is positively related to the number of dependents in a household a large amount of liquid assets may decrease demand because of the ability to selfinsure campbell finds that accumulated household wealth acts as a substitute for life insurance selfemployed individuals do not have access to employerprovided group life insurance which may reduce the likelihood of ownership households that are currently unemployed may lose access to employerprovided life insurance if the coverage is not portable which may reduce the likelihood of ownership campbell finds bequests to be positively associated with the demand for life insurance planning to leave a sizable estate may also increase the demand for life insurance particularly for cash value polices in terms of premium pricing a respondent who indicates that they are in fair or poor health should have a relatively higher premium payment than someone who indicates good or excellent health females have a longer life expectancy compared to males decreasing the cost of a policy covering females finally individual risk preferences should influence the demand for life insurance ownership descriptive statistics table 1 displays the ownership percentages of life insurance based on race and household size life insurance ownership declines for black households as they move from a household size of one three five or more members that trend is not evident for any other racial groups table 2 shows the median face value amounts of term life insurance held by those who own term life products sorted by race and household size table 3 displays the median face value amounts of cash value life insurance held by those who own cash value life products also sorted by race and household size in the larger household size categories only black and other races show a decrease in the face value amount of term life insurance when comparing a household size of four to a household size of five or more for the other race category the same trend holds for cash value life insurance however for black households the face value amount of cash value life insurance increases when moving from a household size of four to a household with five or more members for hispanic households when comparing a household of four to a household of five the face value amount of cash value life insurance actually declines method a logistic regression model is constructed to better understand how interactions between different races and different levels of household size affect the likelihood of owning life insurance if the respondent owns a life insurance policy the variable is coded as one with no ownership of life insurance as the reference group and coded as zero race is broken into categories that include white black hispanic and other races respondents who identified themselves as white are used as the reference group in the multivariate analysis household size does not include people who do not usually live in the household or who are financially independent a household size of five includes households with five or more members our control variables include inflationadjusted income inflationadjusted net worth and inflationadjusted liquid assets income net worth and liquid assets were indexed to 2010 dollars and sorted from lowest to highest quartile other control variables include the age of the respondent and whether the respondent has a bachelors degree owns a home is married is a male is selfemployed is employed plans to leave a sizeable estate has a child present selfidentifies as healthy 1 and is willing to take substantial financial risk with personal investments in addition a dummy variable was included to control for the year in which the survey was conducted the year 1992 was used as the reference group where i ϭ control variables income net worth liquid assets bachelors degree ownership of a home age married male healthy selfemployed unemployed plan to leave a sizeable estate the presence of a child willingness to take substantial financial risk and the year in which the survey was conducted two separate tobit models were constructed to understand how interactions between different races and different levels of household size affect the face value of term life insurance and cash value life insurance common examples of cash value policies include whole straight or universal life insurance the dependent variables contain a large percentage of zero values because of nonownership when a dependent variable contains a large number of zero values the use of an ordinary least squares model may result in biased coefficient estimates a tobit model is not subject to this same bias the insurance face value amounts were inflation adjusted to 2010 dollars and squarerooted to reduce skewness the face amount of cash value life insurance was broken into quartiles and included as a control variable when the dependent variable was the squarerooted face amount of term life insurance the face amount of term life insurance was broken into quartiles and included as a control variable when the dependent variable was the squarerooted face amount of cash value life insurance where i ϭ control variables income net worth liquid assets bachelors degree ownership of a home age married male healthy selfemployed unemployed plan to leave a sizeable estate the presence of a child willingness to take substantial financial risk the year in which the survey was conducted and the face amount of cash value life insurance where i ϭ our control variables income net worth liquid assets bachelors degree ownership of a home age married male healthy selfemployed unemployed plan to leave a sizeable estate the presence of a child willingness to take substantial financial risk the year in which the survey was conducted and the face amount of term life insurance results the results for model are displayed in table 4 as household size rises for black and hispanic families the likelihood of life insurance ownership declines a black family with a household size of three is 2885 2 less likely to own life insurance compared with a nonblack family of the same household size a black household with five or more members is 5355 less likely to own life insurance compared with a nonblack family of a comparable household size a hispanic family with a household size of two is 2482 less likely to own life insurance compared with a nonhispanic family of two a hispanic family with five or more members is 5961 less likely to own life insurance compared with a nonhispanic family of a comparable household size fig 1 graphically displays the likelihood of life insurance ownership for black and hispanic families as household size rises the odds ratios listed in figure 1 are statistically significant tables 5 and7 display the results for model or the relation between the face value amount of term life insurance and household size for black families as household size rises the conditional mean face amount of term life insurance declines a black household with two members has 20475 3 less term life insurance compared with a nonblack family of the same household size a black family of three has 74038 less term life insurance compared with a nonblack family of three the face value of term life insurance is 98910 less for a black household with five or more members compared with a nonblack family of a comparable household size the average face amount of term life insurance is 28560 less for a hispanic family of four compared with a nonhispanic family of the same household size a hispanic family with five or more members has 68583 less term life insurance compared with a nonhispanic family that is the same size fig 2 graphically represents the results in table 7 the odds ratios that are listed are statistically significant the results for model or the interaction between the face amount of cash value life insurance and household size are shown in tables 6 and8 as household size rises the conditional mean face amount of cash value life insurance has a statistically significant decline only for hispanic families with a household size of four or more members a hispanic family with a household size of four has a face amount of cash value life insurance that is 24092 less than a nonhispanic family of the same household size a hispanic family with more than four members has a face amount of cash value life insurance that is 27680 less than a nonhispanic family of a comparable household size conclusions the multivariate results indicate a negative relation between household size and the ownership of life insurance for black and hispanic families when controlling for a variety of demographic and socioeconomic variables the conditional mean face value amount of term life insurance declines for black families as household size rises compared with nonblack families this relation is statistically significant for all black household sizes the conditional mean face value amount of term and cash value life insurance declines for larger hispanic families as household size rises from four to five or more members implications and future research our findings suggest that black and hispanic families used household members as a substitute for life insurance between 1992 and 2010 the use of household members as a life insurance substitute is not utility maximizing and a contingent claim should be purchased to replace the lost human capital in the event of a household members death financial planners or life insurance agents can use these findings to help ensure that black households and larger hispanic households are adequately insured one possible explanation for why black families act as though household members are a substitute for the face value amount of term life insurance but not cash value life insurance is that black families purchase cash value policies specifically for burial purposes the low median face value amounts of cash value policies among black households as compared with all other racial groups provides some additional indication that these cash value policies may be used for that purpose 4 however black families have also been found to have lower risky asset ownership compared with white families as household size rises and so it is possible that black families are using cash value life insurance as an alternative investment financial planners have many tools available to help their clients allocate resources over time life insurance is an important part of a financial plan as it protects families against a sharp decline in consumption however when families have alternative arrangements to meet the needs of the household such as through a large family network purchasing an adequate amount of life insurance might appear to be excessive clients who believe they have a strong family network may be underinsured heo grable and chatterjee find evidence to suggest that life insurance acts as a compliment rather than a substitute for wealth therefore minority households may not be thinking about life insurance as a wealth replacement option upon the death of a household member it can be detrimental to use rules of thumb when assessing the need for life insurance recognizing potential cultural biases and the possible role of household members are topics that financial planners should explore when meeting with their clients to discuss what type of life insurance and how much coverage is needed to meet the goals outlined within a financial plan there are multiple areas for future researchers to explore as it pertains to minority household size and the decision to purchase life insurance future research should focus on why there is a divergence in the decline of the face amount of term and cash value life insurance as household size rises for black families the question of how much human capital is left uninsured by minority households as family size rises also remains unanswered these are questions we hope will be explored in future studies notes 1 as defined as excellent or good health 2 the odds ratio was derived by taking the coefficient for a household size of three and adding it to the interaction variable coefficient the interaction variable coefficient is multiplied by 1 to designate a black household ϩ ϭ ϫ03404 the exponential is then taken to get the odds ratio of 07115 3 this value is derived by taking the coefficient for a household size of two and summing it with the coefficient for a black household size of two the interaction variable coefficient is multiplied by 1 to indicate a black household ϩ ϭ ϫ143092 the solution is then squared since the square root of the dependent variable was originally taken to reduce skewness 2 ˆϭ ϫ20475 the negative sign is retained after the solution is squared 4 refer to table 3

this study uses the 19922010 survey of consumer finances to analyze whether the likelihood of life insurance ownership and the face value amount of life insurance changes for minorities as household size changes we find that the likelihood of life insurance ownership declines for black and larger hispanic families as household size increases when controlling for a variety of socioeconomic and demographic variables there is also a significant decline in the face value amount of term life insurance purchased by black families as household size rises we provide possible explanations for these effects and also discuss implications for financial planners

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indigenous cultural generative acts to reduce generative mismatch and improve health of all generations jordan lewis university of minnesota medical school duluth campus duluth minnesota united states the gerontological literature predominantly focuses on agingrelated losses and less on the gifts we acquire as we age alaska native elders have experienced a lifetime of adversity which persists today but they have also remained resilient one characteristics of successful aging among alaska native elders is their commitment and passion for sharing their teachings with the youth generativity is concerned with using personal resources to improve the quality of life for future generations while not commonly used in gerontological social work research it is a cultural practice among indigenous elders this decade long study has been exploring the concept of successful aging from an alaska native perspective or what it means to age in a good way in alaska native communities qualitative indepth interviews have been conducted with 154 elders representing 20 participating communities across the state of alaska to explore the concept of successful aging and the role of generativity in the aging process for this presentation 108 interviews with alaska native elders explored successful aging this presentation will highlight the critical role generativity plays in alaska native elders ability age in a good way how generativity can be adapted to bridge the generative mismatch happening between generations and support each generation to healthy and meaningful lives this presentation will also explore innovative and culturally responsive ways to teach the youth about aging in a good way and how families and communities can support their elders to be meaningful engaged in the rapidly changing families in the arctic session 2125 abstract citation id igad1040516 building bridges to connect between needs resources and rural residents chair nancy karlin cochair lisa ann wiese discussant cassandra ford the percentage of older adults living in rural areas is predicted to rise with population aging this impacts access to resources creates barriers to effective aging and promotes a unique aging experience consequently demands are growing for services to support healthy aging in rural regions already experiencing healthcare disparities this symposium will focus on location variations in resource availability and unique interventions to promote aging in place in the first and second presentations researchers report on differences in current service utilization satisfaction and perceived future service needsuse among rural versus frontierresiding older adults in wyoming and in nigeria respectively in the third presentation successes and failures of an interdisciplinary approach to increase alzheimers disease and related dementias diagnosistreatment rates are shared the fourth group reports the impact of an intergenerational rct intervention of training older adults in computer literacy and online chair yoga engagement for decreasing pain levels and cognitive risk this is a rural aging interest group sponsored symposium abstract citation id igad1040517 current and future service use satisfaction and need for services as defined by rural and frontier older adults nancy karlin university of northern colorado greeley colorado united states this study focused on differences for current service utilization and satisfaction along with perceived future service use and need for rural versus frontier residing older adults a sample of older adults stratified using united states government and state of wyoming definitions for rural and frontier counties were interviewed frontier respondents reported less education f 1019 p 002 η2 068 monthly income f 1703 p 001 η2 108 with fewer financial resources f 1032 p 002 η2 069 experience with technology f 453 p 035 η2 032 and potential for telehealth f 1927 p 001 η2 112 along with fewer computers f 1108 p 001 η2 084 and less access to the internet f 1019 p 001 η2 073 differences were evident for recent use of senior nutrition programs and meal sites dental care and senior centers along with future use of senior nutrition programs and meal site location food related services hearing and vision clinics and housing needs policy concerns have been identified for the funding of future senior housing medical care transportation and food support in frontier and rural areas we report results from a consortiumled randomized controlled clinical trial to optimize rural community health through interdisciplinary detection and care funded by the florida department of health moore alzheimers disease research foundation this project involving providers nursing students office staff community residents and caregivers targets a health professional shortage area with a 39 poverty rate both the control group and intervention group received training on screening tools and updated adrd information using the florida department of health adrd resource guide the intervention group is participating in an additional four hours of evening online adrd diagnosistreatment training geared towards primary care clinicians available at nocost through washington university both groups are being offered indepth cognitive assessments by adult gerontological nurse practitioners during home visits connections to underutilized local resources are being facilitated by local nursing students initial results include that although prepost total alzheimers disease knowledge scores correlated strongly there was no significant difference in knowledge in the control group there was also no significant increase in adrd diagnostic rates and agnp visits were not requested instead the control group providers report the routine practice of conducting annual cognitive screening in persons over age 65 and referring patients as needed to the nearest neurology providers 30 miles away which residents do not visit however connections to local resources increased by 65 new adrd diagnosistreatment rates in the intervention group will be available august 2023 abstract citation id igad1040519 understanding the current location disparities in adrd and its determinants in nigeria oloaigbe ogidigo 1 okiemute okpalefe 2 kingsley omeje 3 and chioma anosike 4 1 university of miamimiamifloridaunited states2 national biotechnology development agencyabujafederal capital territorynigeria3 university of nigeriansukkaenugunigeria4 university of nigeria enugu enugu nigeria alzheimers disease and related dementias is a growing health challenge in lowand middleincome countries particularly in subsaharan africa evidence of geographical variation is associated with increased adrd incidence and current research suggests that earlylife rural living further increases adrd risk however the scarcity of studies conducted in resourcepoor countries limits conclusions consequently the awareness and response to adrd have been limited in nigeria several rural communities still associate dementia with the normal process of aging with many patients stigmatized and abandoned in the belief that their condition is beyond any medical intervention thus many of those affected delay seeking medical care and endure poor outcomes this is exacerbated by the lack of mental health service access in rural areas this geographic disparity and deeply rooted structural inequalities have posed additional challenges to adequately diagnose and provide care for individuals across the lifespan living in these settings hence populationbased data on adrd incidence in nigeria is required to estimate its true burden and inform the design of adrd prevention and management strategies we report our analysis of the current situation of adrd in rural nigeria while exploring future perspectives and directions for example heath policies to increase the ratio of mental health professionals per number of patients mostly in rural areas foment proactive primary care centers ultimately understanding ruralurban variation in adrd diagnostic incidence and prevalence will inform needed policies to improve timely management and access to supportive services for older adults in nigerian and other underresourced regions abstract citation id igad1040520 maintaining brain health via telehealthbased chair yoga for rural underserved older adults juyoung park lisa ann wiese and janet holt florida atlantic university boca raton florida united states we conducted a randomized control pilot trial in an underserved raciallyethnically diverse community to examine the efficacy of computer literacy training provided by high school students meeting rural older adults in their homes followed by 2 telehealthbased online chair yoga or computer brain games first high school students engaged in a train the trainer computer skills course using a previouslytested curriculum designed for the target population students mentored the older adults in learning computer skills and to access either the ocy or cbg which were randomly assigned outcomes measured at pre post and three months following the 12week intervention included computer proficiency cognitive function pain levels and psychosocial wellbeing in a linear mixed growth model with random intercepts there was a significant linear trend in computerbased competency t 256 p 013 computer proficiency increased significantly in both the ocy and cbg groups importantly there was a significant linear change in pain by group controlling for age and living alone f 664 p 022 η2 32 chronic pain in the ocy group decreased significantly from baseline to 3month

natural and manmade disasters have a great impact on human health especially for ai elders as keepers of cultural and community knowledge aian elders also serve as guides on how to best support their communities this study focuses on a midwestern tribes cultural perceptions of disaster management specifically being generative or passing down disaster management knowledge and practices to future generations inperson semistructured interviews were conducted with eighteen elders from the midwestern tribe recordings were transcribed deidentified and coded thematically using an interpretive phenomenological analysis approach the study received approval from the tribes department of emergency management and the interview guide was reviewed and approved by a community advisory board of six individuals elders described past experiences with natural and manmade disasters including what they did before during and after disasters elders also explained how people cared for one another including the importance of interconnectedness with all beings caring for grandchildren and the role of the tribal government in disaster management elders also described how culture shaped disaster management practices such as traditional practices to follow during a storm and the important role of elders in teaching communities what to do when disasters happen exploring the role of generativity in passing on disasterrelated information is one way to learn how elders knowledge is valued by the community findings suggest that elders can provide important guidance to tribal governments and public health systems to determine effective disaster management strategies for aian communities

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introduction there has been a polio eradication campaign and initiative in pakistan for more than 25 years however the country is still far away from achieving its goal of ending polio in this part of the world 1 polio vaccines oral and injectable contributed to the eradication of the disease and gains were made globally against the disease through stronger immunization programs however missed opportunities to vaccinate children during vaccination drives are becoming increasingly catastrophic for the eradication of polio in pakistan 1 2 3 the vaccination drives in pakistan are still not reaching a large number of children despite efforts such as recruiting female community workers and interacting with afghan authorities at border areas 4 world health organization considers vaccine hesitancy as one of the top 10 health threats in the world manifesting in refusal to vaccinate in both developed and developingtransitional countries 5 in pakistan refusal rates to polio vaccination vary from as low as 315 in islamabad and rawalpindi regions 6 to 81 in quetta 7 279 in bannu district 8 and 613 in karachi 9 vaccination provides substantial benefits by reducing disease disability and death and enhancing herd immunity as a reduction of mortality and morbidity in children under the age of 5 1 religious beliefs and dogmas greatly influence human behavior particularly in healthcare in pakistan the polio vaccination campaign and its mass campaigns are under fire which impedes the achievement of targets to end the situation of endemic polio 10 low maternal literacy rates and human development index a geopolitical situation with misconceptions and a lack of awareness about the polio vaccine are major barriers besides many flaws in the health care as well as the political system approximately 250000 children living in khyber pakhtunkhwa province of pakistan are at risk of contracting polio due to resistance to vaccination which is attributed to a number of factors including inaccessibility to certain geographical areas security threats to vaccination teams a lack of female vaccine providers and refusal to receive vaccination 1011 a periodic evaluation of the knowledge and attitudes of the concerned community is inevitable because it assists in the design of datadriven interventions to change the attitudes taking into account the conclusions published by the local studies regarding knowledge and attitude towards polio and its immunization this research was carried out among residents of the sialkot city of pakistan regarding polio vaccination to help us understand the currently prevailing factors that are driving the polio vaccination acceptance and success in pakistan sialkot with a literacy rate of 59 is located far from developed cities such as lahore and is close to the border putting it in a status in which the gaps in knowledge and attitude of residents regarding polio vaccination and exploring the barriers pertaining to them can be identified to address these factors for the ultimate elimination of this disease from pakistan methods this descriptive mixed method study was conducted at the khawaja muhammad safdar medical college sialkot district of punjab pakistan from april to june 2018 after taking approval from the institutional ethical board an estimated sample size of 350 parents was determined using the who sample size calculator considering the attrition and refusal rates of 10 and the expected probability of previous similar studies 6 parents accompanying children under 5 years of age who had failed to receive or refused to get administered a polio dose during the last two supplementary immunization activities were randomly enrolled in the study through systematic sampling in the pediatric outpatient department of the said hospital the first parent accompanying herhis child was selected randomly from the outdoor register and then every 8 th was approached to participate in the study parents of children already diagnosed with poliomyelitis suffering from chronic illness autoimmune diseases or paralysis other than polio and who were unwilling to participate were excluded a pretested semistructured questionnaire consisting of three sections was used to interview the selected population section a of the questionnaire was about the sociodemographic profile while sections b and c depicted the knowledge and attitude toward polio immunization the data obtained from section a was categorized according to the available statistics from a local registry of pakistan 12 the knowledge and attitude of parents were assessed through a closedended questionnaire after their consent was obtained a pretest was conducted on 20 parents by trained data collectors whose results were not included in the final analysis of the questionnaire the questionnaire was validated for both content and face validity based on the recommendations of the data collectors necessary changes were made data collection lasted 5 weeks 6 days a week with an average of eight interviews done per day the interviews were conducted at the same pace and duration in order to minimize interrater bias a total of 12 questions were designed as part of the knowledge section with one score being given for each correct answer a score of less than 80 was considered inadequate and a score of more than 80 was considered adequate eight attitude questions were asked and responses were scored based on a 5point likert scale ranging from strongly disagree to strongly agree an attitude score of 80 was taken as negative 13 a total of 40 enrolled parents who completely refused to get their children vaccinated were selected for an indepth interview in order to identify the underlying barriers a female researcher initially contacted the parents by telephone to explain the purpose of the call and obtain their consent for the interview in case of the female respondent the assurance call was extended to her male partner and a followup appointment was scheduled telephonic indepth interviews were conducted at the agreed time and the interviews were recorded on the same device after informed consent was taken from the parents statistical analysis statistical package for the social sciences version 230 was used for data entry and analysis percentage and frequencies were determined for qualitative variables like gender while mean and sd were calculated for quantitative variables like age knowledge and attitude for determinants the sociodemographic profile of the parents was taken into account socioeconomic status was categorized as people having monthly incomes 50000 and 50000 chisquare test was used as a test of significance and p value of 005 was considered statistically significant results the study showed that the mean age of the accompanying parent was 2838 ± 2363 years whereas 191 out of 350 were ≤24 years and 159 had age 24 years among 350 children 241 were males and 109 were females with 170 living in urban areas and 180 living in rural areas data from section a of the questionnaire 12 revealed that there were 312 parents with an income 50000 rupees with a mean income of rs 38380 ± 62373 for all the subjects a total of 179 parents were illiterate while 306 were skilled and involved in one or another kind of laborjob out of 350 children a reasonable number 310 of children were vaccinated among which 125 had extended program on immunization cards available to them while analyzing the trend of punctuality for vaccinations 278 parents were found to comply with the scheduled vaccination calendar for their child among all the respondents the overall mean knowledge score was found as 620 ± 251 and mean attitude score was 178 ± 286 among the respondents with age 24 years 68 were found to have adequate knowledge regarding polio and its vaccination whereas 10 had sufficient knowledge at age 24 years according to the gender variation 95 of males and 55 of females had adequate knowledge based on the effect of residence type on level of knowledge 127 of parents from urban areas had adequate knowledge as opposed to 05 of parents from rural areas financial status showed that 18 of parents with income 50000 rupees had adequate knowledge a total of 20 literate and 21 skilled fathers had adequate knowledge regarding the disease and its vaccination the association between age and level of parental attitude showed no significant association among 350 parents 50 literate fathers and 61 skilled fathers exhibited positive attitudes during the indepth interviews the following themes were identified as barrier factors against immunization a fear of side effects b religious reasons c noncompliant family members d lack of knowledge e conspiracy and political agenda of the west f distrust on the government vaccines g security concerns and h myths and misconceptions like infertility loss of potency among male children etc also identified discussion many factors influence the decision of parents regarding their childrens vaccine including but not limited to inadequate knowledge and perception misleading information and strong antivaccination campaigns for political agendas 14 the present study reports a mean score of parental knowledge regarding polio and its vaccination as 620 25 and a parental attitude score of 178 286 a study conducted by mirani et al 15 revealed that most guardians and parents in gadap town karachi pakistan were aware of polio and recognized it as a public health concern khan et al 11 in their two subsequent studies from quetta and peshawar cities of pakistan reported 388 of participants had good knowledge about polio with a mean knowledge score of 735 ± 254 while a significant proportion of the participants had negative attitudes toward polio vaccination with a mean score of 192 ± 239 16 nanbur et al 17 reported in their nonexperimental descriptive study of nigerian mothers that the majority had knowledge of poliomyelitis 943 were aware of the polio vaccine and furthermore it was determined that mothers who knew about poliomyelitis were more likely to accept vaccination for their children this study clearly demonstrated that increasing the publics awareness of polio and its vaccine would be an effective method of eradicating polio it was found that urban residence level of education of both parents higher income and having a skilled job were associated with adequate knowledge parents with higher incomes have greater access to knowledge and vaccinations as reported by shafique et al 18 from another study from pakistan unlike the findings of khan et al 11 where younger participants appeared to have a higher level of knowledge than the older ones no such relation was found in the present study knowledge about polio and its immunization is also lower among parents with low incomes informal education and those living in rural areas 17 vaccination coverage in pakistan is reported to be below global standards for example coverage for the bacillus calmetteguerin vaccine for tuberculosis is reported to be 80 while it is much lower 60 and 67 respectively for polio and measles vaccination there are many factors contributing to this disparity including logistical barriers inadequately trained healthcare personnel insufficient parental awareness and education as well as the business religious and politicsrelated influences on vaccine marketing 19 the present study did not find any association between knowledge regarding polio and its immunization and the gender of the parents the results of this study are concordant with the findings of shafique et al 18 however khan et al 20 found that poor uptake of polio vaccines was associated with illiteracy socioeconomic status and women empowerment zahra et al biomedica 202339 2532 in the current study a positive association of knowledge and attitude with the skilled occupation of fathers was observed merani et al 15 and khan et al 16 found that fathers with private jobs were more knowledgeable about polio vaccinations regarding attitude the present study showed a positive attitude toward the polio vaccine with a mean score of 178 286 in 18 of respondents the positive attitude was found to be related to urban dwellers those having better education and skillful occupation similar findings were reported by khan et al 11 who found that most of their respondents had a negative attitude with a mean score of 1919 ± 239 moreover they found that a rural setting and a lack of education contributed to negative attitudes there was however no evidence found for an association between economic status and attitude of subjects towards polio and its immunization 15 several barriers to polio immunization have been identified in the present study including lack of knowledge noncompliant family members andor spouses lack of trust in the government vaccine security concerns a misconception that the vaccine causes infertility religious beliefs that the contents are haram as well as political agendas of the west and conspiracy theories there is a lack of trust in the quality of the vaccine as well as doubts about maintaining the cold chain temperature there was a concern among parents as the ability of the government to maintain a cold chain in times of frequent power interruptions and concern over the gadgets and equipment used by the healthcare workers during their doortodoor campaigns in extreme weather conditions 2122 it has been found that in order to address the issue of polio vaccine refusal local values as well as cultural religious and political factors must be addressed 2223 khan et al 11 identified similar results with religious beliefs inadequate knowledge and fear of infertility by polio vaccines and security issues as major reported barriers regardless of the situation misinformation and negative attitudes toward the polio vaccine manifest themselves as hostility and security threats to those working on the polio epidemic 24 it was found by verma et al 24 from india that polio was 73 more prevalent during insecure conditions in comparison to secure geographical areas in our study 40 children were never vaccinated which shows the sheer momentum of the missed children during polio campaigns according to our findings and other reported literature transferring knowledge from trusted sources such as religious and community leaders as well as incorporating groupinfluence techniques into advocacy can be of great assistance in overcoming barriers and parental hesitancy towards polio immunization 25 the result of this study will help the stakeholders to evaluate the effectiveness of their policies regarding the eradication of polio from pakistan the insight gained can contribute to highlighting the individual and contextual aspects of polio immunization and its barriers the results of this study may not be generalizable therefore precautionary measures should be taken when interpreting the findings because participation in this study was voluntary we cannot disregard the possibility of selfselection bias by participants who are more concerned with polio conclusion immunization coverage and its compliance are crucial for preventing and eradicating poliovirus infections in pakistan adequate parental knowledge while addressing the barriers like fear of side effects religious beliefs and mistrust about the health safety of the vaccines can bring about a positive change in the attitude of parents towards immunization against this disease limitations of the study the study has many limitations firstly the resource constraints in the form of time money material and expertise were inevitable as it was a nonfunded study the incentive other than travel allowance to a handful of the parents couldnt be given hence telephonic interviews were conducted a better communitybased research study design involving all ethnicities the larger group would have given a clear understanding of the issue parental refusal was more than expected and it might have been more with a larger sample size hence the results of the study from a single center may not be generalizable list of abbreviations who world health organization grant support and financial disclosure none to disclose ethical approval authors details taskeen zahra

background and objectives poliomyelitis still remains a significant public health concern in developing countries though it has been eradicated from most of the world illiteracy cultural constraints and skepticism of the general public regarding vaccination are considered major impediments to its successful eradication from developing countries in this study the authors aimed to evaluate parental knowledge and attitudes about poliomyelitis and its immunization in a local population as well as to elucidate the determinants and barriers relating to the immunization process methods this mixedmethod study was conducted on 350 consenting parents who accompanied their children under 5 years of age at the pediatric outdoors of a tertiary care hospital in sialkot pakistan parents of only those children were included for the study who had failed to receive a polio dose during the last two supplementary immunization activities the parents were interviewed on a pretested semistructured questionnaire statistical package for the social sciences was used for statistical analysis considering pvalue 005 as significant results among 350 parents 917 lacked knowledge about polio vaccination and 82 reported a negative attitude towards the disease and its immunization a total of 114 of subjects completely refused to get their child vaccinated the socioeconomic status religious myths level of literacy and occupation of the parents significantly influenced their level of knowledge and attitude toward the disease and its vaccination p 005 poor knowledge and negative attitudes of parents towards poliomyelitis vaccination were observed fear of side effects and religious beliefs were identified as the most common barriers to immunization toward achieving polio eradication

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introduction e conomic crises create serious political social and employment problems that affect peoples health studies of previous economic crises have shown that the shortterm effects on health occur through impoverishment and unemployment and are most pronounced when economic changes occur rapidly and in scenarios of low social cohesion and protection 12 the worst affected are those who belong to the most vulnerable groups children young people single parents unemployed ethnic minorities elderly and migrants 3 there is widespread agreement that involuntary job loss increases the risk of physical and mental disorders 45 several studies have indicated that in the shortterm unemployment and decrease in income have negative consequences on mental health and increase the suicide risk 6 additionally changes in behaviours such as dietary patterns lead to an increase in the prevalence of obesity 7 furthermore there is some evidence that unemployment also increases health services utilization 8 in the longterm increases have been observed in overall mortality 9 however other studies have reported an improvement in physical health 10 research assessing the health effects of the present crisis is still in the early stages and is mostly based on the general population some findings have indicated an increase in symptoms of severe depression and generalized anxiety disorder among people who have experienced foreclosure 11 furthermore an increase has also been detected in the number of suicides 1213 and suicide attempts compared with previous years together with a higher proportion of suicidal ideation and suicide attempts among people under financial pressure 14 there have also been studies of an increase in the prevalence of poor selfperceived and mental health 1215 in the case of spain demographic changes are also important to consider within europe spain has become a primary destination for migrants the majority of whom have come from lowincome countries attracted by the expanding economy 16 however by 2009 spains period of growth ended as a result of global financial crisis the labour market was severely affected and suffered job losses especially in construction and services the sectors most vulnerable to the recession and those that employed with some differences by gender most of the immigrant population this caused the unemployment rate to rise affecting more immigrants than natives thus while the overall unemployment rate in spain in the fourth quarter of 2012 was 26 the corresponding rate for the immigrant population was 37 similarly the wage gap between immigrants and natives has been accentuated the average wage of the spanish barely increased while that of foreigners decreased strongly 17 to the best of our knowledge no studies to date have assessed how the current crisis affects employment conditions and their health effects on the immigrant population although previous studies have reported the effects of poor employment and working conditions on immigrant health in times of economic boom 1819 thus the objective of the study was to assess the effect of changes in employment conditions on the incidence of poor mental health of immigrant workers in spain after a period of 3 years in the context of economic crisis methods this study formed a part of the itsal project that aims to study the employment and working conditions of immigrant workers and their relationship to health to this end several substudies were conducted including two surveys the first one was conducted in 2008 on a convenience sample of migrant workers from colombia ecuador morocco and romania the most highly represented nationalities in spain 20 the second one was conducted on the same base population in 2011 with the aim of assessing their employment working and health conditions over the period 21 of the 2434 workers surveyed in 2008 a total of 1129 left a telephone number contact was made with 363 of the participants in itsal i of these 318 completed the survey 23 refused to participate and 22 did not complete it of the remaining 766 workers 307 did not answer the phone in 152 cases the number did not exist in 261 cases the telephone number did not belong to the respondent and in 46 cases phone numbers were busy or the connection was lost the response rate was 295 and the cooperation rate 917 the highest response rates were obtained from persons from ecuador women those aged 45 years and persons who worked in industry the lowest response rates were from moroccans persons aged 25 years and those who worked in agriculture data were collected using ad hoc questionnaires available at thus for this analysis we have considered the followup data for the survey at two time points 2008 and 2011 on the same base population to assess the effect of changes in employment conditions on the incidence of poor mental health we selected only those individuals who reported good mental health in itsal i the outcome was mental health status in 2011 this was measured using the spanishlanguage validated version of the 12item general health questionnaire with four response options 2223 the ghq12 is a commonly used instrument in occupational health research and is a wellvalidated measure to detect current nonpsychotic disorders focusing on breaks in normal functioning rather than lifelong traits thus it assesses personality disorders or patterns of adjustment associated with distress 22 23 24 this variable was dichotomized into good mental health and poor mental health for each item a score of 0 or 1 was assigned and the 12 resulting scores were added together a score below 3 indicated good mental health and a score of 3 indicated poor mental health 22 23 24 the main explanatory variables were the employment conditions in 2008 and 2011 we analysed the interviewees legal status employment status at the time of the interview spanish social security system registration employment contract working hours per week number of days off in the last week worked and monthly job net income in euros for those unemployed in 2011 the former five variables were referred to their last employment according to the information on all these employment conditions obtained from the two surveys we created new variables identifying the employment paths of the participants for each of the main explanatory variables the secondary explanatory variables were sex age at the first interview country of origin occupational qualification in spain and educational level first we conducted a descriptive analysis of the variables analysed then we calculated the prevalence of poor mental health in 2008 and the incidence of poor mental health in 2011 according to sociodemographic variables and the employment paths defined in table 1 subsequently we analysed the association between poor mental health in 2011 and employment paths by calculating crude and adjusted odds ratios and 95 ci using separate logistic regression models for each employment path the adjustment variables were sex age country of origin occupation educational level and employment status in 2011 data were processed and analysed using the statistical software packages spss19 and stata110 this study was approved by the parc de salut mar clinical research ethical committee of barcelona confidentiality was guaranteed throughout the process and the respondents gave their consent to participate in the study in accordance with the provisions of spanish organic law 151999 on data protection all data were rendered anonymous results the subgroups of younger workers moroccans nonmanual workers and unemployed with good mental health in 2008 were those reporting the highest incidence of poor mental health in 2011 with regard to employment paths we found a higher incidence of poor mental health among those with illegal status at both time points and among those who did not report having an employment contract or who were not registered in the spanish social security system in either itsal i or itsal ii poorer mental health was also reported by those whose situation changed from employment to unemployment those whose number of working hours per week increased those who reported having 1 or no day off per week in both surveys and among those whose monthly income decreased or who were located in the low monthly income bracket in both surveys table 4 presents the crude and adjusted associations between poor mental health in relation to employment paths showing a statistically significant increased risk among those whose legal status remained temporary or permanent compared with those with spanish nationality or illegal in both itsal i and ii we also detected a statistically significant association with poor mental health among those whose situation changed from employment to unemployment whose number of working hours per week increased and those whose monthly income decreased we also observed a positive association at the 10 level between poor mental health and employment with a lack of contract among those with only one or no day off per week in both surveys and who reported receiving a low income in itsal i and ii in contrast and considering employment paths in relation to social security registration we observed a statistically significant decrease in risk among those whose situation changed from no insurance to insurance discussion the main findings indicated an increased risk of poor mental health between 2008 and 2011 among those whose employment conditions deteriorated changing from employment to unemployment experiencing an increase in the number of working hours or seeing a reduction in their monthly income we also observed an increased risk of poor mental health among people whose legal status was temporary or illegal and among those who reported low incomes at both time points in contrast we observed a decreased risk among those who reported being registered in the social security system in 2011 and not having this coverage in 2008 these results remained unchanged after adjusting for sociodemographic and employment variables the relationship between unemployment and mental health has been well documented identifying poorer mental health among the unemployed 46 furthermore it has been found that job loss is associated with negative changes in mental health whereas finding a new job after a period of unemployment is associated with an improvement 25 our findings indicated the same trend although the association was stronger for the change from employment to unemployment some of the aspects that might explain the relationship between unemployment and health may be related to economic deprivation or lack of control over the situation but also to the latent role or function of work in regards to structuring time providing opportunities for social contact and contributing to status and personal identity 2627 the effects of working hours have also been studied two reviews reported an increase in poor mental health with increased working hours and long working days 2829 our results also showed a positive association between poor mental health and the change in number of working hours especially when these increased some factors that might explain this relationship are the possible changes in routines that imply less time for rest leisure and social relationships less time for domestic responsibilities and perhaps a greater difficulty in balancing workfamily commitments besides it would be necessary to evaluate whether this increase could be related to a possible intensification of the workload increasing fatigue some aspects that might interact are the type of timetable and shift work hours social class marital status andor gender in fact in one followup study it was reported that long working hours and an increase in hours worked constitute a risk factor for developing symptoms of anxiety and depression especially in women 30 in our data poor mental health was also clearly associated with a decrease in income or consistently earning a low income this effect may be due to the difficulties encountered in meeting costs and material needs either because of remaining in the lowincome bracket or having experienced a decrease compared with the previous situation which would require adjusting consumption especially among migrants who often support dependent persons in the country of origin 31 another longitudinal study found an increased risk of depression among those who earned a lower monthly income compared with those who earned the highest amount a circumstance also indicated by our results 32 nevertheless to obtain a clearer picture of the effect on mental health of monthly income earned other factors should be taken into account such as net household income debtfree assets the number of childreneconomically dependent people in the household and having more than one job 32 few studies have addressed the effects of social insurance protections on health in the case of unemployment status a crosssectional study carried out in brazil showed a greater likelihood of common mental disorders among workers in the informal economy compared with those in the formal sector 33 complementarily in our study we observed a decreased risk of poor mental health among those whose situation changed from no social security registration to insurance whereas risk increased for the paths of insurance to no insurance and continuous lack of insurance however it is important to note that in the brazilian study informal workers were defined as those who were not registered with the social security system as well as those who were selfemployed these findings suggest that the improvement in status compared with the starting point could lead to increased knowledge and control over employment and working conditions and a reduction in insecurity given the greater coverage and social protection which might cushion or minimize the risk of poor mental health conversely perceived or attributed job insecurity has been associated with an increased risk of poor mental health 34 even after this circumstance has changed 35 similarly the increased risk of poor mental health among people who reported temporary legal status or continued illegal status could be due to increased insecurity precariousness and vulnerability associated with these circumstances this is due not only to the fears and concerns that such a situation can generate but also to the subjective perception of having a distinct disadvantaged status with respect to others these results are partially consistent with those of a study that indicated worse selfperceived health among migrants without valid documents or holding temporary residence permits 36 it is interesting to note that in this study the health status of migrants was worse not only compared with natives but also compared with migrants who had acquired nationality of the host country previous studies have also found an association between illegal status and poor mental health although only among men who had been resident in the host country for 3 years 19 our research has some limitations there may be selection bias in the participants in the first survey participation in the survey required a sufficient command of spanish thus excluding those without fluency 20 additionally some of the participants in the first survey were not located for the second survey nonparticipants in the second survey may have been more affected by adverse economic and employment situations or may have had more difficulties regarding legal status and residence compared with those who were contacted again finally there is also a possibility of a reverse causation effect owing to the inability to establish an intersurvey temporal sequence regarding employment paths and the effect on health as the health measures analysed were obtained at the incidence and prevalence of poor mental health per 100 individuals 95 ci 95 confidence interval changes in mental health of immigrants in spain same point in time as the exposure thus any change in the health status might have occurred before the employment situation referred to in itsal ii the studys strengths include the opportunity to analyse information about a hardtoreach population as well as the possibility of a followup of the same participants at two important time points 2008 and 2011 although it is impossible to state that the deterioration identified in employment conditions was attributable solely to the crisis the macroeconomic indicators and national and international trends observed suggest a relationship between both phenomena thus the main strength of this study is its longitudinal nature and the analysis of employment conditions converted into employment paths a socioeconomic indicator scarcely analysed in relation to health in summary this study provides an assessment of the effects of different employment paths on the mental health of immigrant workers in spain in the context of economic crisis highlighting the differences in mental health between the conditions analysed nonetheless considering the aforementioned limitations caution should be exercised when interpreting the results therefore we suggest the need for similar studies using larger samples not only to increase statistical power but also to perform separate analyses conduct intergroup comparisons and identify possible differences by gender country of origin length of residence or family reunification 1937 and also with autochthones thus extending existing knowledge these findings indicate the need to design and modify social and employment policies which are closely linked to the social determinants of health associated with migration the main findings indicate that the economic crisis has contributed to deterioration in spanish immigrants employment conditions resulting in poorer mental health in this collective especially among those whose employment conditions deteriorated or were negative at the beginning of the period the findings constitute warning signs that indicate the need to design and modify social and employment policies closely linked to the social determinants of health associated with migration conflicts of interest none declared key points this is the first study to analyse the effects of changes in employment paths on mental health in a context of economic crisis in immigrant population

background migrant workers have been one of the groups most affected by the economic crisis this study evaluates the influence of changes in employment conditions on the incidence of poor mental health of immigrant workers in spain after a period of 3 years in context of economic crisis methods followup survey was conducted at two time points 2008 and 2011 with a reference population of 318 workers from colombia ecuador morocco and romania residing in spain individuals from this population who reported good mental health in the 2008 survey n 214 were interviewed again in 2011 to evaluate their mental health status and the effects of their different employment situations since 2008 by calculating crude and adjusted odds ratios aors for sociodemographic and employment characteristics findings there was an increased risk of poor mental health in workers who lost their jobs aor 362 95 ci 164796 whose number of working hours increased aor 235 95 ci 102544 whose monthly income decreased aor 275 95 ci 108700 or who remained within the lowincome bracket this was also the case for people whose legal status permission for working and residing in spain was temporary or permanent compared with those with spanish nationality aor 332 95 ci 115958 or illegal aor 1734 95 ci 19615323 in contrast a decreased risk was observed among those who attained their registration under spanish social security system aor 010 95 ci 002048 conclusion there was an increase in poor mental health among immigrant workers who experienced deterioration in their employment conditions probably influenced by the economic crisis

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introduction falls and fallinduced injuries in elderly people are major public health problems in most of the regions of the world fall is defined as inadvertently coming to rest on the ground floor or other lower level excluding intentional change in position to rest in furniture wall or other objects 1 falls in older age may cause disabilities and morbidities as a result people suffer a lot with a huge burden to the family health sector and economy of the country many elderly people experience emotional problems such as loss of confidence fear and anxiety following falls which may lead to lack of motivation to do daytoday normal activities in life 2 each year 2835 of people over 65 years and 3242 of people over 70 years experience falls 1 a hospitalbased study of elderly people in colombo sri lanka reported that 233 of people over 65 years were subjected to falls within a year 3 risk factors for falls among elderly people are multifactorial including complex interaction of biological behavioral environmental and socioeconomic factors 1 a study done by laing and his group revealed that 62 of participants identified falls as a very urgent issue facing older adults 69 had identified gait related safe activities and only 21 were concerned about improvement of home safety in order to prevent falls 4 in the same study onethird of participants had good knowledge about recommended falls prevention practices whereas 58 perceived themselves with average knowledge however when considering the perception towards falls 34 of participants had considered falls as a least important problem 4 according to the results of a selfadministered survey conducted by american physical therapy association majority of participants considered falling as a major preventable health problem with safe environmental factors 5 however in an indian study with perspectives from different geographical locations 88 of participants believed that older people do fall and there was no option to prevent falls 6 furthermore elderly people had a belief that falls are an unavoidable consequence of aging and some people did not perceive their personal vulnerability for falls 7 another previous community based descriptive study carried out in sri lanka revealed that 486 had perceived falls among elderly as a significant health problem 8 an australian study revealed that older people preferred messages emphasizing the importance of good health and independence rather than falls prevention 9 even though falls among elderly people is a wellrecognized topic in both medical and nursing literature under various headings it has not been prioritized for research in many regions of the developing world 1 knowledge and perception of falls have positive influence on falls prevention or reduce the risk of falls among elderly people therefore current study was aimed to evaluate the knowledge and perception of falls and related injuries among elderly people in a rural community in southern sri lanka aiming to reduce risk of falls and fallinduced injuries among elderly people material and methods study design and sampling this crosssectional household survey was conducted during april and may 2015 with the participation of 300 community dwelling individuals aged 65 years and above from nagoda divisional secretariat area galle sri lanka the cluster sampling method was used to achieve the required study sample from five out of 53 grama niladhari divisions that are under the administration of nagoda ds office covering 62176 inhabitants with 9024 elderly people aged 65 years and above sixty participants were taken as the cluster size as households within each gn division were randomly selected based on the assumption that at least one ambulatory person aged 65 years or older lives in each household individuals without any acute illness and who can understand the questionnaire were considered as the inclusion criteria data collection the data collection was conducted at the recruited participants residence from the individuals who met the inclusion criteria with the support of a family member for the accuracy of data especially in older elderly people with hearing andor memory impairment a convenient and adequate time was given for responding to the questions which did not interfere with their comfort and daytoday activities pretested intervieweradministered questionnaire was applied by a single investigator to assess sociodemographic profile and different significant aspects related to the knowledge and perception of falls sociodemographic profile included age gender marital status educational status previous employment status and living companion socioeconomic factors such as income and accessibility of health and social care services were also obtained individuals were asked whether they had experienced at least one fall during the previous 12month period knowledge about falls was assessed on several aspects knowledge on who defined four major risk factors for falls such as biological environmental behavioral and socioeconomic status 1 and disease conditions that increase the risk of falling consequences of falls and preventive measures of falls were evaluated under 19 statements the sources of information about falls and preventive measures were also obtained perception of falls was assessed under eight statements in a fivepoint likert scale ranging from strongly agree to strongly disagree there were three negatively and five positively expressed statements these statements were developed by the investigators using the statements which had been used to assess perception regarding falls among elderly people in previous studies 46 statistical analysis statistical analysis was done using statistical package of social sciences version 200 descriptive statistics were performed including mean and standard deviation pearsons chisquare test was used to assess the association between categorical variables statistical significance was set at 𝑝 005 each question was numerically coded for statements on knowledge and perception of falls to obtain the knowledge and perception scores knowledge score maximum mark for a question was 5 the total maximum marks which could be obtained were 95 with a minimum of zero the total score was categorized into three groups individuals who scored less than onethird of points were considered as having poor knowledge those who scored 3263 points were considered as having average knowledge and those who scored 6495 points were considered as having good knowledge perception score each statement was rated based on the likert scale ranging from 1 to 5 the total maximum marks which could be obtained were 40 with a minimum of 08 individuals who scored 0824 were considered as having negative perception and those who scored 2540 points were considered as having positive perception ethical considerations the ethical approval for this study was obtained from the ethical review committee faculty of medicine university of ruhuna sri lanka written informed consent was obtained from each study participant before the administration of questionnaire results sociodemographic profile the sociodemographic characteristics of the study participants are shown in table 1 the sample consisted of 300 participants aged 65 years and over with a mean age of 730 years 58 of participants were females and 42 were males majority lives with their spouse or children and only 107 live alone majority was not currently employed and the women were mainly involved in household work majority had education beyond the secondary level whereas 31 of study participants had only primary education and 7 had no schooling among the participants 343 reported that they experienced at least one fall during the previous 12month period and 359 reported related injuries however only 313 believed that diabetes mellitus increases the risk for falls regarding the awareness on consequences of falls majority believed that falls lead to reduced physical mobility and nearly half considered restriction of daytoday activities however only 173 believed the possibility of social isolation due to disabilities following falls around 72 of participants were able to name at least one or two biological factors such as age and chronic medical conditions which increase the risk of falls around 60 knew that environmental and behavioral factors contribute to falls but only 297 knew the contribution of poor socioeconomic factors in increasing the risk of falls considering overall level of knowledge of the 300 participants 18 of individuals had poor knowledge 61 had average knowledge and 21 had good knowledge on falls related injuries and preventive measures the mean knowledge of the participants was 4814 there were statistically significant associations between knowledge on falls with age educational status and history of falls during previous 12month period further 254 of individuals with overall good knowledge 322 of individuals with average knowledge and 519 with poor knowledge regarding falls reported falls during previous 12month period nearly half of the participants obtained information on falls and preventive measures via television and 323 of participants shared knowledge on falls and related injuries with their neighbors experiences 267 had read newspaper articles regarding falls only 1 of participants had gained knowledge from nurses and 97 were unable to gain information from any source perception of falls perceptions on falls are shown in table 5 of the 300 study participants 373 perceived that older people fall and theres nothing to be done in preventing those falls but 117 strongly disagreed with that statement 227 of individuals did not believe that they were having a risk for falls although 333 of participants agreed that they did not worry about falls 293 disagreed and 173 strongly disagreed with that statement while half of individuals strongly perceived that the safety of their house was good only 64 of individuals disagreed or strongly disagreed with that statement although 153 of individuals strongly agreed and 373 agreed with the statement that they need to do fall prevention activities 33 disagreed or strongly disagreed with the statement and believed that they were not weak individuals strongly believed that falls prevention interventions given after the first fall may be helpful to prevent recurrent falls majority strongly agreed on the importance of falls prevention knowledge training programmes and only 1 of participants disagreed with the statement majority strongly perceived that paying attention to correct medical conditions as a considerable matter only a single individual had neutral perception and no one disagreed on that statement of the 300 participants 203 had negative perception and 797 had positive perception regarding falls there were statistically significant associations between perception of falls with gender age and level of education but there was no statistically significant association between perceptions of falls with history of falls discussion the current study evaluated the knowledge and perception of falls related injuries and preventive measures among elderly people in a rural community in sri lanka and revealed that the majority of study participants had an average level of knowledge and a positive perception of falls nearly half of the participants in the study sample knew that falls are the leading cause of hospital admissions among elderly people this is consistent with the findings of the study conducted in the colombo district which revealed that 486 participants had considered falls among elderly people as a significant health problem 8 these findings reflect the need to encourage elderly people in both urban and rural areas in sri lanka to consider falls as an important health concern and to reduce the economic burden of the country that may arise due to falls a majority of them considered that proper nutrition active lifestyle and protective environmental factors had an effect on falls yet although the majority of subjects were aware about biological behavioral and environmental factors that contribute to increased risk of falls there was a lack of knowledge regarding socioeconomic factors this may be due to indirect contribution of socioeconomic factors towards falls when considering the biological factors even though most of the elderly people had favorable knowledge about hypertension increasing the chance of falls a majority did not believe that diabetes mellitus contributes to increase the risk of falls the reason may be due to lack of awareness regarding symptoms and complications of such chronic disease conditions young elderly people and individuals who were educated beyond primary education had an overall good level of knowledge regarding falls and related injuries significant associations were found between age and educational status with the level of knowledge educated people having a tendency to pay more attention to gain awareness on health issues and young elderly individuals having more social interaction than older elderly people could be the plausible explanations for these observations the findings of the majority of participants with average knowledge on falls and related injuries in our study are consistent with a crosssectional survey done in the usa to assess the fall prevention knowledge attitude and practices of community stakeholders and older adults 4 this study revealed that 58 of individuals were fairly knowledgeable about falls and preventive practices 4 however it contradicted with the findings of another crosssectional study conducted in south india which revealed poor knowledge of indian elderly people regarding falls and preventive measures 6 in sri lanka the most frequent information sources on falls and preventive measures were found to be television and neighbors experiences least frequent was awareness from nurses this reflects the inadequate level of nurseclient relationship and deficit of community health nursing services in the country further it emphasizes health education as a vital responsibility which needs to be developed in the health care system in sri lanka a significant proportion of elderly people was not being able to expose any kind of information source which could be due to isolation or lack of access to resources with regard to the perception of falls 397 disagreed or strongly disagreed with the statement older people do fall and nothing can be done to prevent falls however the previously mentioned indian study reported that only 12 of participants disagreed with the same statement 6 sri lankan elderly people have shown a positive attitude than indians on this specific health matter which may be due to sociocultural and educational differences between the two countries in our study the majority of elderly individuals agreed that the interventions given after the first fall can prevent recurrent falls which is consistent with the previous study reported from india 6 further a majority strongly agreeing with the statement paying attention to correct my medical condition is very important in our study may be due to improved health awareness and free health services in sri lanka we observed that a majority of study participants had positive perception towards falls and significant associations were found between gender and educational status majority of elderly females and individuals educated beyond primary education had positive perception of falls and the reasons for these observations are questionable in our study nearly half of the individuals with poor knowledge had reported history of falls and in contrast only a small proportion of individuals with good knowledge had reported previous fall event further there was a statistically significant association between knowledge and history of falls during the previous 12month period this suggests that having a good knowledge results in lesser chances of falling and related injuries even though there was no significant association most of the individuals with positive perception did not report history of falls during the previous 12month period it indicates that the individuals with positive perception always pay attention to personal susceptibility and follow preventive measures to get rid of falls and related consequences conclusions in this crosssectional study community dwelling older people had average level of knowledge and positive perception towards falls and related injury prevention the most frequent awareness information source on falls was television significant associations were found between age educational status and history of falls with the level of knowledge gender age and educational status were significantly associated with the perception this study emphasizes the importance of increasing the level of knowledge on falls related injuries and preventive measures data availability the data used to support the findings of this study are available from the corresponding author upon request disclosure part of this work has been presented as an abstract in 3rd international conference on multidisciplinary approaches 2016 held at university of sri jayewardenepura sri lanka conflicts of interest the authors declare that they have no conflicts of interest stem cells international

the knowledge and perception of falls facilitate a better pathway to improve the health status among the elderly knowledge and perception of falls among community dwelling elderly were assessed in 300 participants 175 females aged 65 years and above using an intervieweradministered questionnaire mean sd age of the participants was 730 67 years majority 72 knew some biological factors and 60 knew environmental and behavioral factors which increase the risk of falls among 300 participants 18 had poor 61 had average and 21 had good knowledge on falls the mean sd knowledge was 4814 1913 the most frequent 49 information source was television significant associations were found between age 𝑝 0002 and educational status 𝑝 0001 with level of knowledge regarding falls individuals 254 with good knowledge 322 with average knowledge and 519 with poor knowledge had experienced falls during the previous 12 months 𝑝 0007 regarding perception of falls 203 𝑛 61 had negative perception and 797 𝑛 239 had positive perception significant associations were found between gender 𝑝 001 age 𝑝 004 and level of education 𝑝 0001 with perception of falls this study revealed that the community dwelling elders had average knowledge and positive perception regarding falls and preventive measures emphasizing the importance of falls prevention awareness programs

19935_0

introduction tobacco use has reached high epidemic proportions and is a major global public health challenge it is a major risk factor for most leading causes of death worldwide 1 and kills many of its users 2 this has made tobacco the leading threat to the global economy causing loss of productivity plus pain grief and misery 3 globally tobacco use is a major cause of avoidable and premature mortality and morbidity accounting for about 6 million deaths 45 one person smokers are believed to lose one decade of their life expectancy when compared to people who have never smoked 8 the global adult tobacco survey report for nigeria shows that 45 million adults aged 15 years or older currently smoke while 64 million of adults were exposed to secondhand smoke during visits to public places 11 the global youth tobacco survey of nigeria 2008 showed that one in five students aged 1315 years had ever experimented with cigarette smoking and about one in ten students currently smoked cigarettes 12 in a study among pharmacy students in lagos nigeria the current smoking prevalence was low at 55 13 in nigeria 7 in 10 current smokers planned to or were thinking about quitting and 6 in 10 male smokers who visited a health care provider in the previous 12 months were advised to quit 11 several studies have documented that tobacco use and smoking are associated with some sociodemographic factors including age gender marital status education employment occupation religion ethnicity and place of residence 1 2 3 a study in nepal documented that the use of any form of tobacco was significantly associated with respondents age marital status educational status occupation environment and watching television the study found that those aged 3649 years were about 2 times more likely to use any form of tobacco than the younger age group 1524 years men married or in a relationship were about 2 times more likely to use tobacco men with no education were about 4 times more likely than those that had education however watching television at least once weekly was found to reduce the risk of smoking 3 another study found that prevalence amongst men was significantly higher than in women for any type of tobacco use older adult men lesser education and lower wealth quintile were more likely to use all forms of tobacco 2 similarly studies also reported that poor people are more likely to smoke more less willing to quit smoking and more likely to die from smoking than people in the highest socioeconomic groups 4 5 6 7 the same trend is observed in initiation as the likelihood that a young person will start smoking is higher in less privileged groups 8 the identified rising social inequality of smoking and the associated health impacts were attributable to the age of initiation of smoking 679 in previous studies involving the use of tobacco in nigeria representative data for the whole country were not used it was either that residents in big cities or suburbs adolescents or young adults students in higher education institutions or other specific population studies on cigarette smoking in limited areas were studied moreover the way the groups were sampled may have led to an overgeneralization of the findings equally the economical geographical and sociocultural differences of these groups studied make inferences and generalizations to the entire nigerian population difficult patterns of tobacco use especially its use in different forms by the same individuals are not usually considered however the nigerian demographic and health survey is a nationwide survey of nigerians aged 1559 years and thus provides truly reliable and nationally representative data its analysis is expected to provide a comparable and reliable prevalence estimate for tobacco use in nigeria this study aimed to analyse tobaccouse data from the 2013 nigerian demographic and health survey quantify prevalence and describe the sociodemographic correlates of tobacco use among nigerians aged 1549 years methods study area nigeria is in subsaharan africa it is grouped into six geopolitical zones including northwest northeast northcentral southwest southeast and southcentral zones administratively nigeria is divided into 36 states and the federal capital territory of abuja each state is made up of a number of local government areas there are 774 lgas in nigeria each is subdivided into localities there are widely varied regional health indices with the southern region being better than the northern region nigerias urbanization growth rate is estimated at 53 per year 14 nigeria comprises many tribes and languages study design this is a secondarydata analysis involving the 2013 nigeria demographic and health survey the ndhs is a cross sectional survey executed by the national population commission with the main objective to provide updated estimates of basic social demographic economic and health indicators covering human reproductive health maternal and child health awareness and behaviour regarding hivaids other sexually transmitted infections violence against women and information on tobacco use 14 sampling technique and sample size the primary sampling unit used in the survey was defined on the basis of enumeration areas from the 2006 census during the 2006 national population census local government areas were divided into localities and each locality was further subdivided into census eas and then clusters for convenience household enumeration and mapping in the selected clusters were done to produce a list of households that made up the sampling frame the final sample size was 36 800 households selected with a minimum target of 950 completed interviews per state a stratified twostage cluster design that uses probability proportional to size technique was used to identify clusters within the eas and to choose households randomly within the clusters achieving a nationally representative sample that appropriately includes both rural and urban residents as well as both upper middle and high socioeconomic status groups 14 in the first stage a total of 888 clusters 286 in urban and 602 in rural areas were selected by systematic sampling using the pps technique in the second stage an average of 41 households were selected by equal probability systematic sampling in each cluster from a list of all private households study populationparticipants the study populationparticipants include head of selected household who answers questions on the household and provides a listing of household residents as well as visitors who slept over the night before the survey all women aged 1549 years and men 1559 years who were either permanent residents of the households or visitors who stayed overnight on the night before the survey study instruments data collected for the 2013 ndhs involving use of questionnaires were used it was pretested and a standard protocol observed in administering them these questionnaires were adapted to collect information on relevant demographic social economic factors and health statusindicators as well as information about tobacco use from eligible members of the selected households it was translated from english into three major nigerian languages hausa igbo and yoruba the questionnaires were interviewer administered facetoface with all eligible participants data analysis data on 17 322 respondents were extracted from 36 800 participants in the 2013 ndhs data this number represents respondents with complete data on outcome variables of interest data were summarized using frequencies and percentages chisquared test of statistical significance was used to verify associations of sociodemographic factors with tobacco use while binary logistic regression model was used to identify predictors of tobacco use the variables for regression were adjusted for one another the level of statistical significance was determined by p 005 results table 1 shows the sociodemographic characteristics of respondents the mean age of the respondents was 317±117 years the majority of the household heads were males the highest proportion of respondents had attained secondary education also the highest proportion of respondents studied were from the northwest geopolitical zone and the least from the southeast there was approximately an equal distribution of religion christianity 517 and islam 469 about 50 were never in union a higher proportion of respondents lived in the rural area and approximately onefifth of the respondents belonged to the middlewealth index table 2 shows the prevalence and pattern of use of tobacco in different forms about 66 smoked cigarettes 17 used snuff 04 smoked pipe and 02 chewed tobacco of those that smoked cigarettes 31 smoked pipe 24 chewed tobacco and 46 used snuff in addition the range of sticks of cigarettes they smoked was 310 sticks with an average of 5 table 3 shows the prevalence and pattern of use of tobacco in different forms stratified by gender about 66 males and 63 females smoked cigarettes 18 males and 07 females used snuff 04 males and 02 females smoked pipe and 02 males and 04 females chewed tobacco of those studied 02 of males and of females smoked cigarettes and pipe 01 males and 03 females smoked cigarettes and chewed tobacco 03 males and 04 females smoked cigarettes and used snuff only one male respondent chewed tobacco and used snuff and none of the respondents smoked pipe and chewed tobacco or smoked pipe and used snuff table 4 shows the relationship between sociodemographic characteristics and smoking of cigarettes the respondents who were aged 2534 years and ≥35 years were about six times and five times respectively more likely to smoke cigarettes than those aged 1524 years those that had primary education were about 14 times more likely while those that had secondary education were 11 times less likely to smoke cigarettes than those with no formal education those in the south were about 13 times more likely to smoke cigarettes than those in the north moslems were about 17 times less likely to smoke cigarettes than christians middleclass were about 11 times more likely while the wealthier were 11 times less likely to smoke cigarettes than the poorer class discussion the main findings from this study include tobacco use was low males and females use tobacco similarly tobacco is used in both smoked and smokeless form socioeconomic and demographic factors influence tobacco use the proportion of respondents that smoked cigarettes in this survey was low compared to other countries especially developed and some developing countries the finding is similar to that from the global adult tobacco survey that reported 56 among adults aged 15 years and above however other studies have documented that prevalence of tobacco use is widely varied 15 world health organisation reported that the prevalence of overall current tobacco use was 154 20 which is in contrast to our findings on tobacco use the disparity may be as a result of the differences in the population studied in terms of race economic status and life style as well as legislation on tobacco use this finding though low should be made even lower especially when the negative health effects of tobacco use are considered the implication is that even though tobaccocontrol programs are being propagated more effort is required in monitoring of tobacco use so as to improve the implementation of tobaccocontrol measures the approach should be multisectoral including the health sector social media and others this has been suggested by gats in their assertion that services for cessation of tobacco use could be integrated into the health system given that a large portion of smokers are ready to quit smoking 11 those aged 2534 years and ≥35 years were more likely to smoke cigarettes than those aged 1524 years from this study this finding of association between age and cigarette smoking is in line with many studies a study in zaria nigeria documented age to be associated with tobacco use 16 the finding was also supported by a study in nepal that showed that those in age group 3649 years were 24 times more likely to use any form of tobacco than the younger age group 1524 years 17 similar findings have been reported in other studies 18 however the finding of low prevalence of smoking among those aged 1524 years is valid as it has been documented that the age of initiation of smoking is a key factor in cessation of smoking and in relation to the health implications of tobacco use 19 this study reported that those that had secondary education and above were less likely to smoke cigarettes than those with primary education and below this is expected as education comes with enlightenment that allows the better educated to appreciate more the implications of tobacco use similar studies support the finding that men with no education were 35 more likely to smoke tobacco 20 similarly while in ibadan nigeria prevalence of smoking was higher for the higher classes 15 in zaria nigeria the students social class was not associated with adolescent tobacco use 16 a study in brazil equally showed that the number of tobacco users with no education or less than a year schooling were twice those with 2 or more years of education 21 this study showed an association between socioeconomic status and tobacco use but could not identify it as a predictor of tobacco use some studies have also found an association between socioeconomic status and adolescent tobacco use with mixed results a survey in brazil showed that prevalence of smoking was higher among the poor even after controlling for age marital status education employment and residence 21 while a study reported higher use among low socioeconomic status 22 another reported higher use among high socioeconomic status 23 smoking among youth was found more in socially disadvantaged groups 2425 poor people are more likely to start smoking at a younger age smoke more have a lower quit rate and more likely to die from smoking 2627 social determinants of smoking vary between and within countries hence addressing this equity aspect of tobacco is an important political and public health concern 20 those in the southern geopolitical region were more likely to smoke cigarettes than those from the north moreover moslems were less likely to smoke than christians this may be due to differences in religious freedom while the northern part is predominantly moslem the southern part is mainly christian equally the sociocultural differences of these population groups studied can partly be explained by the fact that in the southern part people are more educated with women having a more liberal social life marital status showed no association with tobacco use in this study however other studies showed significant associations between marital status and tobacco use 1720 in this study smoking was slightly higher among men than in women though not significant this finding is in line with many other studies that reported that tobacco use was higher among males than females in both young and old 151728 smoking prevalence among female students at the university of lagos was zero 29 this may be explained partly by differences in lifestyle and the occupation of men and women the design and method used in these studies may be responsible for the differences observed unlike other studies where a region of the country is studied this is supported by a study in nepal that documented association with manual work which males are more likely to be involved in than females 13 however a study documented a higher prevalence of tobacco use among females 3031 moreover other studies found no significant differences between male and female tobacco use 3233 place of residence classified as either urban or rural in this study had no relationship with tobacco use in contrast several studies documented that tobacco use and cigarette smoking is associated with place of residence 1720 while a study reported higher use among rural residents 34 others have reported higher use among urban residents 35 the findings may have been different from this current study owing to differences in the economical geographical and sociocultural practices of these groups limitations it would have been better to use primary data collected by researchers as it would have been more appropriate and representative equally there could have been changes in data or findings due to the difference in time when the data were collected and the present analysis conclusions the use of tobacco by both males and females was low the commonest form of tobacco use was cigarettes and the least used was chewing tobacco the commonest combination was cigarettes and snuff even on stratification by gender none of them smoked pipe and chewed tobacco or smoked pipe and used snuff the identified predictors were age in categories educational level region and religion these findings show that there is serious and urgent need for improved tobacco prevention and control interventions in nigeria despite the low prevalence which is good political will and strong policies need to be put in place to stop people from starting tobacco use while encouraging current users to quit conflicts of interest

dies every six seconds due to tobacco related disease of these deaths 75 occur in low and middle income countries where more than 80 of the worlds smokers including nigerias live 4 the death toll from tobacco is estimated to reach over 8 million deaths per year by 2030 and if unchecked tobacco could kill over 1 billion people in the 21st century 67 it is estimated that 100 million premature deaths occurred globally in the 20th century due to tobacco smoking equally tobacco

19936_0

introduction the integration between work and life has been a topic of interest among researchers for many years in 2006 olsonbuchanan and boswell discussed how boundaries between work and life were blurring fourteen years down the road the intertwined nature between work and life is still being discussed gaskell reiterated how blurred worklife boundary appears to be the new norm while traditionally employees would attempt to segmentize their work and life domain this attempt is futile in the present world where technology such as our smartphones are propelling the afterhours connectivity and blurring the border between work and life fundamentally the belief that work and life are independent domains has been contested and studies have debunked the myth that professional employees will not let their private life interfere with their worklife and vice versa sadly most superiors and organizations fail to accept that work and life are intertwined making it necessary to balance work and life to enhance employee wellbeing most superiors consider worklife balance a fad and choose to turn a blind eye towards this balance the failure to acknowledge the pertinence of wlb and extend the necessary support sends a negative message to employees this is in line with the proposition of organizational support theory this theory posits that employees weigh their value in the organization through the support rendered within their organization the degree to which organizations provide support to employees reflects how much the organization values them as an employee and are concerned about their wellbeing therefore when organizations fail to care about employees need for wlb and provide the required support employees view the organization in a negative light in an effort for organizations to provide the necessary support to establish wlb they need to better understand the conceptualization of the work and life domain while the conceptualization of work is relatively clear most organizations and superiors disregard the notion that life goes beyond family obligations mainly childcare this is especially evident in a developing and culturally unique context such as malaysia similarly most past studies have also equated the term life with family obligations which is focused on childcare this limited understanding of what the life domain entails curtails their ability to render the relevant support therefore the objective of this study is to address the gap and demystify the conceptualization of life in the term wlb especially in the malaysian context demystifying wlb this conceptual paper intends to focus on a better conceptualization of the life component in wlb a review of literature on worklife based research revealed a plethora of studies that employed terms such as wlb workfamily balance worklife conflict workfamily conflict workfamily enrichment and so forth to represent wlb these terms are theoretically distinct and need careful conceptualization while it is impossible to find one best definition that encompasses what wlb represents it is important to understand the distinction and the interrelationship between these commonly used terms firstly it is essential to understand that individuals juggle multiple roles these roles can be generally categorized into professional and personal fundamentally individuals with wlb are found to engage in multiple roles through effective distribution of time and effort across work and nonwork domains wlb has also been signified as engagement in these work and nonwork roles with a minimal conflict between these roles a balance between work and life is said to diminish when there is role conflict on the other hand wlb is found to be enhanced when there is workfamily enrichment and familywork enrichment workfamily enrichment discusses the extent experiences in a particular domain enhances the quality of life in another domain enrichment could either occur through two pathways instrumental pathway where resources obtained from one role promotes improved performance in the other or affective pathway in contrast to these existing views haar russo suñe and olliermalaterre proposed that wlb should be based on kossek valcour and lirio proposition which depicts wlb as a holistic concept unique for each person and that depends upon his or her life values priorities and goals it can be implied that what matters in ones life may not matter to another fundamentally a balance should be perceived as an individuals holistic feeling of satisfaction derived from how they function in multiple roles hence it is important to understand varied perspectives on the life domain as life may be perceived differently by a different group of people within the organization background of malaysia malaysia as a developing nation increasing work demand and transformation of workforce the intertwined nature of work and life is an emerging trend especially in developing countries such as malaysia a brief review of the malaysian scenario could help shed some light on why such a transformation is gaining momentum malaysia is driven to become a highincome nation supported through high growth this drive was noted through malaysias key development eras which commenced with the period of the new economic policy this policy intended to eliminate outright poverty notwithstanding race and abolish the classification of economic function by race moving forward the government kickstarted the journey towards becoming a developed nation by the year 2020 with the establishment of vision 2020 during the tabling of the sixth malaysian plan amidst global changes fuelled by the financial crisis of 2007 to 2010 this vision was reviewed and a higher growth rate was proposed to ensure malaysia inched closer to her dream of becoming an established country by the year 2020 accordingly the national transformation 2050 was announced during the tabling of the 2017 budget the primary aim of this plan is to facilitate malaysias quest to be among the leading states in the world in terms of fiscal progress resident wellbeing and innovation fundamentally malaysias development plans attempt to incorporate inclusive growth that promotes sustainable individual and societal wellbeing the announcement of tn50 is timely and reflected the governments pledge towards helping malaysia become a developed nation however development is often accompanied by hidden negative implications the downside of such drive toward development and performance is its impact on work demand in line with the quest towards development a surge in work demand is expected higher work demand is inadvertently translated to the implicit expectation of longer working hours among malaysian employees while the employment act stipulates maximum working hours of 48 h per week this is hardly enforced for instance ramos francis and philipp found that the respondents from the malaysian banking sector spent on average 52 working hours per week generally malaysian employees worked on average 15 h beyond their stipulated weekly working hours compared to their counterparts in singapore australia and hong kong this could be ascribed to the perception that working extended hours can be perceived as being hardworking and more committed to the organization besides the increasing work demand a transformation in the malaysian workforce was also noted in general eby casper lockwood and brinley concluded that the configuration of the workforce has altered considerably in recent years based on their content analysis of 22years on work and family research given such changes in workforce composition burke found that such transformation further exacerbated the clash between work and life domains the workforce composition in malaysia has also changed from several aspects first the increased involvement of women in the malaysian labor force has influenced the rise of dualearner couples this trend has paved the path for a transition from a traditional family system to a companion family system the traditional family system refers to the system based on family members playing traditional roles in the traditional family system the focus is on raising the family the role of the father and mother are divided where the father serves as the main source of income and the mother is the homemaker on the contrary in a companionship family system the role of the father and mother is based on love communication and tolerance as both parents are involved in the labor force and at the same time are responsible for the family upbringing in such system both men and women partake in activities within both domains of work and family if decades ago men are the breadwinner now they are also involved in house chores on the other hand if decades ago women are mainly involved in house chores now they are also the key player in the workforce hence dualearner couples now struggle to strike a balance between demands of work and other aspects of life such as caring for children and elders in numerous developed countries the companionshipbased family system is prevalent compared to a traditional one similarly in malaysia the companionshipbased family system is generally observed this is especially needed in a context where families are progressively moving towards smaller sized families and the onus of tending for the family unit is shifting onto the shoulders of fewer adults the second notable change in the work domain is the increase of labor force participation of single employees or nevermarried employees recent research shows that there is a decrease in the percentage of married people a rise in the proportion of divorced people and an increase in the median age of marriage the ratio at which families are developing is decelerating and this inevitably is reflected in the increasing percentage of nevermarried individuals this upward trend remains to date the statistics for the 2017 malaysian labor force indicate that approximately 62 of employees are married and the remaining are either never married widowed or divorced while this proportion has not changed significantly since 1982 it is important to note that almost 40 of the workforce constitutes single or never married employees a common misconception that plagues most organizations is that unmarried employees are free of parental or family obligations while it seems obvious that married employees spent most of their nonwork time on activities centered on child care everyday chores and other family needs compared to their single counterparts that does not mean single employees are free from such roles malaysians regardless of their marital status still live with their loved ones in either a nuclear or extended family arrangement such family structure coupled with the collectivist and humane orientation requires all family members to shoulder the responsibility to care for others sadly organizations fail to realize that in most collectivistic cultures unmarried children also bear family responsibilities in the form of caring for their elders this obligation is encapsulated in the concept of filial piety third the inclusion of single and generation y or millennials in the malaysian workforce has increased the necessity to focus on life beyond family commitments there is a pressing need to focus on other nonwork activities such as leisure activities as well for instance single employees also seek opportunities to spend their nonwork time more on hobbies sports time with friends travel voluntary work and personal development a similar expectation is noted among generation y or millennials they are generally younger with about onethird of them still single and about 40 without children therefore they experience reduced family to work conflict and may seek balance in other aspects of life such as leisure activities with the proliferation of generation y in the workforce it is important to address their wlb expectations as well millennials live by the motto yolo hence they aim to live better lives than their parents and strongly advocate the need for wlb pwc found that 97 of millennials deem wlb important wlb tops their list of things that matters to them they are always planning their vacation or minibreaks to allow them to recharge however based on the survey almost half of them felt organizations failed to address their need for wlb malaysias cultural background and worklife conflict the subject of worklife balance has been extensively researched in western and developed countries however there are only a few studies on worklife balance in contexts beyond western countries the lack of attention does not undermine the issue instead this issue is gaining prominence in developing countries and countries with different cultural value systems such as malaysia fundamentally there is a need to view worklife issues from a cultural lens for instance collectivist societies such as malaysia may view and experience wlb differently generally work interference with family is higher than family interference with work however in the malaysian context fiw was significantly greater than wif allen french dumani and shockley reported a similar finding that familytowork conflict was notably higher in more collectivistic cultures compared to individualistic cultures collectivist society experiences a greater sense of connectedness hence enhancing their need to care about each other and understand how their work demands affect their family domain and vice versa it is a common perception that in a collectivist society support is received from extended family members which helps reduce work and family conflict however allen et al found that contrary to the common perception employees in collectivist society experience greater familytowork conflict this reinforces the fact that family is viewed as an obligation in asian culture therefore individuals in such culture experience greater family demands for instance in malaysia family refers to an extended family that can include a large number of members this naturally translates into greater family obligations such as more visits more events to participate in and so forthwhich contributes to fiw and can be exhausting typically unlike individualistic cultures where work and family are treated as distinct domains collectivist cultures treat these two domains as integrated domains work is viewed as a means to provide for the family and is rarely viewed as interference to family life family is embraced as the most pertinent ingroup and includes extended members similarly other cultural orientation or structural variables unique to a specific context may influence worklife practices this raises the question of whether western assumptions on wlb hold to a culture such as malaysia hence this paper will review the issue of work and life in malaysia specifically to better understand the underlying problems within the context to minimize the possibility of workfamily backlash worklife balance in malaysia despite the existence of policies to promote wlb these policies are either underutilized or limited to employees with family obligations such a narrow focus towards the offering of wlb policies may result in a worklife backlasha phenomenon reflecting the negative attitudes negative behaviors and negative emotionsboth individual and collectiveassociated with multiple forms of wlb policies and practices including both the availability and use of these policies to make matters worse these policies are generally adopted to a greater extent within the public sector the private sector is exempted from adhering to these policies as malaysia continues to encourage the private sector to focus on the economic development of the nation and propel malaysia towards her quest to become a developed nation inadvertently the mounting pressure of work demand is expected to negatively influence the life domain increasing work demands will naturally overshadow personal needs longer working hours and afterhours connectivity not only negatively affect employees lifestyle health which includes physical activities but also limits their time available for nonwork life as abdul hadi succinctly states long working hours reduces opportunities for socially productive leisure by restricting the time available for being an effective marriage partner parent and citizen to some extent this can be counterintuitive towards efforts to integrate allencompassing development that encourages sustainable wellbeing for both individual citizen and society there is a call for the malaysian government to reduce the weekly working hours of 48 h to 40 h to allow employees to achieve a better equilibrium between work and life sadly many employers have turned a blind eye towards employees call for better worklife balance and placed this need at the bottom of the ranking to make matters worse the tension between work and life is exuberated with the transformation brewing within the composition of the global workforce in general and the malaysian workforce specifically this includes an increase in dualearner couples and never married employees in the workforce such transformation coupled with the traditional value system that defines malaysia has fuelled the need for the organization to revisit the conceptualization of life in the term wlb in such a conflicting situation the need for wlb has become even more substantial notwithstanding the presence of policies to encourage worklife balance these policies are restricted to employees with family obligations the needs of employees without young children such as generation y single employees childless employees or even employees with older children often take the backstage the failure to accommodate nonfamily aspects of life can induce stress and be detrimental to the wellbeing of employees and their performance at work while the worktoleisure conflict was reported to adversely influence psychological wellbeing contentment with leisure and job this was especially evident in the case of millennials the abovementioned changes in the composition of the workforce and the present cultural norms prompt an important questionwhat signifies wlb in the minds of employees of all demographics more importantly what defines their life domain this paper puts forward the notion that when organizations fail to understand what embodies the life domain of employees they may fail in rending the right support for their employees to strike a balance between work and life it is pertinent for organizations to be aware of the issue of wlb as it significantly influences an employees life work and family most workers are constantly juggling demands and making choices between work and personal life the failure of organizations to extend better support in facilitating the achievement of wlb may jeopardize either their employees performance at work or the quality time for their personal activities or in a worse case both domains of work and life concurrently the following section will distinguish work and nonwork domains to facilitate a better understanding of activities that should be included within work and life domains work versus nonwork domain work demand work demand has been identified as one of the most important antecedents of conflict in the work and life domain work demands refer to physical communal or managerial aspects of a job that require sustained physical or mental effort work demand in this study is defined as the efforts needed to perform the task given in paid employment excellently some scholars used the terms job demand or career demand which brings the same meaning as work demand work demand can be divided into two timebased demand and strainbased demand timebased demand is the time an employee needs to spend on work the amount of time spent on the job has frequently been studied as an antecedent of workhome conflict and work demand was mostly measured by hours worked in wlb study job involvement is one of the examples of timebased demand job involvement describes the extent work situation is essential to a person and their psychological identity individuals are considered to be involved in their work if they keenly partake in their job treat it as their key life concern identifies accomplishment in their job as pivotal to their selfesteem and selfconcept the other example of timebased demand is the type of job according to duxbury and higgins several bodies of research suggest that the type of job an individual hold will affect his or her ability to balance work and family demands there are a few studies that show that travel demand in performing work is also one of the timebased demands as it would be timeconsuming strainbased demand is likely to cause high levels of physical and psychological fatigue job dissatisfaction and turnover intention examples of strainbased demand are work overload work pressure and job insecurity one of the reasons for work overload is downsizing overload is experienced by those who remain in the organization as they are expected to put more commitment to their work domain another strainbased demand is job insecurity job insecurity can be experienced in two forms objective job insecurity and subjective job insecurity work overload and job insecurity will most likely lead to work pressure work pressure or job stress reflects the feeling of having limited time to finish given work working intensely and at a swift in a survey conducted by goveas job stress was identified as employees primary problem to achieve excellence in quality of service lazar et al stated that employers should take a thoughtful consideration of job stress that is faced by employees research found that managerial men and male psychologists value the organizational support that would lessen their job stress and raise their joy in work by having lower intentions to quit and more positive emotional and physical wellbeing it is important to take note that the implication of work demand on work and attitudinal outcomes is predisposed to cultural variation generally employees in malaysia have the perception that the employees must work long hours or take the work home for better career advancement promotion and rewards this commitment is reflected in their willingness to work longer hours compared to their counterparts in singapore australia and hong kong employees in a collectivistic society are still willing to invest additional effort into work to be perceived as someone who sacrifices for their familys wellbeing in such cases the negative implication of work demand on outcomes such as satisfaction is lesser in collectivist society compared to counterparts in individualist society nonwork domain the dominance of family over life the term wfb and wlb has been used interchangeably in past studies most researchers either used the term wlb or wfb at a time these terms were inconsistently defined in past studies some researchers such as shah maharshi and chaturvedi mazerolle goodman and pitney and cowart gilley avery barber and gilley used the term worklife balance in their study which focused on family matters on the contrary researchers such as tomazevic kozjek and stare beham and drobnic and tremblay used the term wfb when their study also examined personal activities beyond family matters the usage of either one of these terms in an inconsistent manner tends to mislead the finding of the research and does not reflect the actual situation fundamentally since the introduction of workfamily research in the 1970s nonwork domain was mainly focused on family responsibilities over time the workfamily concept was replaced with worklife to represent a wider range of activities beyond family responsibilities such as leisure activities social relationships hobbies and so forth despite acknowledging the fact that the nonwork domain involves a wide range of activities family responsibilities remained a prominent component of the life domain hamilton et al stated that many researchers have assumed that life is analogous to family most scholars put family demands especially childcare as one of the compulsory components of nonwork demand for instance burnett et al defined nonwork demand as domestic chores and the hours devoted by parents on housework similarly lakshmi referred to nonwork demand as activities that include babysitting senior care and unpaid duty such as household chores hence in most cases the word life has been defined in a narrow sense and limited to childcare and in some instances elder care in reality the life component in wlb is not limited to family obligations due to such misleading assumptions not all employees appreciate and use the benefits commonly offered by organizations such narrow conceptualization of activities within the nonwork domain has led organizations to overlook the need for wlb among employees of all demographics such as single or childfree employees generation y and others such insular misconception has resulted in many single employees being forced to work long hours assuming that they have no important personal activities out of the work domain generation y employees expressed their disappointment with how organizations deal with the issue of wlb as it does not meet their expectations furthermore many organizations were found to extend compressed work weeks job sharing or telework options for employees with young childrenleaving employees without such responsibilities ineligible and unappreciated the recent covid19 pandemic is proof of such mindset employees with young children were prioritized when remote working was enforced at public and civil services departments surprisingly despite the increasing labor force participation of employees of all demographics organizations have failed to accommodate the need of such employees these employees who do not gain from familyoriented benefits experience frustration and worklife backlash due to perceptions of inequity it is inaccurate to assume that employees without childcare responsibilities do not have other needs hence there is a pressing need for a more flexible peoplecentered approach to workstyle design it is important for organizations to embrace the fact that employees from different demographics are driven by different needs within the life domain in view of this some researchers have accurately used the term wlb to represent activities outside work which is not limited to family matters but also inclusive of personal matters friends and community marcinkus et al associated the nonwork domain with parenting and community work poelmans et al stated that nonwork domains revolve around ones family social and spiritual roles wheatley stated that the nonwork domain comprised of free time spent on leisure activities and family time accordingly stankiewicz bortnowska and łychmus claimed that nonwork refers to family health social activity private interests and so forth it seems like scholars in the most recent years have embraced a clearer description of the nonwork aspect one that incorporates activities other than conventional family obligations the extended conceptualization now includes activities such as favourite pastimes and other forms of relaxation however this trend is not acknowledged in most malaysian organizations with a cultural norm that focuses on family wellbeing most organization pay a great deal of attention to family oriented wlb policies in view of the transforming workforce it is pertinent for organization to understand that nonwork domain encapsulates two distinct dimensionsfamily and personal life in a nutshell malaysian organizations need to embrace the fact that life domain within worklife balance encompasses personal needs that are not limited to family or childcare responsibilities nonwork domain demands vs needs role engagement requires the investment of time and psychological involvement in specific roles roles within the nonwork domain require individuals to invest enough time and effort to experience the satisfaction resulting from these roles while these roles are part and parcel of an individuals life family roles such as child care and eldercare responsibilities are given priority as such roles involve responsibility towards the care of others these roles are clearly demanding as it requires a substantial investment of time psychological involvement in the role and effort of an individual employees bearing such responsibility are expected to navigate work demands as well as fulfill the needs of the child or elders while we can identify family roles as responsibilities activities within the personal domain such as leisure activities seem less of an obligation such a mindset influences employees within collectivist society to prioritize their family responsibilities and be willing to forgo activities within the personal domain however it does not mean activities within this domain are less pertinent leisure activities such as vacation exercise social activities and so forth help individuals to recharge and relieve stress from work and familyrelated responsibilities engagement in such activities generate positive emotions and undeniably helps facilitate the achievement of wlb subsequently individuals who achieve wlb will experience enhanced wellbeing which results in positive workrelated outcome nonworkrelated outcome and low stressrelated outcome this can be related to the principle of positive spillover affect spillover refers to feelings caused by experiences in one life domain influence the other life domain hence when an individual experiences positive emotions from leisure activities this emotion is transferred to other domains such as work and family this facilitates the development of a sense of balance between all domains of life and justifies the need for employers to take responsibility to ensure their employees have enough time for activities and responsibilities within the nonwork domain extending support for wlb to employees of all demographics will create a perception of justice within the organizations based on the organizational support theory if employees deem their employers to be supportive they are likely to return the favor by committing themselves to their workgroup employees will acknowledge the fact that their employer is concerned for the wellbeing and they will naturally reciprocate by contributing greater efforts to help the organization achieve its goals organizational support assures employees that their organization is dedicated adequate attention to their nonwork related needs this sense of assurance nurtures positive attitudes towards the organization and fosters enhanced employee involvement and obligation to invest extra effort in return for further benefits therefore we believe that it is pertinent for employers to distinguish and acknowledge nonwork demands among employees employees of all demographics will experience family responsibilities and personal needs within their nonwork or life domain however their view of family and life obligations differ among individuals according to their responsibilities and commitment the dominance of family responsibilities such as child care and elder care depends on the family configuration of individual employees for instance childcare responsibilities will most likely dominate the nonwork domain of employees with young children compared to their counterparts without young children eldercare responsibilities will most likely dominate the nonwork domain of employees with elder family members to care for compared to their counterparts without a dependent elder family member on the contrary employees without young children or elderly dependent family member will most likely emphasize other interest in their nonwork domain compared to family responsibilities regardless of the extent of family responsibilities employees of all demographics will seek fulfillment in life through activities such as hobbies leisure activities social relationships and so forth to experience enhance wellbeing it helps them cope with demands in life hence worklife balance strategies must consider these needs and expectations implication to practice the need to distinguish wfb and wlb is certainly not a fad but the logical consequences of dramatic and irreversible changes taking place globally in terms of demographic shifts the intensification of work and the fragmentation of time hence the issue should be pursued as a strategy to build a positive work environment which leverages the firms performance employers need to understand their role in extending required support to employees to facilitate the management of their multiple roles be it as parents or nonparent familyfriendly policies or worklife policies do not exist in a vacuum they need to be adapted to different cultural political economic and social conditions in terms of the malaysian context the vision in national transformation 2050 would be a concrete base to force the organizations to sit back and consider the effect of wlb to reach the objectives as planned it would be more significant in years to come as the ministry of women family and community development is consistently pursuing their quest to increase the percentage of women participation in the labor workforce as per the year 2015 womens participation has reached up to 55 and 30 of women in the top management position thus in years to come men and women have to compete as they have equal opportunity to have a better job and better career advancement this action is expected to affect the demographic pattern in the labor population by increasing the mean age of the marriage as priority will be given to stabilize the career before getting married thus the number of single employees will keep increasing to the extent that it would become another main group other than the group of married employees research on this topic can transform governments and employers mindset and provide insights into the formulation and implementation of human resources policies for instance in malaysia the ministry of women family and community development admitted that there is no specific policy on wfb and wlb instead they only have programbased activities to promote wfb which at the moment only targeted the family matter especially caring responsibilities similarly no policies related to wlb were noted within the acts and policies under the malaysian ministry of human resource it is hoped that this conceptual paper opens the minds of officials to formulate and implement wlb policies that encapsulates the life domain and promotes employees wellbeing besides with an assumption that private sector companies are in need to be competent and perform at a greater level these organizations should have a certain level of awareness about the need for wlb policies organizations need to go beyond family obligations when designing wlb policies ultimately it is hoped that this discussion would strengthen the knowledge about the distinction between wfb and wlb in malaysia and help enlighten employers on how they can facilitate the experience of wlb among their employees clearly the one size fits all approach to benefits offered or policies stipulated in administration is underutilized by a certain group of employees in a nutshell this conceptual paper agrees with the notion underlying the ost and strongly proposes that inclusive wlb support for all employees is necessary support should be distinguished between familyoriented support as well as lifeoriented support limitation and direction for future research our conceptual propositions are not without limitations primarily the propositions were based on gaps identified in the literature and reviews about practices at the workplace specifically within the malaysian context while the notions presented may be widely practiced in developed nations this issue remains a problem in developing and collectivist nations such as malaysia furthermore these propositions have yet to be tested empirically future studies need to explore the possible differential effect of family demands and life needs on employees perspectives on wlb and the possibility of minimizing worklife backlash in addition the present paper did not discuss the association of better conceptualization of life with outcomes such as worklife synergy and worklife flexibility future studies should incorporate these constructs to better understand the interrelationship between these variables and wlb it is pertinent to explore if a better conceptualization of the life in the term wlb will lead to enhanced workfamily synergy and help organizations structure better employment scheduling practices conclusion the workforce is not made up of a homogeneous group of people with the inclusion of people with different family or life obligations it is pertinent for organizations to customize the support extended according to the needs of employees adopting the one size fits all approach is not the way forward extended support is only possible if organizations are more proactive in understanding the various responsibilities and interests that fall within the family and life domains of any employee while it may be impossible to understand all aspects of family and life it would be a good initial step towards creating a more balanced life it could assist the management in imposing better and more appropriate support on wfb and wlb to improve their employees wellbeing service quality and performance availability of data and material not applicable authors contributions not applicable compliance with ethical standards conflicts of interest on behalf of all authors the corresponding author states that there is no conflict of interest publishers note springer nature remains neutral with regard to jurisdictional claims in 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traditionally the word life in the concept of worklife balance focuses on family obligations this conceptual paper sets out to present the notion that life goes beyond family responsibilities and is unique to employees of different demographics given the impending difference in how life is viewed by different groups of employees this study reviews the literature and argues for the need to distinguish between different dimensions of the nonwork domain the discussion is centered on the transformation taking place within the malaysian workforce recent trends indicate that life and family are indeed distinct domains there is a need for organizations to acknowledge this distinction and provide relevant support to attain a balance between work life and family the paper will help strengthen the knowledge about the life in the concept of worklife balance and employers better understand the conceptualization of life in worklife balance so that they can strategize and enhance employee wellbeing and eventually gain competitive advantage currently the terms worklife balance and workfamily balance are used interchangeably to represent a balance between the family and work domain this is especially evident in collectivist countries such as malaysia however the emphasis on family without due consideration to the needs of employees with different demographic configurations may result in worklife backlash hence this study argues that the nonwork domain is not limited to family obligations and should encompass both family obligations and personal activities the emphasis on striking a balance between work and family domain should not be done at the expense of the wellbeing of employees with lesser or no family obligations

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background the term disability was first defined by nagi in the 1960s 1 the world health organization has developed an updated framework 2 in 2002 which considers the term as an umbrella term for impairments activity limitations and participation restrictions and emphasizes that disability is a longterm interaction between the person and the overall environment in which the open access correspondence 1 national clinical research center for geriatrics and department of general practice west china hospital sichuan university chengdu china full list of author information is available at the end of the article person lives this implies that disability is a complex and multifactorial state involving multiple risk factors currently there are no uniform standards and methods for assessing and classifying disability in older adults in order to obtain comparable global health data various tools for measuring disability have been developed 3 4 5 6 7 the most commonly used one is the barthel index 8 which can evaluate the ability of older adults to perform daily living activities it is characterized by its simplicity of operation good reliability and sensitivity 9 human life expectancy has reached an alltime high and is on the rise 10 which will lead to the emergence of a large number of older adults with different degrees of disability 11 disability not only affects the quality of life and health outcomes of those people but also significantly increases the cost of care 12 collecting data from representative studies in 37 countries who reports that 14 of the 514 million older people lack the basic skills to lead a meaningful and dignified life 10 by the end of 2015 chinas elderly population had reached 4063 million accounting for 183 of older adults in the same period 13 it is conceivable that china as the largest developing country globally is facing a great socioeconomic burden previous studies have explored a range of factors that may affect the physical functioning activity and social participation of older adults including but not limited to sociodemographic characteristics social networks selfperceived health cognitive functioning mental health disease burden and repeat hospitalizations 14 15 16 17 18 since 2005 many similar studies have been conducted in most regions of china but few studies have been conducted in the southwest 19 20 21 22 given the regional differences in social and economic development there are significant disparities in education employment opportunities social welfare medical resources and geriatric care services between southwest and the eastern coastal regions of china sichuan province a representative province in southwest china is characterized by a large rural population a low level of education for the overall population a multiethnic population and uneven development across regions its gdp per capita is far below that of the eastern provinces 23 in addition data from the sixth national census released by chinas national bureau of statistics in 2011 shows that sichuan province has the largest population and the most severe aging problem in the southwest this means that the disability of a large elderly population in this less developed part of the country has not received the attention it deserves although the local government has introduced some policies on care services for the disabled elderly the overall disability situation in the province is not clear therefore this study was conducted at a provincewide level to determine the prevalence and influencing factors of disability among the elderly in urban and rural areas of the province so as to provide scientific references for local government interventions and the development of care policies from the above analysis there are three gaps between this study and the previous ones first although disability among older adults is relatively common and has a significant impact on individuals families and society relevant research is rare in the less developed regions of southwest china second few largescale studies specifically address disability among older adults in urban and rural communities finally few studies on disability in the elderly encompass social factors physical health mental health and cognitive function functioning method data collection physicians and nurses from local primary care facilities constituted the majority of the interviewers they were asked to attend a comprehensive training course at the national clinical research center for geriatrics prior to the assessment where they were trained in the use of electronic data capture to collect data through facetoface interviews only those who passed both the theoretical and practical exams received a certificate of eligibility from the center in addition missing or incorrect questionnaires were reassessed the entire assessment process of the survey was under the scrutiny of specialized personnel sent from their parent organization disability measurement the adl was measured by the bi scale which were essential in evaluating the independence of selfcare among the aged 24 including personal hygiene bathing self feeding toilet stair climbing dressing bowel control bladder control ambulation and chairbed transfers its excellent reliability and validity values as well as specific increments and values have been detailed in previous studies 25 the bi scale was used to assess disability with scores of 040 representing severe impairment in activities of daily living 4560 representing moderate impairment and 6595 representing mild impairment characteristics this study conceptualized the factors influencing disability into two areas social factors and health status social factors included demographics such as age gender race place of residence marital status education level preretirement occupation and consumption level health factors included hospitalization chronic illness selfrated health accidents cognitive status and mental health the hospitalization rate in the previous year chronic disease selfrated health and accidents within one month were recorded based on the subjects reports comorbidity was defined as the presence of two or more chronic conditions at the same time based on the subjects assessments their selfrated health status was classified into three categories including poor general and good the cognitive state was measured using the minicog test widely used with high reliability and validity 26 the test consisted of a 3word recall and clock drawing test subjects who recalled 0 words were classified as dementia those who recalled 12 words were classified according to the cdt and those who recalled 3 words were classified as normal anxiety symptoms were screened by gad2 27 with subjects with a score ≥ 3 being regarded as anxious and depressive symptoms were evaluated by phq2 28 with subjects with a score ≥ 3 being regarded as depressed subjects with both depressive and anxiety symptoms were assigned to the comorbid depressive and anxiety symptoms group those with anxiety symptoms alone to the anxiety group those with depressive symptoms alone to the depression group and those with none of the above symptoms to the normal group family and friend networks were assessed using lsns6 29 which was highly reliable and valid and has been used in many countries 30 this measurement involves six questions three for friend ties and three for family ties each question was scored on a scale of 0 to 5 with scores ranging from 0 to 30 social isolation was considered for a total score of 12 when the total scores ≥ 12 subjects with a score of 6 for the friend part were classified as alienation from friends and those with a score of 6 for the family part as alienation from relatives statistical analysis continuous variables were described as mean ± sd and categorical variables were described as percentages ttest and x 2 test were adopted to compare the differences in demographic and health characteristics between groups and logistic regression models were performed to correct for relevant confounders we chose a robust poisson regression model for the analysis 3132 the specific model assumptions can be found in supplemental files robust poisson random effects models can be implemented through glms in stata 151 the multivariate model with minimum akaike information criteria and bayesian information criteria was considered the best fitting model all analyses were performed with stata 151 and 005 were considered statistically significant results prevalence and distribution of disability a total of 15385 responses were collected including 8368 from female respondents in this study 194 of the subjects experienced disability and the incidence of mild moderate and severe disability was 168 15 and 11 respectively significant differences were found in the distribution of disability by age group gender and area of residence figure 1 shows that the older people are the higher the prevalence of disability and the degree of impairment the prevalence of the three types of disabilities increased sharply among people aged 7079 years and the proportion of people with severe disabilities reached 366 among those aged 90 years or older among those with severe disabilities the gender gap was the largest with women accounting for 605 in addition we found that 511 of older adults with disabilities were from rural areas more than 50 of older adults with mild and moderate disabilities were from rural areas while only 488 of older adults with severe disabilities were from rural areas the social relevance of disability in the present study the mean age of the disabled group was greater than that of the nondisabled group as shown in table 1 there was a statistically significant difference between the different age groups it was found that people with disabilities were more likely to be older women and people living in rural areas or former farmers in addition disability was more common among older adults who were widowed had no formal education or had low consumption levels the results also showed that alienation from relatives and friends was significantly associated with disability healthrelated factors of disability as shown in table 2 the distribution of disability by health characteristics showed a correlation between disability and hospitalization ratesdays disability was more common in patients with chronic conditions and its incidence increased with the number of comorbid conditions as expected the number of disabilities increased with worsening selfrated health status and the incidence of falls in addition impairment in cognitive function and the occurrence of depressive and anxiety symptoms were significantly associated with the incidence of disability distributions of adl component table 3 and fig 2 show the distribution of impairments for the different items in the bi scale functional impairments in older adults with mild disabilities mainly included stair climbing bladder control and chairbed transfer those with moderate to severe disabilities showed similarities in limitations in abilities mainly involving lower limb function figure 3 confirms that the incidence of impairments in all daily activities under assessment saw a significant increase with aging among which the impairment of climbing was the earliest and the most common one followed by ambulation chairbed transfers and bathing at a generally consistent pace factors associated with disability based on the results of many correlation studies and univariate analysis we finally included 14 relevant variables to construct different models 1618 33 34 35 36 the best fitting model had an aic value of 088 a bic value of 14057420 after adjusting for all significant variables only higher levels of education could be used as a protective factor for disability in the fully adjusted model gender marital status and consumption level were no longer associated with the prevalence of disability discussion in this study the prevalence of disability among older adults in sichuan province was 194 higher than the worldwide average 37 as well as the results in the reports of many countries such as poland 38 and some domestic studies 39 such a high disability rate among the elderly in a place with low per capita income severe aging a significant exodus of the working population uneven regional development and limited medical resources undoubtedly poses a considerable challenge to the local health care system 2340 the key to solving this problem lies in reliable estimation and effective fig 1 a combination of three figures disability was divided into three levels mild moderate and severe age was divided into four groups the one on the left showed the distribution of different disabilities by age the middle one showed the distribution of different disabilities by genders the one on the right showed the distribution of different disabilities by residency areas disability prevention therefore this study aimed to investigate the prevalence and influencing factors of disability among the elderly in urban and rural sichuan which is of great significance to the best of our knowledge this is the first largescale survey of disability in urban and rural areas in southwest china theoretically these results can be generalized to southwest china and other populations with similar characteristics similar to the findings of other scholars 34 the earliest and most severe impairments in the disabled elderly involved their lower limb function such as stair climbing ambulation and bathing self the worsened lower limb function can be explained by related factors 1 natural aging reduces lower limb muscle strength and quality 41 2 chronic diseases such as osteoarthritis 42 diabetes and chronic obstructive pulmonary disease 43 and falls will cause mobility limitation further decreasing their physical function 3 dementia will cause gait disorders decreased balance function and increased risk of falls eventually increasing physical dependence 44 4 in the case of repeated hospitalization 45 physical inactivity in the elderly prolonged bed rest and reduced intake all decrease lower limb function therefore it is crucial to maintain lower limb mobility in the elderly and promote postinjury rehabilitation health education and targeted physical activity interventions have been introduced in many countries 46 however the rapid aging of the population continues to leave lowand middleincome countries unprepared in 2016 the chinese government included healthy aging in its national development program and introduced longterm care insurance for the elderly with disabilities in many pilot cities 47 this insurance focuses on financial compensation while care services are mostly provided by thirdparty institutions the quality and quantity of daily care services still do not meet the existing needs of these elderly people 396 of elderly people with disabilities selfrated their health as poor which may be related to unmet needs 48 what is certain is that the burden of care for moderate and severe disabilities is high we need to reduce the future burden of care by working to prevent mild disabilities especially in economically disadvantaged areas 49 by developing appropriate physical activity patterns improving the quality of chronic disease management and optimizing inpatient management concepts we can maximize the prevention of lower extremity mobility loss in older adults the results of this study suggest that aging contributes to the onset and progression of disability as has been confirmed in numerous articles 50 however followup cohort studies are still needed to elucidate the specific trajectory of disability aging poses a number of psychiatric problems in older adults that are caused by many factors including 1 decreased sensory function 51 2 decreased adaptability to environmental changes and social roles and status and 3 increased likelihood of exposure to negative life events such as retirement and death of a relative in this study 82 of the elderly screened positive for mental disorders and the rates of positive depression and anxietydepression comorbidity were significantly higher in the disabled elderly in addition less interaction with family and friends increased the incidence of disability however alienation from family alone did not have a statistically significant effect on disability which may be related to the current situation of empty nesters in china older adults rely more on interactions with friends than the next generation who are busy with work according to the metaanalysis the prevalence of depression among chinese empty nesters was 386 52 research suggests a bidirectional relationship between social isolation and depression or anxiety which naturally accelerates the onset of disability 53 however public spending on mental health in developing countries remains low and is mostly focused on psychiatric hospitals 54 while these hospitals do not provide community mental health services that can provide longterm care and support as early as 2004 china attempted to establish a comprehensive community mental health system however the system continues to face significant challenges due to low national awareness of the need for mental health services lack of specialized physicians and financial difficulties 55 this study will provide a reference for regional epidemiological data on mental disorders in the elderly and also call for relevant authorities to pay attention to the mental health problems of the elderly consistent with previous studies 56 our findings suggest a strong association between cognitive function and disability the survey showed that 1179 elderly people had positive dementia screening results and the proportion of dementia in the disabled population was 48 times higher than that in the nondisabled population which fully indicates that dementia is an important cause of loss of selfcare in the elderly as the country with the largest number of dementia patients in the world 57 china has not yet established a service system specifically for dementia early detection of cognitive impairment is not possible due to low public awareness of dementia and the lack of routine screening mechanisms in most medical facilities many people with dementia rely on home care which is increasingly being incorporated into longterm care however the lack of caregivers with spiritual and professional background makes it difficult to improve the quality of life of these elderly 58 therefore the following steps should focus on increasing public awareness of dementia earlier identification and prevention of cognitive impairment and the establishment of a joint disability service system for dementia statistically significant differences in disability were observed between genders and the older women were more prone to experience functional impairment however after adjusting for other variables the incidence of disability became similar between genders following fig 4 factors associated with disability adjusted rate ratio were calculated using robust poisson regression adjusted for all variables abbreviation ci confidence interval mci mild cognitive impairment adjustment of other variables which might be explained by higher rates of chronic diseases such as osteoarthritis dementia falls and mental disorder in women 59 as well as differences in body composition and life expectancy gaps 60 for social factors the analysis showed that older adults who live in urban areas and have formal education are better able to maintain their abilities as has been well documented in many studies this may be because they have access to health knowledge and resources from a variety of sources 61 as well as a range of social and recreational activities which can help them maintain good mental health 62 despite chinas increasing spending on healthcare and health inefficiencies and uneven distribution of resources persist because of the differences in economics healthcare urbanization and population density between the east and west it is difficult to see a boom in care services and elderly care in the rural west anytime soon 63 this study will offer policy implications and help local elder population to improve the quality of life this study has several strengths first this large sample study can provide highquality and rich information for existing disability research and the findings are important for followup studies and the global literature on the disability process and its associated factors second comprehensive training of professional bodies and various quality control measures yielded reliable data finally the study results provide a scientific basis for government policies and resource allocation to enable local older adults to have a higher quality of life and gradually achieve healthy aging several limitations should be taken into account when interpreting this study as this study is a crosssectional study the results failed to determine a causal relationship between influencing factors and disability therefore although many factors influencing disability were identified in this study it cannot be denied that disability may also influence related factors to some extent further cohort studies are needed to determine the causal relationships some of the data on health characteristics and adl items were selfreported and biases in recall and reporting may have affected the information future studies should add more objective indicators and try to assess disability in multiple dimensions rather than just selecting adl as the only criterion for determining disability this study served as a baseline investigation for our project and more followup and exploration of interventions are needed in the future conclusions a higher prevalence of disability was found among urban and rural older adults in sichuan where disability was strongly associated with aging lower education levels living in rural areas hospitalization comorbidities selfrated poor health falls cognitive impairment psychological problems and changes in social networks the findings underscore the need for early screening for disability effective prevention policies smaller urbanrural disparities and agefriendly society • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more biomedcentralcomsubmissions ready to submit your research ready to submit your research choose bmc and benefit from choose bmc and benefit from abbreviations additional file 1 authors contributions rq contributed to conceptualization methodology formal analysis investigation data curation writing original draft review and editing of the paper sj contributed to data curation validation review and editing of the paper wz contributed to methodology review and editing of the paper xx contributed to data curation formal analysis visualization of the paper qs contributed to the revision of the paper lh contributed to methodology supervision of the paper dl contributed to supervision project administration of the paper fh contributed to investigation data curation of the paper bd contributed to conceptualization methodology funding acquisition project administration supervision review and editing of the paper all authors saw and approved the final version of the manuscript competing interests the authors declare that they have no competing interests

background as one of the challenges of aging older adults with disabilities are often overlooked in remote areas of many developing countries including southwest china similar populations would undoubtedly benefit from a representative highquality survey of large samples which would also enrich global disability data this study aims to assess the prevalence of disability and associated factors among urban and rural older adults in a typical representative region method a largescale baseline survey was conducted between march and september 2020 using facetoface interviews with a multistage stratified random sample of 16536 participants aged ≥ 60 years disability was assessed using the bi scale with a score of 100 representing normal status 6595 as mild disability 4560 as moderate disability and 040 as severe disability the prevalence of disability was estimated by demographics and health characteristics and their associations were explored by robust poisson regression analysisthe prevalence of disability among older adults was 194 and the prevalence of mild moderate and severe disability was 168 15 and 11 respectively all variables including older age residence in a rural area higher number of hospitalizations comorbidities poor selfrated health falls cognitive impairment mental impairment and alienation from friends and relatives were shown to be associated with a higher adjusted prevalence of disability only formal education can reduce the risk of disabilitythe prevalence of disability among older adults is high in both urban and rural settings in southwest china and a number of important factors associated with disability have been identified in addition to increased attention to the health status of older adults further research on scientific management and effective disability interventions is needed

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випуск 10 2023 issue 10 2023 20 результати проведеного дослідження дозволяють зробити висновок про те що незалежно від віку соціального статусу та способу життя кожна людина в своєму розумінні здорового способу життя ототожнює це розуміння із поняттям життєвих цінностей що є дуже важливим фактором у формуванні стратегії фізичного виховання населення різних вікових груп яка лежить в основі як державної програм та стратегії розвитку так і роботи кожного окремо взятого тренера вчителя та керівника підрозділу будьякої компанії чи виробництва ключові слова життєві цінності здоровя фізична культура людина спосіб життя здоровий спосіб життя formulation of the problem the health of the countrys population is the main indicator of the wellbeing of the state which is why work on its preservation is a task at the national level nevertheless according to the testimony of experts there is a constant decline in interest in the formation of healthy lifestyle skills and this category is growing especially rapidly among young people 27 today according to the world health organization one out of five adults and four out of every five adolescents do not engage in physical activity or engage in insufficient physical activity 8 at the same time according to the who global action plan for physical activity and health for 20182030 by 2025 it is planned to comprehensively help reduce the level of physical inactivity by 1015 8 the purpose of the research was to determine the life values and attitude towards a healthy lifestyle of representatives of different age and social groups analysis of recent research and publications playing sports and various types of healthoriented motor activity provide quality leisure time during free time from studying prevent the emergence of harmful habits form a healthy lifestyle help young people to realize themselves establish new friendships 59 according to m dutchak 3 the social effect of such activities can be felt only if more than a third of the states population is engaged in organized physical activity at a sufficient level scientists note the existence of a problem of passive leisure time sometimes of a destructive nature 7 a significant reason for this is insufficient attention to recreation physical culture as institutions that provide extended recovery of the psychophysical state and productive forces of a person 5 the the last decades have been marked by the intensification of physical activity among the masses in the most economically developed countries of the world which resulted not only in the improvement of the quality of life but also in the growth of work capacity and health methods of research analysis and generalization of scientific and methodological literature programmatic and regulatory documents internet data comparison synthesis deduction retrospective analysis survey as well as methods of mathematical statistics results of the research and discussion in order to supplement the data of the scientific and methodological literature to obtain reliable information about the problem under investigation a survey was conducted the following participated in the survey 300 people and nonphysical education institutions employees of ksu as well as people of various age groups the survey was conducted for the purpose of • determining the relationship to a healthy lifestyle of individuals the place of organized physical activity harmful habits in a persons life the choice of a type of leisure • determination of the number of persons leading a healthy lifestyle and their life values we asked what people of different ages and strata of the population understand by the concept of healthy lifestyle young people associate a healthy lifestyle with a healthy ie rational diet sufficient physical activity students of the faculty of physical education and sports also note in addition to the mentioned factors the absence of bad habits among the interviewed mature and elderly persons such decisive factors were also mentioned such as compliance with the sleep regime food regime daily regime and the feeling of peace and harmony is also important however the components of a healthy lifestyle which the respondents identified for themselves are significantly inferior in number to those recommended by specialists according to the survey which useful habits students noticed during their studies at the university they answered • take a shower and be hardened • follow the daily routine • wake up early adhere to a rational diet drink a sufficient amount of water such perceived traits as collectivism willpower patriotism responsibility selfcontrol etc have increased in addition to useful habits bad habits can also be present we tried to find out whether people understand what factors can negatively affect the body and what habits are present in a particular persons life all interviewees regardless of age named smoking addiction drug addiction and alcohol abuse as bad habits respondents of mature age also mentioned the problem of overeating when asked which conditions of a healthy lifestyle are difficult for them to follow the students named adequate sleep and a healthy diet students of a physical education institution student youth mature and elderly people took part in the survey to determine the relationship to a healthy lifestyle and its components research by specialists has revealed the influence of human universal or spiritual values on a persons life so people who profess universal human values have not only a higher level of health a less stressful life but also a more stable married life a higher level of financial wellbeing a sense of selfrespect and the meaning of life comparing the answers of average youth and representatives of the sports environment namely students of the college of physical education where health motor activity is the foundation of professional development we found the following results the value of health harmony of body and spirit is a more important factor in life athletes compared to nonathletes the older the respondents the higher the value of health life values of representatives of mature and elderly age were distributed as follows human health as the value of life has more weight with age this applies to valuing spiritual traits material wealth and the value of education decrease with age on the contrary 43 of 1styear students rate their own health as excellent and 32 consider it as excellent in the 4th year in many classifications of values health is one of the first places it is along with such values as a happy family life peace friendship respect of society a valuegoal to which a person must certainly strive a valuebased attitude to health is a set of views and ways of human life characterized by a responsible and attentive attitude to ones health as one of the most important personal values a conscious need to preserve it a focus on strengthening the body and improving the skills necessary for this at the same time a logical question arises can health be the only goal for the sake of a goal health is not only a goal but also a tool through which other values are acquired family active life interesting and creative work fullness and emotional richness of life freedom material security friendship confidence in yourself public recognition and respect etc thus health is not just a value in itself that one must strive for but a value without which it is impossible to achieve other values that form the essence of a prosperous life a kind of foundation for building the future the formation in a person of a system of family values values of friendship responsibility will health justice and others should help strengthen and preserve human health in all its manifestations social moral physical emotional spiritual and moral all true values that contribute to human improvement are the values of a healthy lifestyle it is impossible to derive a single system of personal values each person has his own at every stage of life health is a tool for achieving the most significant goals for a person at that moment so for a primary school student the importance of health as an important condition for active longevity does not exist for a child what is happening here and now is more important friendship study sports achievements etc for students and young people love career social success etc take priority for older people active longevity wisdom wellbeing of offspring etc approaching health as both a goal and a means to achieve life goals is the only true way to develop a responsible attitude towards oneself and others in a person conclusions human health as the value of life has more weight with age this applies to valuing spiritual traits material wealth and the value of education decrease with age on the contrary compared to young people students of a physical education institution rate their own health indicators higher this also applies to workers in the field of physical education and sports according to experts in the field of health it is characteristic of youth to exaggerate the level of ones own health it is also typical for students the answers of the respondents show that the percentage of people who rate their own health as unsatisfactory increases with age as the results of the survey showed the majority of respondents give the concept of health as values a prominent place as part of the concept of health all respondents mentioned rational nutrition and physical activity the forms of which change with age but the need remains throughout the entire life of the individual the value of health the harmony of body and spirit is a more important factor in the life of athletes compared to people who are not representatives of the sports environment young people consider communication with peers to be more important than representatives of other age categories who prefer material means comfort and rest each person sets priorities individually at the same time determining the importance and significance of these or other phenomena

the article presents the concept of life values as a way of attitude of people belonging to different age and social groups to a healthy lifestyle regardless of the individual priorities of each person the following are common for most family friendship material wellbeing career health creativity selfdevelopment and spirituality it was determined that for most people the concept of life values includes relationships with loved ones harmony health and beauty both external and internal and with age the vector changes in the direction of spiritual values and recreation but the general understanding of values remains constant it has been established that physical education and sports are important in the formation of a healthy lifestyle of a person spiritual and physical development where the rejection of bad habits is a prerequisite for a healthy lifestyle the question of free time requires a more conscious attitude to its planning and filling the opportunity to think about the content of ones own free time led to an understanding of the unconscious and uncontrolled use of time

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introduction 1it is becoming increasingly important for managers and leaders to consider performance improvement and job enrichment strategies that extend beyond traditional classroom training tenure promotions and seniority perks in a complex decentralized and global economy with dynamic organizational workplaces in light of the above statement job rotation has theoretical and practical importance in uplifting organizational moore 2000hsieh chao 2004 the internationalization of academicians contributes to more diverse and inclusive student learning experiences in addition to promoting knowledge exchange job rotation programs foster collaboration increase research productivity and contribute to the development of a globally connected community among academics in this way a country can develop intellectually socially and economically an individuals job performance is also defined by how effectively efficiently and qualitatively they carry out their workrelated tasks and responsibilities within an organization employee performance is evaluated based on their ability to meet job requirements and expectations job performance is typically evaluated through a combination of objective measures it evaluates an employees ability to effectively communicate collaborate and build positive relationships with colleagues superiors clients and other stakeholders this assesses an employees ability to adapt to changing circumstances handle new challenges and adjust their approach to work when necessary social support refers to the assistance care and resources provided by individuals social networks and communities to promote wellbeing cope with challenges and enhance resilience it involves various forms of support including emotional informational instrumental and appraisal support friends peers and colleagues can provide social support through companionship listening advice and shared experiences they offer emotional understanding social interaction and a network of support social support contributes to positive mental health outcomes such as reduced stress improved selfesteem increased resilience and lower levels of anxiety and depression social support can positively impact job performance by providing employees with the resources encouragement and assistance needed to succeed heres how social support can relate to job performance researchers observed many challenges in the university environment especially in employee promotions hiring new employees performance evaluations skill development and knowledge development in addition job rotation refers to moving employees between different positions within an organization the purpose of this strategy is to expose employees to a variety of responsibilities and roles the organization will become more familiar to them through this process the current study tries to understand job rotation which stimulates employees in the universities of malakand division of kp pakistan universities must also develop strategies for evaluating performance support from the organization and individuals in job rotation for their employees as part of the current study the employees rotation social support and performance at universities will also be evaluated so that authorities can make decisions the government of pakistan has struggled to improve the organization through tools like skilled workers social activities and increasing pressure on employees but has ignored their basic needs in order to achieve the best results the gop has planned the most effective performance rewards for different techniques and tools pakistan contributes significantly to the global economy thus the gop assumes improving employee productivity throughout institutions by motivating employees to achieve goals they examine university improvements employee engagement employee skills and talent in the present world universities are the linchpin of any countrys economic growth consequently the organizations employees will be able to adapt and be more innovative in their leadership practices in addition the article examines how social support impacts job rotation and performance in malakand division universities in pakistan literature review job rotation can increase employee momentum and encourage them to participate actively an organization develops employee abilities enthusiasm skills leadership adaptability and innovation encouragement and motivation through job rotation it is imperative to consider the skills and aspirations of employees and the organizations strategic goals when implementing job rotation by rotating jobs employees gain work skills from various activities and avoid burnout it allows academicians to expand their admiration of organizational objectives it is also an opportunity to gain a deeper understanding of a field that is very different from your own build up a strong network of organizational associates and increase the number of new employees they hire rotating jobs allows employees to acquire different skills and knowledge exposure to different tasks and roles enhances their ability to adapt to changing job requirements as a primary purpose of rotations they were created to develop workforce skills however organizational designs centered on employees needs and desires led to a second motivational purpose by rotating jobs academic members expand their professional networks learn different teaching methods engage in collaborative research and acquire new skills exposure to different institutions and academic cultures can enhance research productivity teaching effectiveness and professional development kampkötter et al 2018 contend that it enhances the quality of education universities provide in the country job rotation programs at universities foster innovation collaboration and intellectual growth academic members and researchers worldwide often flock to such institutions due to their reputation within the educational community it contributes to the countrys competitiveness and excellence in higher education job rotation can positively impact job performance by providing employees with various benefits and growth opportunities in addition it can expose employees to different responsibilities and roles within an organization as a result they can learn new skills expand their knowledge base and gain a broader understanding of the organizations operations in addition to gaining diverse skills through job rotation employees also become more adaptable and versatile which can enhance their job performance rotating jobs can provide career advancement opportunities for employees employees need to gain experience in various roles to develop a wellrounded skill set and demonstrate their ability to perform effectively in various roles as a result job performance can be enhanced by promotions lateral moves or higherlevel responsibilities it facilitates the exchange of knowledge and expertise between employees from different departments or functions rotating between positions allows employees to learn from colleagues with specialized knowledge and skills employees can benefit from this knowledge transfer by acquiring valuable insights and best practices across the organization during crosstraining employees of a specific unit or department gain varied skills it is also considered a practical way to enrich and expand their job duties employees are exposed to different aspects of the organization through job rotation including different teams departments and functions in this way employees gain a broader perspective and better understand how their work contributes to the organizations goals employees are more likely to make informed decisions with a holistic view of an organization moreover it can help them understand how various areas are interconnected repeating tasks for an extended period can lead to monotony and boredom job rotation can motivate and engage employees by introducing variety and challenging challenges motivated and engaged employees are likelier to put forth effort and strive for excellence resulting in improved job performance job performance can be positively impacted by social support stress related to work can be buffered by social support it is easier for employees to cope with job demands and stressors when their social networks support them and provide them with resources and emotional support it is possible to improve job performance by reducing stress levels social support at work contributes to higher job satisfaction which in turn contributes to better performance at work a work environment where employees feel valued appreciated and supported increases motivation and engagement employees can share knowledge and learn from one another through social support networks having contacts can enable a person to develop skills knowledge and perspectives that can enhance their performance on the job supportive relationships within an organization can fuel the development of a learning and development culture additionally social support can reduce turnover intentions in organizations with strong social support employees feel more connected and committed increasing stability and continuity in the workplace can positively impact job performance by reducing turnover having a positive relationship between social support and job rotation is beneficial for both individuals and organizations families friends colleagues supervisors and other social networks provide social support to people during a job rotation employees change roles or positions within an organization in literature job performance is viewed from inrole and innovative perspectives when someone performs their duties under their job title it reflects their inrole performance formal behaviors are required for individuals to achieve performance objectives innovative job performance aims to achieve novel results beyond routine requirements it is imperative to generate and adopt novel ideas and implement them successfully to improve organizational performance based on the particular situation and its characteristics inrole and innovative job performance can be used to evaluate individuals contributions to organizational objectives moderation role of social support the importance of realizing that moderation effects can vary from study to study and from context to context cannot be overstated researchers continue to investigate social support to identify the conditions that most likely affect job performance furthermore they identify when it has a greater or lesser impact various contextual factors can influence the moderation role of social support such as the nature of the job or the work environment social support may improve job performance in jobs that require higher levels of interpersonal interaction or teamwork than solitary or independent work it is also possible for organizational culture and climate to affect the relationship between social support and job performance moreover supportive relationships and collaboration may significantly impact job performance in organizations that prioritize and encourage supportive relationships the effects of social support on job performance may be reduced in organizations with a competitive or unsupportive culture job performance may be affected by emotional instrumental or informational social support supporting specific jobrelated skills or performance may be more effective when provided through information alternatively emotional support may enhance overall job performance and reduce stress this study proposes the following hypotheses based on the discussion above • h1 job rotation has positive associated with job performance among employees • h2 social support moderates the relationship between job rotation and job performance among the employees methodology spss was used to analyze data collected in this study to collect the data a selfadministered questionnaire was used in this study likert scales ranging from 1 to 5 were used using a reliable scale job rotation performance and social support can be measured a questionnaire consists of four sections demographics such as age marital status gender and experience are covered in the first section while job rotation is discussed in the second questions regarding job performance are asked in the third section while those regarding social support are asked in the last section a total of 18 factors were used to analyze job performance six items analyzed job rotation at a reliability of 083 and five items analyzed social support at a reliability of 091 in the current study simple random sampling was conducted and the malakand division was selected the researcher visited different heis and distributed the questionnaire to all employees a total of 235 were collected which was suitable for final data analysis in the current study descriptive statistics are employed kps malakand division is examined in this study to determine respondents characteristics and the prevalence of study variables in order to analyze the relationships between the variables a correlation analysis was conducted along with a regression analysis results discussion the selfadministered questionnaire was distributed among the members and the response rate of the returned questionnaire was 70 based on the current studys findings table 1 presents respondents personal and demographic characteristics from heis in malakand kp based on the table results 235 questionnaires were used for the final data analysis in pakistan females have more difficulty performing their jobs in every sector so there were more male respondents most women are housewives women in higher education cannot take care of their homes because the working hours are extremely long as a result 52 percent of the students in the current hei study are male while 43 percent are female and 4 percent remain undetermined additionally the table shows that workers in heis who are between 30 and 40 are more engaged in their workplace because young people like to rotate within their organization they are more innovative and adaptable to new environments for further analysis the study objective has to identify the relationship of the variables which are determined based on the correlation in addition to the correlation table 2 shows the cronbach alpha which determines the reliability of the variable and is in the acceptable range of the study the present study used the hmra model to analyze the objectives as shown in table 3 the independent variablejob rotationwas associated with the dependent variablejob performance in the first model of hmra table 3 shows that the f values are 69001 and the variation in job performance is 237 along with independent variables social support was also entered with job performance which showed a variation of 245 in the last step of the hmra model the interaction term of job rotation and resources with social support and the dependent variable of job performance were entered into the model based on table 3 274 variation occurred in the model while the interaction term was significant at p 005 after considering the above results the current study identifies a positive correlation between job rotation job performance and social support camion et al reported that as rotation increases job performance increases thereby increasing the productivity of organizations and individuals moreover the current studys findings suggest that social support moderates the relationship between job rotation and performance which explains that employees productivity increases as support from coworkers and supervisors increases conclusion recommendations this study examined job rotation job performance and social support in heis in the malakand division of khyber pakhtunkhwa pakistan it is evident from the study results that as rotation within the working environment increases employee performance increases which leads to greater commitment and loyalty among employees in contrast job rotation increases employees motivation resulting in better performance managing job rotation regularly and fairly is a practical and effective way universities utilize their human resources in addition the findings suggest that reducing role ambiguity in role stress is the most effective way to increase employees organizational commitment the ultimate goal is to increase employees job satisfaction and encourage them to stay in their careers this would avoid the vicious circle of high turnover which wastes valuable human resources finally based on the findings management should ensure employees are loyal satisfied and committed to job rotation practices to enhance their performance a job rotation policy should foster employee growth development and creativity it is not just a routine practice or punishment every study has some limitations and this study has not been exempted the study was conducted with limited financial and time resources the study was conducted in several kp district divisions using quantitative data through a selfadministered questionnaire the researcher collected a single shot data called crosssectional based on the abovediscussed limitations the researcher suggested that proper funding be allocated for the data collection and proper time be given moreover the study should be conducted through longitudinal survey analysis to enhance the results in addition it further suggested that the data may be collected from another part of the province or any other province that can compare the results ta similar culture may find the findings of this study highly relevant empirical evidence from other countries or crossculture comparisons are necessary to generalize the findings of this research the study does not consider personality traits when investigating the role of information technology in enhancing job performance different personality traits have unique characteristics which may influence knowledge sharing in digital work future studies should examine the effects of personality traits on knowledge sharing in digital work conflict interests the authors declare no conflict of interest

this study examines the relationship between job rotation and job performance in the higher education institutions of malakand division of khyber pakhtunkhwa pakistan with the moderating effect of social support for the data collection the researcher used simple random sampling to distribute the selfadministered questionnaire among the 235 academician members the data was analyzed using statistical tools through spss for the studys final results it has been found that job rotation job performance and social support are positively correlated indicating that rotation can enhance employee performance when coworkers support the employee furthermore social support moderates the relationship between job rotation and employee performance in heis academicians can learn about study results from the university by supporting them and providing limitations and recommendations at the end of the study

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introduction veterinary professionals are at higher risk of mental health concerns and suicidality data on suicidality of veterinary professionals spans decades first being mentioned in a review of causes of death of us veterinarians from 1947 to 1977 which showed white male veterinarians had a 17fold risk of death by suicide compared to the general public elevated risk of death by suicide was expanded to include female veterinarians in a review of the causes of death in california veterinarians spanning from 1960 to 1992 where male and female veterinarians were shown to be at 25 and 59 times the risk of the general public to die by suicide this elevated risk level is reflected in literature from several countries including norway the united kingdom belgium and australia literature regarding suicidal behavior and the veterinary profession has primarily focused on veterinarians however a 2019 study showed that veterinary technicians were also at significantly higher risk of dying by suicide when compared to the general public with male and female technicians having a 5 and 23 fold risk respectively the cause of this increased risk is multifactorial and the literature reflects a variety of personality and occupational stressors a variety of mental health concerns are reported in veterinarians in a study of us veterinarians male and female veterinarians were found to have elevated levels of serious psychological distress when compared to the general public the percentage of men and women in the general public that were shown to have high psychological distress were 24 and 39 a study of over 5000 us veterinarians found 502 had low mental wellbeing scores and 589 had high secondary traumatic stress scores broadly the concerns include personality factors financial concerns interpersonal conflict and coworker dynamics client interactions worklife balance concerns exposure to euthanasia and access to means one personality factor that warrants particular attention is neuroticismalso known as emotional instability this is one of five factors in the big five personality traits modelthe others being agreeableness conscientiousness extraversion and openness neuroticism is associated with experiencing more negative emotions and being more sensitive to stress it is not only associated with having more negative mental health experiences generally but was also the strongest predictor of psychological distress and low wellbeing in a representative sample of united states veterinarians rates of this personality factor were also higher in veterinarians than in the general population making this a particularly important part of understanding mental distress and low wellbeing in veterinarians perfectionism which has been shown to be strongly correlated with neuroticism is also associated with decreased resilience and enhanced experience of moral stressors in veterinary professionals diverse demographics another aspect of human experience that can contribute to increased psychological distress and suicidal thoughts is an individuals social location and identity given the events surrounding racism in 2020 even more pressure has been put on researchers to update and expand demographic questions on surveys for two purposes to increase research integrity by accurately describing a sample and to be inclusive of the multiple social identities a research participant may be experiencing previous research has evaluated mental health in veterinary professionals through the demographic lens of age binary gender and income however multiple other demographics are missing in the literature recently a study was conducted that identified psychological distress in veterinary professionals who identified with diverse gender and sexual orientation identities findings indicated that transgender nonbinary nonheterosexual cis women and nonheterosexual cis men had even higher rates of suicidal ideation and psychological distress than previously reported binary veterinarians to our knowledge wittes study is the first published study to look at diverse gender and sexual orientation demographics race and ethnicity are also important to consider in the general population race and ethnicity are known factors that correlate with worse physical and mental health there are several pathways by which these outcomes occur such as structural cultural and individual racism the profession of veterinary medicine is predominantly a white nonhispanic population rates of this veterinary demographic are higher than in the general usa population for instance estimates in 2020 indicate 875 of usa veterinarians were nonhispanic whites compared to 619 of people in the general population among veterinary technologists rates are similar 73 of veterinary technicians were nonhispanic whites compared to the general population which was 619 although there has been a steady increase of veterinary students with racial and ethnic diversity since the 1980s in 2020 the prevalence of racially diverse students in veterinary colleges was somewhere between 25 30 whereas among human medical students it was 49 disability status should also be considered a demographic identity individuals who experience a disability are more likely to experience psychological distress than those without a disability in veterinary medical education it can be a challenge to successfully attend to student learning differences due to disability status while also meeting curricular competencies particularly the clinical year having to access these accommodations within veterinary medical education can be difficult for some students who may not want others to be aware of their unique learning needs marital status is also included as a demographic identity as research often indicates that the builtin support through marriage is a protective factor for mental health and that those who are separated divorced never married or widowed are at higher risk of psychological distress however in the veterinary profession cisgender female veterinarians report feeling less career support from their spouses and increased marital stress than cisgender male veterinarians in a study of veterinary officers higher scores of burnout depression and anxiety were reported for married veterinarians than for single veterinarians covid19 and civil unrest it is important context that the data presented here were collected at the beginning of 2021 at the time of data collection several external factors had the potential to impact mental health including additionally this survey found that essential workers were at increased risk when compared to the general public for mental health effects of the pandemic including suicidal ideation veterinary professionals in clinically facing roles were deemed essential workers in most jurisdictions of the united states the aim of the current study was to identify psychological distress suicidal thoughts and suicidal behavior in a sample that had the opportunity to disclose diverse demographic identities our research questions were 1 what is the relationship between demographic factors in veterinary professionals psychological distress and suicidal experiences 2 what demographic factors put veterinary professionals most at risk for psychological distress and suicidal experiences materials and methods a crosssectional webbased questionnaire was designed in the qualtrics survey platform to assess the prevalence of diversity psychological distress and suicidality the survey was distributed across social media channels and emails among various veterinary organizations data were collected between february 10 2021 and april 6 2021 with weekly invitations to participate on social media and listservs the veterinary organizations that received invitations to participate ranged in size from 491 members to 38000 to participate in the survey individuals needed to work or study in the veterinary field in the united states and be 18 or older this study was acknowledged as exempt by the university of tennessee institutional review board as this survey was distributed through social media the prevent indexing qualtrics feature was enabled to block web engines from listing the survey in search results also any completed response that took less than 10 min was removed from the survey in addition respondent data was manually checked for batch entries survey the demographic portion of the survey questions included race ethnicity marital status social class gender sexual orientation disability status income and age additionally jobrelated questions such as role and setting were asked these demographic questions were selfreport questions some questions had yesnoprefer not to answer whereas others listed categories for example for annual income there was a list of income ranges to choose from the survey also included mental health measures of mental wellbeing psychological distress and suicidality mental health outcomes psychological distress the kessler 6 measures psychological distress and has been used in multiple studies that assess risk in the veterinary community k6 asks questions based on a likert scale eg during the past 30 days about how often did you feel hopeless all of the time most of the time some of the time a little of the time or none of the time the scores are then added together to get a total sum score between 024 as the score increases the level of distress increases scores of 13 or higher indicate serious risk of psychological distress a score between 512 indicates risk of moderate psychological distress a score of 4 or lower indicates low psychological distress in the current study the reliability of k6 scores as estimated by coefficient alpha was 095 in the current study the focus was on scores of 13 or higher indicative of serious risk of psychological distress a dichotomous variable was created indicating whether a respondents k6 score was equal to or greater than 13 a dependability index for this classification equivalent to the brennankane dependability index was computed this index for this study was 095 suicidal thinking and behaviors suicidal thinking and behaviors were assessed using dichotomous questions that asked about the presence of suicidal thoughts plans and attempts in the last 12 months asking about suicidal thinking and behaviors within the past 12 months is a common practice in large populationbased studies such as the national survey on drug use and health the nsduh has asked these questions since 2015 and have multiple large data sets in which suicide risk has been analyzed for example a recent study used the 2018 wave to identify suicide risk in sexual minority adults and found an increased risk for suicidal thinking and behaviors compared to heterosexual populations data analysis descriptive statistics were used to provide a depiction of the characteristics of the sample in the current study two main research questions were investigated in binary logistic regression analyses what demographic characteristics are associated with severe psychological distress as indicated by k6 scores of 13 or higher and what demographic characteristics over and above severe psychological distress are associated with suicidal thinking in these logistic regression analyses the independent variables were age gender identification sexual orientation marital status ethnicity race practice type professional role disability status social class number of children in respondents family and total annual income the dependent variable was respondents answer to the following question at any time in the past 12 months up to and including today did you seriously think about trying to kill yourself with yes coded as 1 and no coded as 0 given the large number of independent variables type i error control was important thus tests of the statistical significance of individual independent variables were not conducted unless the overall logistic regression model was statistically significant at the 00001 level further specific comparisons of subcategories of categorical variables such as comparing sexual orientations of heterosexual with gaylesbian were only made if the overall categorical variable was statistically significant the logistic regression analyses were conducted using mplus version 74 and missing data were managed using full information maximum likelihood robust maximum likelihood estimation was used some subcategories of categorical variables had small numbers of cases which is often handled by combining categories because of methodological issues associated with small sample sizes and sparse data in the current study this was not done given the important objective of inclusion of all forms of diversity in the data analyses to help control for problems incurred by small sample sizes in subcategories 99 confidence intervals were used to help facilitate interpretations of results involving subcategories with small sample sizes results results of descriptive statistics of the overall sample 888 respondents were experiencing serious psychological distress in the gender category cisgender males had the lowest percentage of respondents experiencing psychological distress the highest were those who identified as gender fluid and gender nonconforming however all of these sample sizes were small the categories with the highest percentage of those that considered suicide in the past 12 months were agender transgender male gender nonconforming and questioning in the largest gender category cisgender female the percentage of serious psychological distress was 399 for the age category the younger the participant the more likely they were to have serious psychological distress for example in the age range of 4554 254 had high k6 scores whereas in the 1824 years category 621 did those in the youngest age bracket also had the highest percentage of respondents who had considered suicide in the past year for race the categories that experienced the highest rates of psychological distress was middle eastern african diaspora indigenous and two or more races each of these categories had small sample sizes however requiring caution in interpreting for those who frontiers in veterinary science 05 frontiersinorg in the sexual orientation category those who identified as questioning had the highest rate of serious distress they were followed by bisexual asexual and fluid with the exception of the bisexual category all of the other above categories had a small sample size those who identified as heterosexual had the lowest rate of psychological distress five respondents who identified as fluid and one hundred respondents who identified as bisexual indicated they considered suicide in the past year for disability status those who indicated they were currently experiencing a disability had a higher percentage experiencing serious psychological distress over those who were not experiencing a disability the percentage of those with a current disability that considered suicide in the past 12 months was 223 in the marital status category those who selected the response of separated had the highest k6 scores followed by never married the lowest rate of k6 scores for marital status was the widowed and in a married or committed relationship for the number of children those who selected 0 children had the highest k6 scores the lowest rate of serious psychological distress in the children category was for those who have three children again small sample sizes needs to be interpreted with caution the categories that had the highest percentage of those who considered suicide in the last 12 months were also those who were separated never married did not have any children or had one child in the demographic category of annual income those who selected 2500050000 had the highest k6 scores in general as the income bracket increased the rates of serious psychological distress decreased this same trend was true for social class for those who selected poor social class 695 had high k6 scores for those who selected an affluent social class 193 had high k6 scores for those that considered suicide in the past 12 months the highest percentages were in the income bracket of under 25000 25000500000 and 5000075000 poor social class and working class with professional roles those who selected unlicensed veterinarian assistants had the highest rates of serious k6 scores this was followed by customer service and student practice owners had the lowest percentage of serious psychological distress followed by associate veterinarians this trend is similar for those that considered suicide in the past 12 months those who identified as having a customer service or unlicensed veterinarian assistant role had the highest percentages of considering suicide results of logistic regression analyses results for k6 level the overall chisquare for this model was χ 2 28579 p 00000001 statistically significant chisquare values for specific variables were for gender χ 2 1774 p 0038 social class χ 2 5259 p 00001 age χ 2 1047 p 00012 number of children χ 2 482 p 0028 and disability χ 2 1104 p 00009 these were statistically significant predictors of significant levels of k6 professional role χ 2 916 p 033 sexual orientation χ 2 1333 p 010 professional practice χ 2 165 p 028 marital status χ 2 458 p 033 annual income χ 2 083 p 036 race χ 2 317 p 079 and ethnicity χ 2 453 p 021 were statistically nonsignificant predictors of k6 level the r 2 for this model was 019 z 982 p 0001 about 19 of the total variation in k6 scores was explained by the independent variables in terms of area under the curve this effect size is 075 the specific results for the statistically significant predictors are shown in these results strongly suggested that social class age and disability were associated with significant k6 scores specifically the odds of those identifying as being poor were about three times greater than those identifying as in the middle class to have significant k6 scores those identifying as working class were about 18 times more likely than those identifying as middle class to have significant k6 scores those identifying as upper middle class were slightly more than half as likely to have significant k6 scores than those identifying as middle class those reporting some form of disability were nearly oneandahalf time more likely to have significant k6 scores as those not reporting any disability as the age of respondents increased the odds they had significant k6 scores decreased results also suggested at the 005 level of statistical significance that as the numbers of children a respondent had increased the less likely they were to have significant k6 scores those selfidentifying as gender nonconforming were more likely than those identifying as cisgender female to have significant k6 scores though these specific results were based on a very small sample of respondents identifying as gender nonconforming so these results should be interpreted cautiously and as tentative the categorical variable sexual orientation as a whole was statistically nonsignificant χ 2 133 p 10 but the bi category results for suicidal thinking with k6 level as a predictor the overall chisquare for this model was χ 2 33442 p 00000001 sexual orientation χ 2 2986 p 00002 marital status χ 2 1082 p 0029 professional role χ 2 1794 p 0022 and k6 χ 2 1853 p 00001 were statistically significant predictors of suicidal thinking race χ 2 974 p 014 gender χ 2 233 p 098 professional practice role χ 2 1642 p 029 ethnicity χ 2 058 p 090 annual income χ 2 082 p 036 age χ 2 335 p 007 disability χ 2 213 p 014 social class χ 2 225 p 081 and number of children χ 2 050 p 048 were statistically nonsignificant the r 2 for this analysis was 027 z 1173 p 0001 this model accounted for 27 of the variation in suicidal thinking scores this effect size is 080 in terms of auc the specific results for statistically significant predictors are shown in table 6 statistically nonsignificant results are not included in this table in the interest of space and brevity these results suggested at the 0001 level of statistical significance that those selfidentifying as monosexual bisexual pansexual or omnisexual were more than twice as likely to report suicidal thinking holding k6 level constant than those selfidentifying as heterosexual if this sexual orientation is compared with all others except gender fluid the odds a respondent identifying as monosexual bisexual pansexual or omnisexual remain twice as likely as any of the other sexual orientations to report suicidal thinking a weaker finding based on only 13 respondents hinted that those identifying as gender fluid may be as much as 3 times more likely than those identifying as heterosexual to report suicidal thinking if gender fluid is compared with all other sexual orientations the odds drop to slightly more than 2 times that those identifying as gender fluid will report suicidal thinking as will those identifying as any of the other sexual orientations this finding given the very small sample size involved should be taken as suggestive and interpreted within the context of the very small sample size of n 13 results also suggested at the 005 level of statistical significance that persons separated from a spouse or partner may be nearly 3 times more likely to report suicidal thinking than those married or in a committed relationship this finding is based on a small sample of persons separated so these findings should be taken as suggestive and tentative results also suggested at the 001 level of statistical significance that those in the role of a relief vet were about 22 times more likely to report suicidal thinking than those in the role of an associate vet this result should be interpreted cautiously as the sample of respondents identifying as relief vets was only 78 results further suggested at the 002 level of statistical significance that those in other professional roles were only about half as likely to report suicidal thinking as those in the role of associate vet if these professional roles are compared with all other professional roles those in the role of relief vet were about 2 times more likely and those in other professional roles less than half as likely as those in any other professional roles to report suicidal thinking holding k6 level constant finally results strongly suggested at the 00001 level of statistical significance that respondents with significant k6 scores were more than 5 times more likely to report suicidal thinking than those with nonsignificant k6 scores kessler 6 and suicidal thoughts the younger the participant x 2 99579 p 0001 and the lower social class x 2 185903 p 0001 they selected the more likely they were to experience psychological distress compared to married participants those who were separated were more likely to experience serious distress x 2 36654 p 0001 compared to those who did not identify as disabled those with disabilities were more likely to have a higher k6 score x 2 20594 p 0001 in the gender category those who identified as questioning were less likely to meet threshold k6 levels than cisgender women x 2 28730 p 0001 bisexualnonmonosexual individuals were also more likely to have serious psychological distress when compared to heterosexual individuals x 2 62910 p 0001 for those more likely to experience a serious psychological distress score they were also more likely to have lower mental wellbeing x 2 302940 p 0001 and more likely to have suicidal thoughts x 2 175743 p 0001 sexual orientation a post hoc analysis of sexual orientation was performed merging results into three categories heterosexual gaylesbian and bisexual other participants who identified as bisexual fluid queer questioning asexual or other were more likely to have serious psychological distress and considered suicide in the past 12 months they also were more likely to make a suicide plan in the past 12 months this post hoc analysis used pairwise comparisons using the ztest of two proportions with a bonferroni correction discussion there has been growing attention to mental health and suicidal thinking and behaviors in veterinary medicine for the past several years the findings of this research continue to shed light on this topic and affirm that those in the field of veterinary medicine experience both psychological distress as well as suicidal thinking and behaviors within context the 2021 results of the national survey on drug use and health indicate that 228 of adults a metaanalysis of 54 studies exploring suicidal behaviors during the pandemic found 108 of respondents experienced suicidal thinking however estimates for health care workers were higher for instance a cross sectional study exploring mental health impacts of covid among health care workers found 57 reported acute stress 48 symptoms of depression and 33 symptoms of anxiety in another study 26 of essential workers which members of the veterinary industry were reported suicidal thinking thus our rates of psychological distress and suicidal thinking were also found in other similar populations during the pandemic additionally several demographics were associated with increased risk of psychological distress and suicidal thinking in our findings demographic identity gender identity cisgender women were more likely than cisgender men to experience psychological distress male veterinarians have been shown to have higher wellbeing scores than their female counterparts in several studies while those analyses did not account for gender identity within their samples there is evidence in both the veterinary and general literature that cisgender identification is protective for wellbeing those who identified as transgender females transgender males gender nonconforming or gender fluid were more likely to experience serious psychological distress than cisgender male and cisgender females of all the gender categories the only one that showed statistical significance in the logistic regression was gender nonconforming however the sample size was very small as compared with cisgender female though many of the other categories did not reach statistical significance the above trends as indicated by percentages are in line with much of the literature published on gender identity and psychological distress including studies within the veterinary community wherein individuals with minoritized gender identities score lower in various wellbeing measurements and higher in suicidality risk a larger sample size might bring these trends into significance within the literature on gender identity and psychological well being factors such as outness a sense of belonging and exposure to violence have been shown to have impact on wellbeing and suicidality in minoritized gender identity groups as these variables were not quantified in this dataset and the sample size of nonbinary categories definitive conclusions are difficult to draw sexual identity heterosexuality was associated with a decreased k6 score and thoughts of suicide in comparison to other groups the protective relationship of heterosexuality to psychological distress has been well shown in the literature nonheterosexual identities may face a number of challenges to their wellbeing including threats of violence discrimination and harassment previous large studies of veterinary wellbeing and suicidality did not directly compare heterosexuals to other sexual identities however in a recent analysis nonheterosexual identities were found to have higher levels of suicidal ideation and attempts and nonheterosexual women were found to have higher k6 scores than veterinary populations as a whole in the current study many of the sexual orientation categories had small sample sizes thus have limitations however the category of bisexual had a sample size of 275 and demonstrated a clear statistical significantly increased risk of serious psychological distress in addition identifying as bisexual was also significantly associated with a higher risk of suicidal thinking identifying as gay or lesbian in our study had a slightly higher percentage of respondents with serious k6 scores however this category did not demonstrate statistical significance this could be because of the small sample size of the gaylesbian category however in a recent representative study that took place during covid19 65 of those who identified as bisexual experienced depression or anxiety whereas 50 of those who identified as gay or lesbian experienced depression or anxiety the same trend was true for suicidal ideation those who identified as bisexual were much more likely to experience suicidal ideation than those who identified as gay or lesbian in a good deal of the literature binonmonosexual queer questioning and asexual identities are often combined or not represented at all even within an umbrella of bisexuality there is a relative lack of inclusion of the bisexual community in psychological literature in one large scale review of lgbtq depression and anxiety 52 of the articles were rejected as they did not report separate data for bisexual people in our post hoc analysis nongaylesbian heterosexual orientations were more likely to have serious psychological distress they were also more likely to have considered and made a suicide plan in the past 12 months this is in line with the available data for these communities and mental health poor mental health outcomes within these communities have been largely attributed to erasureinvisibility a lack of affirming support as well as double discrimination from both the hetero and lgbtq communities these factors contribute to a lack of a supportive community and sense of belonging which has been shown to negatively impact mental health outcomes in sexual minorities social class the results of this research indicate social class was associated with psychological distress the lower the social class the higher the percentage of respondents who met criteria for serious psychological distress those who identified in the poor working class or upper middle class were statistically more likely to experience serious psychological distress financial problems have a high association with psychological distress and mental wellbeing because role is often associated with social class individuals who seem to carry more professional roles and have higher socioeconomic status have better mental health than those who are in roles of direct labor even so health care workers with higher levels of socioeconomic status experience more serious psychological distress than the general public marital status for relationship status those who indicated they were separated had statistically increased k6 scores and were more likely to have suicidal thoughts in the last 12 months than those who were married or for those that were single some literature indicates that marriage is a protective factor for psychological distress whereas some literature indicates that marriage is a risk factor considering the 2 the underlying preexisting vulnerabilities in their relationship prepandemic disability currently experiencing a disabilitylimitation statistically increased k6 and whether or not an individual considered suicide the relationship between disability status and psychological distress is well represented in the literature those who have a disability may experience serious psychological distress at a rate of seven times more than those who do not have a disability historically individuals with disabilities were not welcome in veterinary medicine as they were seen as unable to comply with the high demands of the field odunayo and zenithson argue that when those with disabilities are provided with appropriate accommodations they enrich the field of veterinary medicine veterinary scholars suggest increasing diversity equity and inclusion training in clinics and professional organizations to include disability topics age age is consistently found as protective for mental health concerns in veterinary populations this is in line with findings in the general population that mental health improves with age during 2021 nsduh findings indicate that 337 of 1825 yearsolds had psychological distress 218 of those 2649 and 15 of those older than 50 reported psychological distress these findings are likely related to improved emotional regulation communication and coping skills developed over time in our findings age also significantly predicted serious psychological distressspecifically as age went up distress went down race surprisingly in this study race was not a statistical predictor of psychological distress suicidal thinking or suicidal behaviors however when looking at the descriptive statistics there are a higher percentage of respondents who have high k6 scores if they selected their race as african americanblack indigenous middle eastern or two or more races than for those who selected their race as white although the relationship between experiences with race and psychological distress is documented in the medical profession there is a lack of studies on the connection between raceethnicity and psychological distress suicidal thoughts or suicidal behaviors in the veterinary profession for our study likely due to large differences in sample size between diverse race and ethnic diversity and white participants the analysis was not able to make any statistically meaningful inferences further studies need to be conducted to identify a clearer picture of the relationship between raceethnicity and psychological distress in the veterinary profession covid19 influence data collection for this analysis occurred during the covid19 pandemic negative mental health and wellbeing impacts of the pandemic have been noted on a global scale specific challenges in the veterinary community have included increased exposure to ethically challenging situations increased workload and decreased staffing impacts on wellbeing and mental health are mixed in the literature an analysis of us veterinarians showed no change in veterinary wellbeing nor in the prevalence of suicidal ideation or attempts compared to their 2019 analysis however this same analysis did note a significant increase in serious psychological distress and declines in veterinary wellbeing have been noted by other authors as a consequence of the pandemic the intersectional relationship of social class raceethnicity as well as sexual and gender identity with covid 19 impacts is still being explored early analysis shows that minority populations have been disproportionately affected by the impacts of covid19 racial minorities and lower income populations have an increased exposure to covid19 increased mortality increased economic impacts as well as decreased access to healthcare gender inequalities were also exacerbated during the pandemic as domestic violence increased during the pandemic and women were subjected to greater economic impacts than their male counterparts sexual and gender minorities have also been shown to have increased mental health and wellbeing disturbances due to covid19 pandemic compared to straight and cis counterparts role in practice the respondents who identified their professional role as customer service or unlicensed veterinary assistant had higher percentages of serious psychological distress and considering suicide in the past 12 months than other roles in the profession there was generally a trend that support staff and students had worse wellbeing and mental health than their dvm counterparts this difference has been noted in other literature as well in a 2021 survey veterinary support staff were found to have higher suicidal ideation suicide attempts burnout and serious psychological distress than their dvm counterparts another analysis found that while there was a significant general decrease in wellbeing across all professional categories there was a greater impact in nursing staff and students compared to their dvm counterparts this is true across the healthcare workforce as support workers are at higher risk for many negative health conditions in comparison to the role of associate vet those who identified as a relief vet or other professional role were statistically significantly more likely to have suicidal thoughts this difference has been noted in other literature as well the merck animal health veterinary wellbeing study found that relief vets had higher levels of psychological distress than other veterinarian roles limitations to our knowledge this is one of the first studies in veterinary medicine to identify multiple diverse social locations and their role in psychological distress suicidal thinking and suicidal behaviors during the covid19 pandemic an important goal for the research team was to not other any demographic category because categories were not grouped together in a dichotomous majority and other several statistical challenges existed for example due to small cell sizes in several race categories there was not enough statistical power to make an accurate comparison between races this challenge impacted seeing a clear picture of how race impacted psychological distress and suicide factors we intentionally recruited participants using diversity language in the recruitment advertisements this could have led to a selfselection bias to include only participants who either identified as diverse or who felt comfortable with intersectionality language however the selfreport nature of this research may have resulted in respondents under over or incorrectly reporting their demographic or experiences of distress this is entirely possible given issues of stigma related to our research questions we recruited from multiple veterinary organizations some of which are designed to assist those seeking mental health support this could have led to an oversampling of respondents experiencing serious psychological distress because of selfselection bias and small numbers in some demographic categories it is important to interpret these findings with caution moreover the findings should not be generalized to the entire population of individuals working in veterinary medicine implications of research findings attending to the demographic factors that may make an individual more susceptible to psychological distress and suicidal thinking is important to consider sexual identity and orientation social class being a support staff and having a disability may make a person working in veterinary medicine more susceptible to experiencing distress cultural competence skills are important for veterinary practices to integrate into their training efforts toward creating veterinary communities of care and belonging additionally we also found that those people who met criteria for psychological distress were 5 times more likely to endorse suicidal thinking the k6 instrument is a very brief tool that has been widely used with many populations it is free and open access our findings support other research that notes this tool can be helpful in identifying suicidal thinking thus the k6 may be a useful tool individuals can use to monitor their mental health paired with resources for seeking support and a culture that encourages accessing mental health care this tool could be an important part of a suicide prevention approach in veterinary medicine data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement the studies involving human participants were reviewed and approved by university of tennessee institutional review board written informed consent for participation was not required for 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 supplementary material the supplementary material for this article can be found online at full supplementarymaterial

this study aimed to determine the relationship between demographic diversity and veterinary professionals regarding their psychological distress and suicidal experiences this study also aimed to determine what demographic factors were associated with psychological distress and suicidal experiences for veterinary professionals methods this study used a crosssectional webbased questionnaire to assess the prevalence of diversity psychological distress and suicidality in individuals over 18 working in the veterinary field within the united states the study received 2482 responses resulting in 2208 responses that were included in the analysis descriptive statistics were performed to identify the categories with the highest rates of psychological distress suicidal thoughts and suicidal behaviors binomial logistic regressions were conducted to identify the strongest statistical predictors of psychological distress kessler6k6 suicidal thinking and suicide behaviors results of the 2208 respondents included in the analysis 888 41 were experiencing serious psychological distress and 381 173 had considered suicide in the past 12 months results of the binomial regressions indicate gender social class age and disability status were the strongest predictors of psychological distress when controlling for psychological distress the strongest predictors of suicidal thinking were sexual orientation marital status and professional role implications limited research has been done to explore the relationship between demographic diversity of veterinary professionals and psychological distress suicidal thoughts and suicidal behaviors specifically these results shed light on multiple demographic factors that promote and attenuate mental health as well as the importance of asking respondents their demographic identities in veterinary medicine research this research attempts to identify these mental health factors without collapsing categories with small sample sizes which does cause a limitation in statistical power yet also demonstrates how to increase inclusivity in research

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introduction while annual global population growth rates have declined since the 1960s population sizes in the least developed countries of asia and in subsaharan africa have been growing fast and are predicted to grow at substantial levels in the coming decades 1 alongside the prevalence of contraceptive use has increased worldwide 2 however millions of women in low and middle income countries remain vulnerable to short spaced unintended pregnancies due to limited access to suitable contraceptives recent un and who estimates suggest that more than 220 million women of childbearing age in lmic are not using any method of contraception 2 3 4 the long acting reversible contraceptives including implants and intrauterine device are highly effective contraceptives the larcs are suitable for women of all ages in comparison there is significant contraceptive failure with other contraceptive methods particularly among younger aged women 5 moreover larcs convey many other advantages for clients in terms of convenience satisfaction ease of continuation likelihood of avoiding unintendedunwanted pregnancy and noncontraceptive benefits 6 7 8 however larc use in south asia accounts for only 2 of the total modern contraceptive methods mix 49 barriers for uptake of larc include issues of access affordability and insufficient promotion and misconceptions about their effects 1011 despite evidence from dhs surveys that 98 of the adult pakistani population have an awareness of at least one modern contraceptive method 12 only 25 of married couples in pakistan used a modern method of contraception larc usage has increased only modestly over the past decade in pakistan from 21 to 3 12 13 14 such low uptake of larcs appears somewhat puzzling in the context of high awareness of modern methods and larc methods being made available through public sector facilities at subsidized costs 1516 this level of use is lower than in other areas of south east asia particularly neighboring iran where larc methods are used by 8 of contraceptive users 17 past research exploring pakistani womens perceptions about larcs especially about iucds showed similar barriers in other countries including fear of side effects husband disapproval and religious opposition 18 19 20 21 22 23 24 women with a higher educational level employment status and in a more favorable economic position were significantly more likely than other women to use larcs 25 availability and affordability of larc methods are documented to be barriers to the use of larcs particularly among postpartum women 26 27 28 there is a need for better understanding the issues affecting larc uptake to increase use and create demand for all fp methods using mass media community health workers and subsidized services previous research on contraceptive use among pakistani women has focused on assessing reasons for nonuse of modern contraceptives documenting knowledge gaps and access barriers but it has not investigated in depth social networks associated with the uptake and motivations to use larcs 23 29 30 31 32 this study aims to fill this gap and to develop an indepth understanding of social influences in initiating and continuing use of an larc methods including married womens motivations information pathways accessed decision making process for contraception in rural pakistan methods study setting this study derives from a larger research project that sought to study the fp knowledge and practices among increased risks of pregnancy and childbirthrelated maternal morbidity the decision to initiate use and continue the use of contraceptives is influenced by a number of factors a greater understanding of these factors will inform policymakers programmers and other stakeholders to strengthen family planning and other health intervention programs to achieve the sdgs targeted maternal and under5 child mortality reduction thus the main objective of this study was to understand the social influences in initiating and continuing use of an larc methods for contraception in a rural setting in pakistan using qualitative research the analysis was done from a total of 27 women aged 1549 years who started the use of long acting reversible contraceptive in the year preceding the study the findings have an implication for policymakers programmers health care providers and other stakeholders to evaluate and strengthen the provision of different contraceptive methods and improve support provided to women through the family planning programs the findings of this study strongly recommended the provision of quality counseling on side effects and availability of contraceptive methods peer support and support for decisionmaking regarding long acting reversible contraceptive use married men and women living in rural islamabad pakistan conducted in six rural communities driven by the study objective the study population was identified from those rural areas where contraceptive products and services were provided through both public and private sector providers 12 in the public sector the department of health provides services through a network of reproductive health services clinics attached to hospitals and the population welfare department provide services through family welfare centers in rural areas and mobile service units for hardtoreach areas a female community health worker based in each village have records of each household where they counsel women provide advice on the benefits of family planning and also provide women a selected range of contraceptives doh and pwd clinics provide larcs at a subsidized cost such that iucds cost rs 200 while implants are provided at no cost in the six study areas identified for this research five basic health units one rural health center and three family welfare centers were operational and providing family planning products and services through a medical doctor and licensed midwives study design data examined in this paper includes indepth interviews with women identified during a broader study of fp knowledge and practices with 800 married men and women living in rural communities of the study area 33 as the objective of this study was to understand factors affecting use of larc among married men and women in rural communities of islamabad a sufficient sample size for undertaking logistic regression modelling was recruited sampling and recruitment the respondents for the qualitative study were identified from among the 400 women who participated in a reproductive health and family planning survey conducted in six rural areas of islamabad 33 for the survey married women who were less than 35 years of age and whose youngest child was ≤ 5 years of age were identified by local lhws from their household records among those women 47 married women were identified as being a current or past user of larc and invited for participation in this study however after subsequent screening to exclude those who had used a larc over the past twelve months back and those who had discontinued 27 respondents fulfilled all criteria these women were interviewed in their own homes in the local language by the first author and a research associate both women and trained in qualitative research methods using a semistructured in depth interview guide respondents knowledge of contraceptive and fp methods sources of information current and past use of contraceptives reason for using selected method and experience with the acquired method and its continuing use or nonuse role of social networks and decisionmaking process on usenonuse of larc was collected although data saturation was achieved after interviews with 12 women it was decided to interview all women identified to develop insights on differing perspectives interviews lasting 30 to 60 min were recorded with respondents permission transcribed into english by the ra verified and finalized by main author detailing context where necessary using notes taken during interviews and field visits daily field notes and a reflexive journal were also maintained by the interviewing researcher to record social and interactive nuances observed as well as to contextualize and corroborate information gathered from interviews data analysis interviews were conducted in the local language and audiorecorded with respondents permission the data were transcribed directly to english by a person fluent in both english and potohari ms checked the transcripts against the recordings to ensure accuracy and appended the field notes taken during the interactions transcripts were discussed with participants for checking reporting accuracy the final transcripts were deidentified prior to data analysis using qualitative analysis software program nvivo 12 the data was analysed using content analysis approach keeping in mind the context of the study 34 research team members undertook an iterative inductive process of data analysis by independently reading a few of the transcripts to identify meaning units emerging patterns and develop a coding structure the developed codes were then discussed among the research team members to compare and resolve discrepancies three transcripts were also shared with two other qualitative researchers for independent coding and verification differences in interpretation were addressed through discussion and incorporated in the coding structure the final coding structure from codes to categories and themes was then used to code all the transcripts the themes connecting the codes within each category were then identified and are reported descriptively in this manuscript the consolidated criteria for reporting qualitative studies 32item checklist 35 was followed to ensure reporting consistency trustworthiness of qualitative data methodological rigor for this research was achieved through first authors prolonged engagement with the respondents respondent validation maintaining a chronological audit trail team debriefings and triangulation for data analysis with the coauthors 3637 some of the data were also collected transcribed and coded by the research assistant to ensure that the first authors professional orientation as medical doctor and public health researcher did not impact on data collection approach and analysis process probes were used to explore the responses and provide context for the information shared throughout the process of data collection and analysis ongoing critical reflection peer discussions as well as respondent validation ensured interpretative accuracy of the results contextual details of the study site were captured through field notes pictures of some areas and a reflexive journal all of which were used to provide a holistic description of the study area setting and participants neutrality of findings was maintained through debriefings within in the team combining perspectives of the entire research team ethical approval ethical approval for the study was obtained from human research ethics committee of university of new south wales and national bioethics board pakistan informed consents were solicited and participants were assured of confidentiality of information shared initials have been used throughout to protect participants identities results participant characteristics the age of the 27 participants ranged from 20 to 33 years and had 2 to 4 children each 55 had attended primary school only and none were formally employed and all were housewives most of the women interviewed had used other types of modern contraceptive methods prior to using an larc with 63 using condoms currently 23 were using iucd as larc qualitative study findings womens experiences with initiating and continuing use of an larc are explained under four themes use of trusted networks for information on larcs personal motivation and family support in decision to use larc choice of larc methods and access to providers and social and professional support instrumental in long term use of larc supported by subthemes the figure below shows a conceptual model of larc use decision making which emerged inductively from the data it illustrates womens staged decisionmaking process about larc uptake and use providing a framework for understanding important influences at each stage the model identifies the social influences operating at each stage provided social relationships and personal interactions as shown in the model women are interested in initiating use of a contraceptive due to personal motives they then proceed to gathering information about methods and providers from trusted sources including female relatives and local lhws experiences of satisfied users lessened womens reservations about larc methods any lingering doubts were also addressed by skilled providers helping them overcome this barrier to adopting use of a larc women then proceeded to deciding the type of method to use with support from their spouse who also accompanied them to the provider after initiating use of a larc method ongoing support of spouse and skilled providers gave women the confidence to continue use of this contraceptive method use of trusted networks for information on larcs women sought to obtain information about different types of contraceptives particularly about larcs from different sources when they were contemplating using an larc communication networks most stated that their source of information about contraceptives in general and larcs were predominantly from female relatives in all cases these female relatives had also used contraceptive methods including larcs mostly iucds it seems a common practice even normative for married women to share their experiences of contraceptives with other women in their relatives network my older sisters are married and they would talk about family planning methods so i knew from them that there were things you can use for having a gap in children one of my sisters has been using the ring for 5 6 years now when we have a health problem we first ask our mother or sister sometimes motherinlaw also … respondent 3 in cases where had medical interventions they received information about larc methods by their obstetricians and nurses however they consulted with family members about such advice doctor said that i should have a gap of at least 3 years between children because of operation she told me that the hospital has family planning clinic and i can get the challah and capsule from there after my postpartum period ends i asked my mother about this she and my sister had also used challah and they also told me to start using something … respondent 6 26yearold verifying information from experienced users and professionals various misconceptions about both larc methods were common many mentioned knowing someone who had experienced adverse side effects of iucd or they knew women who had become pregnant while using these contraceptive methods … my younger sister also had it but she conceived with the tube inside and had her daughter same time as my son respondent 12 24yearold information fueling these misconceptions was reportedly shared through social networks where sometimes the use of a particular larc was discouraged even by the lhw … i have heard that the rods can stop menstrual cycles and cause infertility if used for a long time so i decided to use the ring respondent 18 33yearold it was also found that in addition to seeking information from female relatives women sought advice of local lhws which was sometimes biased … my sisterinlaw was using the capsules so i asked her about her experience with using it she said it was easy to use and she had no problems then i asked baji about it but she said the capsules can cause problem in the womans system like i can stop having my periods or i can have too much bleeding or spotting she also told me that some women had to take treatment before they could become pregnant again she said better to get the tube so i decided to get that respondent 16 some of the women who had experienced regular interactions with a doctor or a nurse at ante natal clinics and hospital following cesarean section were more likely to take advice from their doctor or a nurse about starting the use of an larc … both my children were born by operation after my second operation doctor told me to use a family planning method she said they have capsules which they put in the arm … respondent 14 27yearold personal motivation and family support in decision to use larc personal circumstance motivates decision to use larc womens concerns for their own or their childs health was found to be a primary determinant in their decision to start using an larc method especially when traditional methods failed … the lhw told me that i will not get pregnant if i breastfeed the baby but i became pregnant again when my daughter was 7 months old both my children were born by csection operation its very difficult to care for two young children especially after operation so i thought i will have a gap of four five years before having another baby respondent 11 25yearold a common factor among all the women who opted for larc was the prior use of other modern contraceptive methods condoms had been used by all while some women had also used the contraceptive pill and injections women reported the desire to start using a longterm method citing their husbands reluctance to use condoms as well as their own difficulties with adherence to the regular taking of pills and receiving injections … we used saathi a few times but my husband did not want to use the condoms and we did not want another child for some time so i decided to get the tube respondent 24 26yearold capsules are good better than injection or the tube with the tablets you have to remember to take it every day and sometimes you can forget to take it on time injection also same problem respondent 7 30yearold support of spouse in decision making all the women shared that they had discussed child spacing with their husbands and had together considered the longterm contraceptive methods available the duration of each and the number of children they wanted since there is a cultural norm in pakistan of seeking the approval of ones husband in such matters of having an larc my husband is also in favor of having gap in children i told him about the tube and i can have it for five years or ten years he said to get the 5 year one respondent 6 26yearsold i talked to my husband about it he told me to get the iucd when we had our first daughter but i wanted to have another girl before getting this respondent 30 28yearsold importance of support from female family members in decision making process the supportive role of an older female relative most typically mother motherinlaw or elder sister was significant for respondents in choosing an larc method and even influencing the spouse both my children were born with gap of just six month and i wanted to have some gap before another child so i talked to my husband about this challah method and told him that there is option for 5 years and 10 years but he did not allow me then i asked my motherinlaw and she told him to give permission to get the challah respondent 34 24yearsold this supportive role of older female relatives was also observed in situations where a female relative of the respondent expressed support for the decision of the respondent citing reasons of low income and high costs of living … i got the iucd after i had two children … … after her second daughter i told her to get the tube i also told my daughter the same thing for me both are equal and having a boy or girl is allahs decision nowadays everything is so expensive and raising children properly in limited income is difficult choice of larc method and access to providers after having decided on starting use of an larc women selected the appropriate larc method and provider both these decisions were driven by the experiences of trusted members in their social networks testimonies of larc users respondents sought trusted female family members to enquire about appropriate larc methods and providers their experience with either of the two larc methods influenced respondents in deciding the choice of method and provider i got the capsules because two three of my relative got the challah and they suffered from a lot of health problems they said not to get it respondent 27 29yearold women also preferred getting advice about larc methods from providers recommended by a trusted relative … i asked my cousin also about the tube i knew she had it she said she got it from nih so i went there after the postpartum period ended respondent 17 27yearold endorsement by professionals lhws are generally trusted for advice about womens health especially reproductive health as well as their knowledge of contraceptive methods and their recommendations about suitable larc providers some women also relied on their local lhw to accompany them to the selected larc provider respondents invariably approached the larc provider who was recommended by either a relative or the local lhw or their obstetrician i asked baji about the capsules she also said it is good and very easy to use she went with me also to poly clinic to get the capsules … respondent 18 28yearold ease of access to providers none of the respondents indicated access issues about larc use including distance to provider or affordability if the chosen provider was at some distance from their residence respondents generally travelled via public transport often accompanied by a female relative local lhw or spousehusband i went to poly clinic on the local transport from here with my sisterinlaw she had also got hers from there so i asked her to go with me respondent 5 29yearsold … she took me to n bajis house and asked her to go with us to the doctor in falahi markaz my motherinlaw said to get the tube which is for 10 years and i had that placed from there respondent 13 the respondents mentioned the availability of larc methods at the local public sector health facilities including local primary health care and population welfare department clinics the respondents had easy access to these facilities … i had the tube placed from falahi markaz here in our village other women in the village also got it from there its also near my house and was easy for me to go to … respondent 7 social and professional support is instrumental in continuing use of larc women who were using an larc were generally satisfied with the method and planned on continuing use for spacing or having reached their desired number of children intended to continue it spousal and family support for continued use of larc in continuing to use an larc the level of support from ones spouse and social networks was found to be important women countered any negative social criticism when they had the support of their husband they considered women who did not have support of their husband to be helpless and vulnerable to multiple pregnancies interspaced with very short time intervals i told my neighbor about this method as well but she said her husband did not agree and now the poor thing is pregnant again with her third child its all about the husbands support in using the contraceptive methods people say all kinds of things to me but i say if my husband is with me on this then i dont care what you say respondent 2 24yearsold women reported seeking advice from female family members about side effects and any discomfort experienced they were generally advised by female family members not to worry about side effects as they were told these effects would settle over time women were reportedly reassured by such supportive advice especially those who were using an larc for the first time few days after i had my ring placed i felt some irritation and burning i told my sister about it and she said it happens for some time but it will go away in some days so dont worry about it she said she also had it after she got hers but then it was fine she has had it for four five years now actually she had told me to get it after my daughter was born respondent 19 seeking counselling and timely treatment from health care providers normality in monthly cycles was considered important by all participants a deviation from routine was worrisome leading to fears of this being an imminent sign of developing side effects respondents shared that their initial experience of some side effects like pain or some spotting or of heavier menstrual bleeding than normal was alarming for them and they were anxious about developing more serious health problems women reported dreading the thought of having the larc removed as they did not want another child at that time initially i did not have any problem but after about three months i had some spotting two or three times that really scared me because i had heard of other women who had similar problems but then it settled with the medicine doctor had given me and now im afraid to share with anyone that all is ok for fear that i might develop some side effect again respondent 35 both current and past larc users appeared to have been counselled well by their provider about the method and any expected side effects as a result when women initially noticed side effects they reported not seeking immediate care in anticipation of the side effects resolving or subsiding with time larc providers were generally approached when side effects continued or increased in intensity after the iucd i had prolonged monthly bleeding like it was 8 or 9 days and i was still having bleeding so i went back to the falahi markaz and doctor there gave me a medicine to take for one week told me not to worry about this … i took the medicine and now its been almost a year and thank god i have not had any problem again respondent 16 discussion this study set out to investigate social influences on womens decision making about larc use and provides an insight on womens motivations information pathways accessed and decisionmaking process for larc uptake in rural pakistan where previous studies examined barriers to and discontinuance of larc 18233038 this is the first study offering insight on key people and their various roles in influencing and supporting women in their decision to use and continue to use larcs the study identifies four themes in the pathways of married pakistani women choice to take up an larc and continue its use use of trusted networks for information on larcs personal motivation and family support in decision to use larc choice of larc methods and access to providers and social and professional support instrumental in long term use of larc each of these themes fit a temporal sequence in adoption of larc but cannot be taken as stages as often there is overlap between each of them and are discussed together policy implications of the findings are also discussed in the context of current policy in pakistan the effects of social networks and interpersonal communication on shaping womens attitudes about family planning and contraceptives is well established in social networks research which has shown to have had effect on contraceptive use behavior 39 40 41 42 research evidence from regional countries similar in context to pakistan have also reported that womens communications with female family and social network members influenced their knowledge and attitudes towards contraceptive use in family planning 43 44 45 however in the current study the trusted social network was comprised mainly of female relatives rather than friends or experts external to the family this difference may be attributable to the culture of consanguineous marriages norms of sociocultural interactions limited to extended family and restrictions on womens mobility without a male or an older female escort in pakistan 3246 conversations about contraceptive use are rare and unconventional with nonfamily members of ones social network and may contravene established social and cultural norms in pakistan as such it remains to be seen whether the diffusion of larcs could be enhanced through extended female social networks that have used larcs or whether such conversations will generally be confined to female family members and fp providers prior qualitative studies have shown that pakistani women have had some reluctance to use contraceptives especially larcs because of myths and misconceptions about long term sideeffects which have largely been driven by rumors and shared through social communications 2329 the current study also found such occurrences some which were spread by providers specifically the lhw however what this study found was that women who adopted larcs were able to discuss this with trusted female family member the shortcomings of the lhws may be because of gaps in their knowledge and deficits in counselling skills arising from limited training as community health workers as well as a lack of formal training in health care which were factors identified in an external evaluation of the lhw program 4748 the national population policy 49 identifies lhws as key personnel to provide counselling to reduce the unmet need for contraception on pakistan it would be fair to surmise that uptake will increase when a sufficient cohort of older female family members with experience of an larc are available to counter these myths and misconceptions the study findings suggest that increasing pakistani womens access to satisfied larc users within peer networks have the potential to support women in their decision making for uptake and use of larcs experience of neighboring countries with interventions for increasing use of larcs may also offer ideas for implementation in pakistan for example in countries such as india nepal and bangladesh where women are influenced in their decisions about maternity care and contraceptive use by other women in their social networks 50 51 52 53 those countries have introduced behavior change communication programs such programs are aimed at improving uptake of contraceptive methods through joint discussions with womens groups comprising younger married women alongside other experienced women including mothers and mothersinlaw 3954 however it remains unclear whether such strategies would suit the cultural conditions in pakistan husband endorsement and their shared role in family planning decisionmaking was acknowledged by the women as necessary for their larc uptake as well as for their continued use of an larc participating women told us how they tried to influence their spouses to arrive at a joint decision and when such a joint decision was not forthcoming how they relied on more senior women in their husbands family to influence their husband the pivotal role of spousal support in contraceptive choice is highlighted in research from pakistan which has explored mens roles in family planning and have promoted couple counselling based on that premise 404155 previous qualitative research which explored mens family planning attitudes and information needs has also highlighted the importance of involving husbands in family planning discussions and the need to establish forums for men as a way of raising awareness addressing myths and concerns and advocating for supporting womens use of larc 4042 while husband endorsement to use a modern contraceptive was vitally important for the women in the current study the greatest influence on their decision to use an larc appeared to be older female family members limitations and strengths as the study concentrated only on current users of larc the views of nonusers and those who discontinued was not available for a nuanced comparison however given issues of nonuse and discontinuation have been looked at in other studies this study sought a unique contribution another limitation is the relatively small number of hormonal implant users as compared to the iucd users however as per the pdhs 20172018 in the overall contraceptives mix use in pakistan implants are used by only 04 women and this disproportion is also reflected by our study sample as with any study based on convenience samples caution is needed before generalizing the findings beyond the sample group a key strength of the study was identification of respondents for the qualitative research subsequent to a community survey this allowed triangulating the qualitative findings such as contraceptive knowledge and practice gaps and the role and influence of peers in promoting the use of contraceptives in addition these study findings have importance beyond the sample studied as they contribute valuable insight for policy makers and program managers for family planning services development conclusion much of the existing body of research on womens use of larcs in pakistan is based on surveys measuring womens knowledge and use of all types of contraceptives including larcs this study was unique in exploring in depth the decisionmaking process of women who adopted larc and maintained use results have highlighted the significant role of their immediate social network of female family members as the key influencers of decisions at all points of the process women who proceeded to use an larc and who persisted with its use despite the experience of side effects and social pressures were able to do so with support from their spouse and other female family members study findings have to be considered in light of national policy of using the lhw to motivate use of modern contraceptives creating informed demand for larc in pakistan requires more intensive communitylevel efforts it is proposed that as more women in an area adopt larcs access to satisfied users within social networks should be facilitated which can increase and create a more favorable environment for uptake of larcs expanding womens choice abbreviations authors contributions ms rj and sh participated in the design of the study and performed the data analysis pr and ma contributed to interpretation of data ms drafted the manuscript which was reviewed and revised by all authors all authors read and approved the final manuscript competing interests authors declare that there is no conflict of interest

introduction despite evidence from recent demographic health surveys that show 98 of the adult pakistani population have an awareness of at least one modern contraceptive method only 25 of married couples in pakistan used a modern method of contraception of the modern contraceptive methods larc usage has increased only from 21 to 3 this low uptake is puzzling in the context of high awareness of larc methods and its availability through public sector facilities at subsidized costs this study aimed to understand the social influences in initiating and continuing use of an larc methods for contraception in a rural setting in pakistanindepth interviews were conducted with 27 women who were using a larc method for contraception data was managed using nvivo 12 and themes were identified using a content analysis approach to analyze the transcriptsfour key themes supported by subthemes relating to a temporal model were identified to explain womens experiences with initiating and continuing use of a larc the themes were i use of trusted networks for information on larcs ii personal motivation and family support in decision to use larc iii choice of larc methods and access to providers and iv social and professional support instrumental in long term use of larc results highlight the significant role of immediate social network of female family members in supporting the women in initiating larcs and maintaining the methods usethis study contributes to an in depth understanding of the decisionmaking process of women who adopted larc and maintained its use women who proceeded to use an larc and who persisted with its use despite the experience of side effects and social pressures were able to do so with support from other female family members and spouse

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introduction knowledge accumulation and technological progress are the sources of sustained regional economic growth 12 as carriers of knowledge and technology highly educated talents are the key drivers of national and regional development the attraction and retention of talents have become a focus of international attention as well as the more effective exploration of important talents 3 the agglomeration of talents will produce various agglomeration and fusion effects such as knowledge spillovers lowcost communication and learning externalities and specialized talent pool for industries that require high intelligence 4 in recent years china has undergone significant economic restructuring and industrial upgrading in the new normal economy technological innovation has become the core driving force for national and regional development 56 talents are the primary resources driving technological innovation and regional economic and social development 7 chinese government attaches great importance to the talents and has formulated and implemented various talent policies and plans 8 chinese local governments attract talents through strategies for talent exploration household registration system reform improving public service capabilities and building humanistic urban environment 9 10 11 12 recruiting and retaining talents is a comprehensive public policy and the key to retaining talents lies in providing higherlevel public services and creating a good urban environment in recent years chinas local governments have formulated a series of public policies to retain highly educated talents 213 in addition the migration is an inevitable phenomenon in the process of social and economic development 14 since chinas economic reforms in 1978 the number and distance of migrants have continued to increase according to the data from the 7th national census of china the migrant population in china has reached 376 million and the migration structure has gradually become diversified with the majority being highly educated migrants born after 1980 who are known as newgeneration highly educated migrants according to the data from the 2015 nationwide 1 population sample survey china has a population of 17093 million with a university education or above an increase of 4287 compared to 2010 in the rapid process of economic development and urbanization the new generation of highly educated migrants with higher competitiveness and higher quality human capital play an important role in optimizing the labor force age structure and alleviating the challenges of population aging in destination city however due to the social spatial mobility and residential instability of migrants the floating of migrants is considered unsustainable for the future urbanization of china 15 therefore the permanent settlement of nghems in destination cities is crucial for sustainable urbanization in china highly educated migrants may be attracted by the talent welfare policies of the destination city the settlement intentions of these individuals are influenced by both the hard and soft power of the city such as economy environment urban culture urban governance and highlevel public service capabilities 1617 notably the younger generation of chinese individuals places significant emphasis on personal happiness 9 and the consideration of physical and mental health plays a vital role in determining their settlement intentions 18 therefore cities that prioritize these aspects are more likely to attract and retain highly educated migrants under the background of the national strategy of vigorously promoting informatization driving industrialization through informatization promoting informatization through industrialization and pursuing a new path of industrialization urban eservices have emerged as a vital strategic initiative in chinas informatization process 1920 amidst the covid19 pandemic the chinese government effectively utilized digital technology and the urban eservice network to promptly disseminate information with a result the epidemic is controlled within a short timeframe successfully and the production is restored gradually 21 with the help of the digital technology and the urban eservice network a more resilient society capable of withstanding risks is developed in the digital era urban digitization is the foundation of urban eservices and the improvement of urban eservice capabilities can reciprocally facilitate the advancement of urban digitization with the rapid development of digital city construction in china the ability of digital public services improve unremittingly it may take new impact mechanism on the longterm or permanent settlement intention of newgeneration highly educated migrants however most research primarily focuses on the influence of household registration and public services 2223 on the settlement intention of chinas highly educated migrants the research aims to address the following questions how does the urban eservice capability impact the settlement intention of nghems in china what are the differences in the impact of urban eservices on the settlement intention of nghems based on individual characteristics and the scale of the city what mechanisms underlie the influence of the settlement intention of nghems this paper is organized as follows in literature review we review and summarize the literatures on the settlement intention of highly educated migrants and propose theoretical hypotheses regarding the settlement intention of nghems in data and methodology we describe data variable selection and research methods of this paper in results we measure the impact of urban eservice capabilities on the settlement of nghems we also test the robustness of the results conduct heterogeneity tests and investigate the mechanisms through a mediation model finally in conclusion we conclude with the main findings and provide suggestions based on the results literature review urban eservices and the settlement intention of highly educated migrants in the past decades there has been a flourishing research on internal migration in western countries the availability of early microcensus or survey data has enabled scholars to study the migration of specific groups many studies have focused on the migration and redistribution of educated or skilled labor force who played a crucial role in economic growth during chinas transition period these studies include distribution patterns 24 migration modes 25 driving forces 26 spatial spillover effects 27 impact factors 28 29 30 and the impact of internal skilled labor migration on regional economies 731 some studies indicate the existence of spatial agglomeration patterns of skilled talents 2426 and identify job opportunities as key factors 24 the scale of interregional migration is positively related to the population stock in the origin and destination regions 3233 with the development of chinas economy and urbanization determinants of migrants settlement intention are studied from different perspectives one of these perspectives is urban public services as a kind of public service urban eservice has been studied more from the perspective of urban public services or social welfare to analyze the impact on the migrants settlement intention some studies argue that talent migration is primarily driven by regional welfare differentials 34 35 36 some studies indicate that urban public service level is the key factor affecting the migrants intention to stay including educational public service social citizenship public service social insurance and urban public service quality 12 37 38 39 40 41 as highly educated migrants have higher social acceptance and more employment options they face fewer barriers to migration highly educated migrants consider various factors including personal spatial preference the quality of city services and governance cultural adaptability and opportunities for personal development when they choose destination cities to settle down 42 43 44 so they have higher expectations for the overall strength and attractiveness of the destination city as urban industries and economies evolve the demand for talent in cities grows steadily scholars have analyzed the public services on the determination of highly educated migrants settlement intention such as high capacity of urban public services advanced healthcare facilities highquality educational resources highquality smart city environment and wellestablished amenities all of which make the destination city more attractive for highly educated immigrants to settle down 42 43 44 45 46 47 48 based on those theories hypothesis 1 is proposed hypothesis 1 for other factors being equal urban eservice can promote the settlement intention of the newgeneration highly educated migrants urban eservices livability of city and the settlement intention of newgeneration highly educated migrants eservices have requirements and characteristics of globality strategic importance public nature hierarchy ubiquity and precision 49 50 51 52 with the gradual expansion of national governance in china encompassing both physical and digital realms and forming aggregated social networks eservices place emphasis on intelligent office intelligent regulation intelligent services and intelligent decisionmaking 53 54 55 the impact of urban eservices on urban livability is reflected in the following two aspects on one hand eservices focus on prioritizing public needs prioritizing service orientation improving the efficiency of public services providing efficient and convenient public services to the public enhancing the transparency of administrative enforcement promoting communication among the public enterprises and government and reducing the costs of business and personal affairs 56 57 58 59 60 on the other hand eservices give full play to the value and role of data by adhering to the concept of more data to run less people to run it has greatly shortened the time needed for handling various business links reduced the cost for enterprises and individuals to handle business thus enhancing the livability of cities from the economic point of view urban livability is usually considered as a kind of commodity and people move their place of residence to meet the demand for this kind of commodity 61 with the deepening of research the connotation of urban livability is gradually enriched it mainly includes elements such as natural conditions public services education healthcare transportation and communication and cultural atmosphere 62 63 64 65 enhancing urban livability is beneficial in meeting the growing demands of city residents for a better quality of life thereby increasing the attractiveness of cities to migrants migrants choose to migrate to a particular city not only to secure higher salaries and employment opportunities but also to avail themselves of public services such as education and healthcare 6667 the quality of urban public service provision has a significant positive impact on the settlement patterns of migrants 6869 a higher level of urban livability contributes to improving residents quality of life and fulfilling their aspirations for a better life so hypothesis 2 is proposed hypothesis 2 urban eservices enhance the settlement intention of newgeneration highly educated migrants by improving urban livability urban eservices urban innovation and the settlement intention of newgeneration highly educated migrants the impact of eservices on the level of regional innovation is mainly reflected in the following two aspects on one hand the implementation of eservices imposes higher demands on infrastructure promoting technological upgrades and structural adjustments and ultimately advancing the level of regional innovation directly 5054 on the other hand eservices can enhance technology management capabilities and optimize operational environments thereby improving public service capabilities optimizing service decisionmaking and promoting resource sharing 5270 this attracts the concentration of businesses and promotes entrepreneurial activities and innovation ultimately raising the regions innovation level under the background of entrepreneurship and innovation the improvement of urban innovation and entrepreneurial levels can enhance the attractiveness of cities for migrants stable jobs and high incomes can improve the settlement intention of migrants 7172 the labor force tends to choose jobs that can enhance their own productivity as it helps them gain better employment prospects and higher salary returns based on the technological innovation driven by the urban eservices highly educated migrants can work with higher efficiency and own higher economic income cities take the advantages of eservices to drive technological innovation and foster the clustering of upstream and downstream industries this promotes the scale of economies facilitates the spillover of knowledge and technology and enhances the innovation capabilities and levels of enterprises and cities the combination of innovation capabilities and income improvement will promote the settlement intention of highly educated migrants 7173 therefore hypothesis 3 is proposed hypothesis 3 urban eservices enhances the settlement intention of newgeneration highly educated migrants in destination cities by improving the urban innovation based on the review of the literature the theory frame of this work is proposed as shown in fig 1 data and methodology data source the data utilized in this study was extracted from the china migrants dynamic survey conducted in 2017 74 the cmds is a nationally representative crosssectional survey that provides open access to its data the survey focused on migrants aged 16 and above who had relocated across county boundaries from their registered place of residence and had resided in their current location for at least one month to ensure representativeness the survey employed a stratified multistage random sampling method using the probability proportional to size approach a total of 169989 samples from the floating population were collected across 348 cities covering 32 provincial units in china additionally data from the evaluation report of government eservice capability index 75 were employed to assess urban eservice capability according to previous studies 427677 and the widely acknowledged definition of talent in the current variable selection dependent variable this paper constructs a comprehensive index system including 3 indicators urban stay intention longterm cityresidence intention and hukou transfer intention these indicators are used to assess the urban settlement intention of nghems the 3 indicators correspond to the following questions do you have plans to stay in this locality in the future if you plan to stay how long you expect to stay if you meet the local settlement conditions are you willing to transfer your household registration to the locality typically migrants initially express the intention to stay in the city which further leads to the desire for longterm settlement and hukou transfer in this paper a value of 1 is assigned if respondents choose consideration to stay in city and willing to transfer hukou into local city otherwise the value is set to 0 for a stay duration of 610 years a value of 1 is assigned while a value of 2 is assigned for a stay duration exceeding 10 years otherwise the value is set to 0 the cumulative value of the 3 indicators with equal weighting represents the settlement intention of nghems in destination cities it is expressed using a scale of values where 0 signifies no settlement intention 1 denotes low settlement intention 2 indicates moderate settlement intention 3 represents high settlement intention and 4 signifies very high settlement intention core explanatory variable eservice capability is the key variable being studied in this paper the urban eservice level is measured based on multiple dimensions including service provision capability participation service capability information service capability and civil affair service capability provided by government microblogs wechat and government apps as outlined in the evaluation report of government eservice capability index 75 in this study the composite index of wci and bci is utilized to assess the urban eservice level while the app index is employed for robustness analysis control variables the variables that may impact the urban settlement intention of nghems are categorized into individuallevel variables and citylevel variables the individuallevel variables encompass the following aspects individual characteristics variables such as family members living together gender age education level hukou party membership and marital status economic characteristics including total monthly household income and total monthly housing expenses over the past year as well as whether the nghems possesses selfowned housing migration characteristics variables such as the total number of cities migrated to whether the father or mother has had migration experience migration alone the level of interaction with local residents during leisure time the extent of geographical floating and the duration of migration health variables including selfperceived health condition whether they have established a health record in the past year and whether they have experienced any illnesses or health issues in the previous year social integration variables such as whether they pay attention to the changes in the city they currently reside in their willingness to assimilate with the local community and whether they have rural cooperative medical insurance or a personal social security card the city dimensional variables include per capita gdp number of hospital beds per thousand and the number of primary and secondary school teachers per thousand the data for these variables were obtained from the china city statistical yearbook 78 these control variables have been selected for inclusion in this study mediating variables urban livability urban livability is assessed based on five indicators education level measured by the studenttoteacher ratio in regular higher education institutions in regular vocational schools in regular secondary schools and in regular primary schools healthcare facilities including number of hospitals and clinics per 10000 people number of hospital beds per 10000 people number of licensed or assistant doctors per 10000 people public transportation evaluated by the number of taxis per 10000 people and the number of public buses and trams per 10000 people environmental quality gauged by the comprehensive utilization rate of general industrial solid waste the centralized treatment rate of sewage treatment plants the harmless treatment rate of household waste and the extent of green coverage in urban areas online living measured by the ratio of internet broadband access users and mobile phone users 79 all indicators are positive attributes and the entropy weighting method 80 is utilized for the analysis and calculation of urban livability indicators the data is sourced from the 2017 china urban statistical yearbook 78 urban innovation urban innovation is determined by the city innovation index derived from the chinas city and industry innovativeness report 2017 81 a higher innovation index signifies a stronger innovation capability of the city model in this study descriptive analysis of variables was initially conducted using stata 151 the lasso model was then utilized for variable selection subsequently the logistic regression analysis was employed to examine the precise impact of urban eservice on the settlement intention of nghems finally a mediation model was employed to analyze the potential influence mechanisms lasso model to address the issue of multicollinearity in the data and mitigate potential estimation bias of the variables the maximization process of the likelihood function with a lasso penalty term is employed this allows for the estimation of lasso regression coefficient values and selects the relevant variables the model can be expressed as where is the nonnegative canonical adjustment coefficient and j is the number of variables lasso method will set the coefficients value of unimportant variables as 0 by utilizing the sklearn library in python the lassocv function is employed to eliminate variables with coefficient equal to 0 so that the unimportant variables can be deleted the lasso penalty term penalizes each regression coefficient resulting in an estimator deviation therefore an ordinal logit regression is constructed for the variables selected the maximum likelihood estimation method is employed to obtain consistent estimates of regression coefficients and statistically significant results effectively mitigating estimation bias in limited samples as a result the variables are delimited including party membership rent whether they have more interaction with local residents whether they have experienced any illnesses or health issues in the previous year whether they have participated in the free medical care program β arg min y p j1 βeservice ij θ x ij αcity ij 2 p j1 β ij ordinal logit model the settlement intention of nghems in destination cities is presented by a value with a higher value indicating a stronger settlement intention therefore the probability of urban settlement intention for nghems can be expressed as where p ij p denotes the cumulative prob ability that settlement intention of nghems takes preceding j values p ij denotes the response probability for individual i in city jα is a constant eservice is the urban eservice x is micro variables city is the countylevel variables β and θ are the estimated coefficients of inde pendent variables mediating effect model theoretical analysis indicates that the capability of urban eservices can influence the settlement intention of nghems by altering urban livability and employment rate to validate it we establish the following threestep mediation model for verification where y ij represents the settlement intention of nghems eservice ij represents the capability of urban eservices mid i represents urban livability or urban innovationx i is control variableα β δ γ φ θ are the coefficients of variables respectively ε i is error term the verification process is as follows test the significance of the coefficient β if it is significant proceed to step otherwise there is no mediating effect perform consecutive tests on γ and θ if both coeffi cients are significant continue with the test for φ if φ is significant it indicates a significant mediating effect otherwise there is a complete mediating effect if either γ or θ is not significant conduct a sobel test the statis tical value is calculated as z γ θ where s 2 γ and s 2 θ are the the standard deviation of γ and θ respectively if z is significant it indicates the presence of a mediating effect and the magnitude of the mediating effect can be calculated using γ θ other wise there is no significant mediating effect log ln p ij 1 p ij α βeservice ij θ x ij αcity ij y ij α βeservice ij δx ij νcity ij ε i 4 mid ij α γ dig ij ϕx ij σ city ij ε i y ij α φeservice ij θ mid i ϕx i ηcity ij ε i results descriptive analysis according to table 1 the settlement intention of nghems is between medium settlement intention and high settlement intention the average urban eservice capability is 0549 regarding individual characteristics variables the majority of the respondents were rural residents married and nonparty members and league members and with an average of 27 family members living together additionally the logarithm of the total monthly household income for nghems is 8941 equivalent to an income of approximately 8000 yuan and majority of them do not own a house in terms of migration characteristics and health status the average number of cities where nghems have floated is 1837 indicating that most have migrated to one or two cities the majority of respondents have migrated alone have limited interaction with local registered residents migrated innerprovincial possess no health records have poor health conditions have been migrating for about 45 years and have parents without migrant experience 316 of respondents have participated in rural cooperative medical insurance while about 725 possess personal social security cards they care the change happening in the city they live in and express a desire to blend in with the local population as for the citylevel variables number of primary and secondary school teachers per 1000 population is 8722 and the number of hospital beds per 1000 inhabitants is 7111 the sample characteristics align closely with the data from chinas seventh national population census indicating the credibility and representativeness of the survey samples and data benchmark regression table 2 presents the regression results of urban eservice capabilitys influence on the urban settlement intention of nghdms in which the ordinal logit model is used in model 1 the influence of urban eservice capability on the settlement intention of nghdms is examined the regression coefficient of urban eservices is 1430 which is statistically significant at the 5 level the regression results indicate that the enhancement of urban eservices contributes to an increased likelihood of nghems choosing to reside in the city specifically a 1 improvement in urban eservices corresponds to a 143 increase in the probability of nghdms selecting the city as their settlement destination in the regression results from all models consistently demonstrate that a higher urban eservice capability has a positive impact on the settlement intention of nghdms in destination cities confirming hypothesis 1 model 7 includes all control variables so we will primarily discuss the results from this model the individual characteristics variables of gender age education level household registration and marital status have statistically significant positive effects on the urban settlement intention of nghems gender has a significant negative impact on the urban settlement intention of nghems compared to females males are less likely to choose the migrant cities as their settlement destination the settlement intention of nghems is higher among those with characteristics such as older age higher education level urban household registration and being married which is consistent with the research findings of zhu huizhen et al 82 for economic characteristics variables higher income and owning housing in city have a positive impact on the settlement intention of nghems in destination cities 83 84 85 for health variables having an urban health record and experiencing poorer physical health are factors that promote the settlement intention of nghems table 2 benchmark regression results are significant at 1 5 and 10 significant levels respectively the standard errors clustered by city are in parentheses the same below possibly due to the better medical care and social security systems available in cities for migration characteristics variables migrants who have parents with migration experience longer migration history have migrated alone and have interprovincial migration will facilitate the settlement intention of nghems in destination cities which aligns with the findings of a study conducted by yang and fan in 2019 86 as longer duration in destination cities allows nghems to establish more relationships and have access to more job opportunities 87 thereby facilitating their integration into urban society and strengthening their settlement intention in terms of social integration variables regression results indicate that nghems who are interested in the citys dynamics willing to integrate into local communities and have applied for urban social security cards exhibit a higher settlement intention in destination cities for citylevel variables higher per capita gdp and a greater number of hospital beds per thousand people are associated with a higher settlement intention of nghems however having more primary and secondary school teachers per thousand people reduces the settlement intention of nghems this can be attributed to the inefficient allocation of teacher resources in small and mediumsized cities where the teacher resources ratio tends to be lower compared to larger cities as small and mediumsized cities experience population outflows the smaller number of teachers per thousand people negatively affects the settlement intention of nghems in destination cities robustness analysis the robustness of the regression results is verified from three aspects ordinal probit regression and poisson regression instrumental variable method and regression with intercepted data the regression results are shown in table 3 ordinal probit regression and poisson regression model 8 and model 9 in table 3 give the regression results of ordinal probit regression and poisson regression respectively and the results are consistent with the previous results instrumental variable method there may be a correlation between eservices capability and the settlement intention of nghems in destination cities to address endogeneity issues the instrumental variable method was utilized the capability of government app services was employed as an instrumental variable for robustness testing correlation analysis revealed a strong positive correlation between the capability of government app services and the dual micro electronic services to ensure the validity of the instrumental variable a weak instrument test utilizing the kleibergenpaap wald f statistic was conducted 88 the results show that the value of the f statistic was significantly greater than 10 indicating the absence of weak instrument problems therefore the selection of the capability of government app services as the instrumental variable was deemed valid both liml and 2sls estimations yielded consistent results the regression results of model 10 estimated by liml provided strong evidence that urban eservices promote the settlement intention of nghems regression with intercepted data to validate the robustness of the regression results in model 11 intercepted data was used due to potential variations in the multivariate data the first 1 and the last 1 of the urban eservice level variables were eliminated the results confirmed the robustness of the previous findings the results of the robustness tests show that chinas urban eservice capability promotes the settlement intention of nghems in destination cities heterogeneity analysis based on the assumption that the migrants have the same preference for government public services this part analyzes the settlement intention of nghems from multiple perspective to examine the heterogeneity effect of eservice capability on the settlement intention of nghems the ordinal logit regression model was employed gender marriage and hukou table 4 shows the regression results of the urban eservices on the settlement intention of nghems stratified by gender marital status and household registration the regression results of model 12 and model 13 reveal that urban eservices can significantly promote the settlement intention of both male and female nghems for each unit of improvement in eservice level the probability of nghdms selecting the city as their settlement destination increased by 0784 units while for females it increased by 0682 units model 14 and model 15 examine the influence of marital status on the settlement intention of nghems the regression results demonstrate that urban eservices have a positive impact on the settlement intention of married nghems but has little effect on single nghems this could be attributed to the lower migration costs for single nghems making them less sensitive to urban eservice capability models 16 and 17 consider urban and rural household registration the findings reveal that urban eservices positively affect the settlement intention of nghems with both urban and rural household registration with a stronger effect observed among those with urban household registration for each unit improvement in eservice level the probability of nghdms selecting the city as their settlement destination with urban household registration increased by 1117 units to attract a larger number of settlers cities should prioritize the improvement of urban eservice capability along with chinas urbanization rate city size and regionalization in 2019 the general office of the communist party of china central committee and the general office of the state council have issued the opinions on promoting the reform of the system and mechanism for the social mobility of labor and talent according to the opinions the settlement restrictions were canceled for cities with a population of less than 3millions table 5 shows the regression results of the urban eservices on the settlement intention of nghems stratified by city size and regionalization in model 18 and model 19 the settlement intentions of nghems in destination cities is examined model 18 focused on cities with a permanent resident population in the city exceeding 3 million while model 19 focused on cities with a population less than 3 million the regression results show that urban eservices have a significant impact on the settlement intention of nghems in cities with a population exceeding 3 million for each unit of improvement in eservice capability the probability of nghdms selecting the city as their settlement destination will increase by 0709 units in contrast for cities with a population less than 3 million with a 0415 unit increase in settlement intention for each unit improvement in eservice capability the results imply that nghems in big cities are more sensitive to eservice capability model 2022 respectively examines the impact of urban eservice capability on the settlement intention of nghems in the eastern central and western regions of china the results indicate that the impact of eservice capability varies across regions with the eastern region having the highest impact followed by the western region and finally the central region in the eastern region each unit improvement in eservice capability leads to a 1035 unit increase in the probability of nghdms selecting the city as their settlement destination in the western region this impact is slightly lower at 0811 units the results suggest that the settlement intentions of nghems may be influenced by the regional differences in china with the nghems in the eastern region showing greater sensitivity to eservice capability mechanism analysis the above analysis show that urban eservices play a crucial role in increasing the settlement intention of nghems in destination cities to further validate the impact mechanisms we utilizes mediating effect model to investigate urban livability building upon the previous analysis urban eservices can enhance the settlement intention of nghems by improving the livability of cities to verify hypothesis 2 a mediating effect model was employed to investigate the mechanism that urban livability influences the settlement intention of nghems the results are shown in table 6 the results in table 6 demonstrate that urban eservices have a significant positive impact on the settlement intention of nghems with a significance level of 5 which indicates that urban eservices promote the settlement intention of nghems in destination cities in table 6 the positive regression coefficient of urban eservices on urban livability indicates that urban eservices contribute to the improvement of cities overall livability the results in table 6 reveal a significantly positive regression coefficient for both urban eservices and urban livability on the settlement intentions of nghems this result indicates the presence of a mediating effect whereby urban livability serves as an intermediary between urban eservices and the settlement intentions of nghems in other words urban eservices have a positive impact on the settlement intentions of nghems by creating a more livable urban environment urban innovation innovation serves as a powerful driving force for the highquality development of both cities and enterprises as the urban innovation capacity directly influences the economic development and overall quality of the city through the promotion of technological innovation in enterprises employee welfare can be enhanced and more job opportunities can be created thereby facilitating the retention of population to verify hypothesis 3 a mediating effect model is employed to investigate the mechanism that urban innovation influences the settlement intention of nghems the results are shown in table 6 the results in table 6 show that urban eservices have a significantly positive impact on the settlement intention of nghems with a significance level of 5 which indicates that urban eservices promote the settlement intention of nghems in table 6 the positive regression coefficient of urban eservices on urban innovation indicates that urban eservices contribute to the improvement of urban innovation capacity the results in table 6 reveals a significantly positive regression coefficient for both urban eservices and urban innovation on the settlement intention of nghems this result indicates the presence of a mediating effect whereby urban innovation serves as an intermediary between urban eservices and the settlement intentions of nghems in other words urban eservices have a positive impact on the settlement intentions of nghems by leveraging the innovation capacity of cities limitations cities as the drivers of new urbanization play a vital role in attracting and retaining the newgeneration highly educated migrants thereby supporting chinas economic and social development these newgeneration highly educated migrants are highly floating making it crucial to understand how to attract and retain the talents in order to promote urban economic growth this paper focuses on the influence of urban eservice capability on the settlement intention of nghems in destination cities the influence mechanisms are analyzed from the individual characteristics economic characteristics migration characteristics health characteristics and social integration characteristics and citylevel characteristics furthermore it is recommended that additional factors with potential influence on settlement intentions such as psychological pressure house price levels and the quality of living environments should be considered for further study additionally the uneven distribution of resources leads to imbalances in economic development among regions with economically advanced areas like beijing tianjin jiangsu zhejiang and shanghai being favored destinations for nghems the concentration of talents is particularly prominent in eastern china in the context of the new competition for talents it is important to examine and explore the impact of preferential policies implemented in different regions conclusion this paper utilizes china migrants dynamic survey in 2017 evaluation report of government eservice capability index and the china statistical yearbook data of 2017 an ordinal logit model is employed to examine the impact of urban eservice capability on the settlement intentions of newgeneration highly educated migrants in destination cities the results reveal that urban eservices have a significant and positive influence on the settlement intention of nghems through a series of robustness tests the results remain robust and consistent furthermore the analysis of individual and regional heterogeneity indicates that urban eservices notably enhance the settlement intentions of both male and female nghems as well as those who are married and possess urban household registration moreover the positive effect of urban eservices are more pronounced among nghems in cities with a population above 3 million and those in the eastern part of china subsequent tests suggest that this influence is mediated by the enhancement of urban livability and urban innovation consequently it is recommended that the government prioritize the improvement of eservice capability in chinese cities particularly in larger cities and the eastern region simultaneously attention should be given to enhancing urban livability and urban innovation as these factors play a crucial role in influencing the settlement intentions of nghems although the data employed in this study are specific to china the findings can potentially serve as a theoretical basis for enhancing population migration policies globally author contributions fz conceptualization methodology software data curation writingoriginal draft validation lx software data collection data curation writingoriginal draft all authors read and approved the final manuscript competing interests the authors declare no competing interests

background talent is a crucial resource for economic and social development serving as the driving force behind urban progress as china experiences rapid growth in digital city construction the capability of eservices continues to improve incessantly in china the newgeneration highly educated migrants nghems account for 2030 of the total floating populations this study aimed to explore the settlement intention of newgeneration highly educated migrations in china from the new perspective of urban eservice capabilities furthermore the mechanism of the urban eservices on the settlement intention on the nghems will be provedthis paper employed data of china migrants dynamic survey in 2017 and evaluation report of government eservice capability index 2017 descriptive analyses were conducted to investigate the factors influencing the settlement intention of nghems in the destination city based on the principle of utility maximization lasso regression was employed to select individual and city characteristics that determined the settlement intention of nghems the impact of urban eservices on settlement intention was analyzed by using ordinal logit model additionally robustness check endogeneity analysis and heterogeneity analysis were performed to validate the benchmark regression results finally mediation model was employed to examine whether urban eservices enhance the settlement intention of nghems by improving urban livability and urban innovationthe results indicate that the urban eservices promote the nghems settlement intention in the destination cities moreover the results are still robust through a series of robustness tests furthermore from the perspective of individual and regional heterogeneity urban eservices significantly enhances the settlement intention of nghems with male and female married and urban household registration and urban eservices can promote the settlement intention of nghems with over 3 million inhabitants and those in the eastern regions of china finally the intermediary effect test shows that urban eservices promote the settlement intention of nghems through urban livability and urban innovationthis study highlights the important impact of urban eservices on the settlement intention of newgeneration highly educated migrants the conclusions of this study provide suggestions for the government to use when designing policies to enhance the settlement intention of the nghems and to improve the development of urban eservices

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of the presence of a relationship between each pairwise combination of students in their classroom this differs from social cognitive mapping which focuses on childrens identification of peer groups rather than individual relationships thus css provides data about both childrens selfreported relationships and their perceptions of classmates relationships making it useful for comparing real and inferred relationships children tend to form relationships with others who are socially proximate and spatially proximate although this paper examines hanging out relationships the mechanisms of proximity are expected to operate on most types of affiliative relationships thus we review the literature that includes both childhood friendships and hanging out relationships using the word relationship to refer generically to positive linkages that exist between two children but words like friendship when discussing specific previous studies that refer to particular types of linkages the preference to form samesex peer relationships is well documented from preschool to early adolescence children form sexsegregated peer groups at an early age leading developmental researchers to describe the worlds of boys and girls as two cultures martin et al demonstrated that sex segregation in preschool peer groups is explained in part by childrens preferential selection of samesex play partners these tendencies remain present through middle childhood and early adolescence and longitudinal research has demonstrated that children are more likely to become friends with samesex peers children also tend to form relationships with others who are similar on a range of behavioral characteristics including academic orientation and athleticism which provide opportunities for children to form relationships academic grouping may bring children with similar academic orientations into contact while similarly athletic children may have opportunities to interact through sports participation spatial proximity also affects relationship formation by providing opportunities for individuals to interact george and hartmann found that elementary school children form almost half of their friendships with peers in the same classroom where seating arrangements facilitate childrens opportunities to interact and shape their liking of one another thus we hypothesize that real relationships are more likely between children who are both boys or both girls both have positive academic orientation both have athletic ability or sit near one another in class peers are often considered expert observers of classroom relationships but as outside observers they lack direct knowledge of the existence of relationships there is variation in how children perceive their classroom social networks and reciprocated selfreported relationships are often only moderately correlated with peerreported relationships lacking direct knowledge peers must use environmental cues as markers to infer the likely existence of relationships in middle childhood childrens conceptions of friendship include expectations of demographic similarity participation in common activities or physical propinquity thus we hypothesize that peers are more likely to infer a relationship exists between two other children who are both boys or both girls both have positive academic orientation both have athletic ability or sit near one another in class not all dimensions of proximity are equally visible to peers similarity in sex or proximity in classroom seating is readily observable whereas similarities in behavioral characteristics are less obvious visible dimensions of social and spatial proximity may play a particularly important role in peerinferred relationships in middle childhood when children tend to focus on concrete characteristics when conceptualizing friendship demographic similarity and physical propinquity emerge as expectations of friendship in middle childhood but children are less likely to invoke complex intangible characteristics like loyalty commitment and trust thus we expect differences in the effects of proximities on the existence of real and inferred relationships first we hypothesize that proximity along more highly visible dimensions more strongly predicts the existence of inferred than real relationships second we hypothesize that proximity along more highly visible dimensions more strongly predicts the existence of inferred relationships than proximity among less visible dimensions finally we hypothesize that the proximities under consideration predict inferred relationships better than real relationships because inferences are based on observable cues while the formation of real relationships is driven by multiple complex processes across grades children consistently have more samesex friends but less is known about whether associations between other proximities and real relationships differ through middle childhood associations between proximities and inferred relationships may change as children become increasingly likely to agree with peers in their perceptions of the classroom network and change their conceptions of what constitutes friendship associations between proximities and inferred relationships may also differ by the inferrers sex but evidence is mixed on whether girls have more accurate social perceptions thus we explore whether the associations between proximities and real and inferred relationships vary by grade in middle childhood or by the sex of inferrers method setting and sample data were collected in five urban public elementary schools in the midwestern united states among 682 students in second through fourth grade classrooms across these schools 426 had active parental consent and assent yielding withinclassroom response rates ranging between 45 and 92 classroom response rates did not differ by grade the sample included roughly equal percentages of girls and boys and across the 2 nd grade 3 rd grade and 4 th grade because most participants were african american and free or reduced price lunch eligible we include only children with both characteristics to avoid variance error data from participating students were analyzed dyadically within classroom resulting in a final sample of 2695 pairwise combinations procedure participants completed two inclass surveys constructed using class rosters one survey used css to collect selfreports of who the participant hangs out with often and inferences about who each classmate hangs out with often following previous uses to examine elementary school peer relationships another survey used peer nominations to measure participants perceptions of their classmates behaviors the lead researcher read each behavioral descriptor and asked participants to circle the names of classmates who fit that descriptor participants were not limited in the number of classmates they could circle measures relationshipsa real relationship is present between two children a and b when both a reported hanging out often with b and b reported hanging out often with a viewing such relationships as real is warranted because the reports are crossvalidated and provided by the only individuals to have direct knowledge of its existence an inferred relationship is present between two children a and b when more than 50 of these childrens participating peers reported they hang out often sensitivity tests indicate that other thresholds yielded similar results and do not impact the findings and conclusions proximitiesthe binary variable samesex is coded 1 when the teacher reported that both members of a dyad are of the same sex the binary variable bothsmart is coded as 1 when both members of the dyad were nominated by an aboveclassroomaverage number of their peers as smart and do ing good work in class the binary variable bothsport is coded as 1 when both members of the dyad were nominated by an aboveclassroomaverage number of their peers as good at most sports and games the binary variable sitsnear is coded 1 if one or both members of the dyad indicated they sit next to each other results descriptive analyses the sample is composed of withinclassroom pairwise combinations of children table 1 presents means and tetrachoric correlations table 2 compares the presence and absence of real vs inferred relationships peer inferences are accurate in 80 of cases however in 6 of cases peers infer that a real relationship exists when it does not while in 14 of cases peers infer that a real relationship does not exist when it does children in each grade made inferences with similar accuracy 802 in 2 nd grade 795 in 3 rd grade and 806 in 4 th grade but girls made slightly more accurate inferences than boys logistic regression models predicting childrens real and inferred relationships table 3 reports the results from two logistic regression models estimated for the entire sample statistical significance was assessed using grouped dyadic standard errors which corrects for bias due to clustering by classroom and dyad testing h3 the column labeled ri reports a test of significant difference between the real and inferred coefficients testing h4 within the model predicting inferred relationships shared subscripts identify significantly different pairs of coefficients based on nonoverlap of their 95 confidence intervals we find that all four dimensions of proximity are significant positive predictors of real and inferred relationships children are more likely to have a real relationship and peers are more likely to infer the relationship exists when they are the same sex sit near one another are both smart or are both good at sports comparing the magnitudes of these coefficients across the two models we find partial support for h3 consistent with our hypothesis sex similarity more strongly predicts inferred relationships than real relationships samesex children are nine times more likely to have a real relationship but peers are more than 50 times more likely to infer they have a relationship in contrast to our hypothesis physical proximity does not predict inferred relationships more strongly than real relationships comparing the effects of different dimensions of proximity on inferred relationships we find partial support for h4 consistent with our hypothesis we find that sex similarity plays a significantly larger role in childrens inferences about the existence of relationships than any other dimension of proximity sex similarity leads peers to be 50 times more likely to infer a relationship exists between two children while other dimensions of proximity are associated with only a 23 times greater likelihood of such an inference contrary to our hypothesis we do not find that spatial proximity plays a larger role than other dimensions finally these two models abilities to predict the presence of peer relationships can be compared by examining the area under their receiver operating characteristic curves which ranges from 05 for a nonpredictive model to 1 for a perfectly predictive model comparing the two models rocareas we find that proximities are more useful for predicting inferred relationships than real relationships lending support for h5 to consider whether these patterns are consistent across grades in middle childhood and by the inferrers sex we repeated these analyses within subsamples we find generally identical patterns in these subsamples the only exception is that while sex similarity more strongly predicts inferred relationships than real relationships among 3 rd and 4 th grade children there is no difference for 2 nd grade children we find no betweengrade differences in predictors of real relationships or of inferred relationships although withinclassroom response rates vary in our sample sensitivity tests confirmed that response rates are not associated with the presence of real or inferred relationships and do not impact the findings specifically we repeated each of the above analyses separately examining classrooms with below 75 participation and those with at least 75 participation the coefficients in models predicting real relationships are unchanged while coefficients in models predicting perceived relationships vary slightly however in all cases the pattern of magnitudes and the results of all statistical tests and contrasts remain the same discussion confirming prior research real and inferred relationships were more likely between children who were socially and spatially proximate real and inferred relationships were more likely between children of the same sex reflecting recognized preferences in middle childhood to form samesex peer relationships and beliefs that peers prefer samesex play partners moreover real and inferred relationships were more likely between children who shared a positive academic orientation or athleticism suggesting that shared behaviors may be linked to opportunities for children to form relationships and for their peers to observe these relationships finally consistent with the link between physical propinquity and childhood relationships real and inferred relationships were more likely between children who sat next to one another in class sex similarity plays a key role in peers inferences about their classmates relationships it had a much larger effect on inferred than real relationships and also had a much larger effect on inferred relationships than any other dimension of proximity this suggests that peers rely heavily on sex as a highly visible marker to infer the existence of relationships such heavy reliance on this characteristic may lead peers to overestimate the importance of sex similarity in relationships and to incorrectly perceive the social structures surrounding them seating proximity although presumably also highly visible did not play a similarly key role unlike sex similarity which is immutable seating proximity may change periodically making it less visible additionally because classroom seating is often assigned rather than chosen children may not weight this information as heavily the small set of proximities in this study more accurately predicts inferred relationships than real relationships this is consistent with the notion that in middle childhood peers make inferences about relationships using a relatively limited set of observable markers while in contrast real relationships are driven by a larger more complex set of factors thus although proximity markers offer children heuristics to navigate their social worlds they do so at the expense of accuracy only one grade level difference emerged in the findings 3 rd and 4 th grade children overemphasized sex similarity in their inferences about peer relationships while 2 nd grade children did not this mirrors prior developmental research which has found that children started including demographic similarity as a feature of their expectations about friendship in the third grade and that childrens conceptions of peer relationships become increasingly sexdifferentiated although girls were slightly more accurate in their inferred relationships than boys no differences emerged in the role of proximities by the inferrers sex adding to the already mixed literature on sex differences in social perception while findings regarding real relationships confirm past work findings regarding inferred relationships advance theoretical understandings of how proximities shape childrens social perceptions children may take cognitive shortcuts in inferring peer relationships relying heavily on sex similarity as a marker this has realworld implications because childrens ability to accurately infer peer relationships is important for promoting positive social adjustment and school functioning given high levels of sex segregation in middle childhood using sex similarity as a marker may be adaptive because it provides an easy and often correct proxy for the existence of peer relationships however it can also lead to errors in judgment that compromise childrens ability to navigate peer relationships more research is needed to examine how childrens use of proximity markers help or hinder their social adjustment and school functioning this study also has practical implications for methods in research on peer relationships touted as alternatives to selfreport methods in the case of limited response rates peerreport methods of collecting classroom relationship data like css and scm are widespread these methods assume that peers are capable of describing much of the basic information about the social structure in their classroom but our results suggest peers overestimate the effect of sex similarity which can lead them to make erroneous reports about who is affiliated with whom analysis of peerreported data may lead to inflated estimates of sex segregation in the classroom and researchers using these methods should be cognizant of how peers use of proximity markers may distort data on peer relationships girls more accurate inferences also suggest considering the sex composition of peer reporters these results should be interpreted within the context of some limitations first the homogeneity of the sample prevented examining the impact of race social class or longerrange developmental trends on classroom relationships second although sensitivity tests revealed that results did not vary by classroom response rates we note that some of these rates were low and may limit measurement accuracy third the crosssectional design prevented determining the direction of associations nonetheless in some cases there are good reasons to assume directionality time ordering requires that sex similarity is a cause and not effect of relationship formation and because teachers assigned classroom seating the same is likely true for spatial proximity fourth we examined only academic and athletic dimensions of behavioral similarity but other dimensions like prosociality may also be important finally this study only examined hanging out relationships replication studies are needed to determine whether proximities operate similarly for other affiliative relationships research for supplemental research funding we also thank marc s atkins for his support of this research and all of the participants in this project q area under the receiver operating characteristic curve

using social network data this study examines which features of social and spatial proximity predict selfreported or real and peerreported or inferred relationships among 2695 pairwise combinations of african american second through fourth grade students ages 711 relationships were more likely to exist and more likely to be inferred to exist by peers between pairs of children who were the same sex sat near one another shared a positive academic orientation or shared athletic ability sex similarity had a dramatically larger effect on peers inferences about relationships than on selfreported real relationships suggesting that children overestimate the importance of sex in their inferences about relationships results were stable across different grade levels in middle childhood and for boys and girls

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introduction when the computerbased wave of rationalization hit industry trade business and the public sector during the 1970s and the 1980s many occupational groups feared they would lose control of their work and eventually their jobs the microelectronics revolution during the mid1970s transformed the job made by graphic workers 12 many of them lost their jobs and especially in the united states and great britain extinction threatened the very existence of the occupation in the anglosaxon countries the counterstrategies developed by organized labor were in general ludditian ie characterized by a resistance towards technological change 3 4 5 this paper demonstrates that the responses articulated by the labor movement in the nordic countries developed along a different path the nordic trade unions argued that if new technology could be developed on the premises of workers it would be possible for them to keep their occupations by investigating the conscious counterstrategies elaborated by nordic trade unions and politically radical computer scientists during the 1970s and 1980s this paper shows that they aimed to organize themselves with the help of technology rather than against technology particular attention will be paid to the utopiaproject and its attempts to develop computer hardware and software for the graphic industries the important contextual elements discussed are the altering notions of technological change during the postwar period the question and old dream of industrial democracy the strong welfare states and longlasting social democratic rule in the nordic countries and the belief in allegedly nordicscandinavian values such as consensus participation and democracy the utopiaproject the utopiaproject was a nordic research project on trade union based development of and training in computer technology and work organization especially text and image processing in the graphic industries 1 it occurred between 1981 and 1986 utopia was an acronym in swedish for training technology and products from a skilled workers perspective utbildning teknik och produkt i arbetskvalitetsperspektiv utopia was conducted in close cooperation with the nordic graphic workers union at the swedish center for working life the royal institute of technology in stockholm sweden and aarhus university in denmark the project received the majority of its funding from the swedish center for working life and the national board for technical development 6 two different social groups were brought together in the project on the one hand system designers computer scientists and workefficiency experts and on the other activists and officials from unions representing some 120000 printers typographers lithographers and other skilled workers in the newspaper and printing industries of the five nordic countries the combination of politically radical scientists and graphic workers unions was probably decisive for the outcome of the project about fifteen people participated in the project the nordic graphic workers union appointed a group consisting of representatives from denmark finland norway and sweden who followed the project at various stages the project cooperated with the swedish stateowned publishing company and computer supplier liber and its development project text and image processing system the swedish social democratic newspaper aftonbladet and the danish independent centerleftist newspaper information that was owned by its coworkers between 1970 and 1986 6 obviously utopia developed in a very particular setting stateor unionowned companies and cooperatively owned newspapers agreed either to support the project financially and ideologically or to participate as customers without this complex of government agencies the realization of the project would probably not have occurred technology as ideology the norwegian mathematician and computer scientist kristen nygaard who worked at the norwegian defense research agency and later at norsk regnesentral inspired the researchers in the utopiaproject originally liberal in his views he was influenced by the social movements of the 1960s and engaged himself politically to the left his interests moved toward the social consequences of computerization together with olav terje bergo he cooperated in the early 1970s with the norwegian iron and metal workers union on a project that dealt with planning control and data processing in enterprises from the perspectives of the employees 7 another important source of inspiration was harry bravermans seminal book from 1974 on the degradation of work labor and monopoly capital which was translated into swedish in 1977 89 the njmfproject received a couple of nordic successors in the 1970s the danish dueproject and the swedish demosproject demos an acronym for demokratisk styrning och planering took place between 1975 and 1980 as a form of cooperation between the swedish center for working life and a number of trade unions it dealt with planning control and the use of computers from a wageearner perspective aiming to accumulate knowledge for the union movement 10 like its precursors utopia was an explicitly ideological project from the outset the research program for the project from 1980 stated the experience gained by organized labor and the research conducted by trade unions during the 1970s into the ability to influence new technology and the organization of work at local level highlighted a number of problems one fundamental experience gained is that the degrees of freedom available to design the content and organization of work utilizes existing technology is often considerably less than that required to meet trade unions demands or expressed another way existing production technology more and more often constitutes an insurmountable barrier preventing the realization of trade union demands for the quality of work and a meaningful job 11 p 255 according to its participants technology was an expression of the sort of society in which we live it was valueladen and the participants argued that existing technology and new technology largely reflected corporate interests instead of the interests of workers hence it constrained the demands of workers and trade unions in contrast to the trade unions earlier defensive strategies for coping with technological change the participants in the utopiaproject worked with a yet untried offensive strategy the trade unions themselves were supposed to develop alternative technologies that mirrored the interests of trade unions rather than the ones of corporations the trade union movement itself draws up the technological and training alternatives and takes the sole responsibility for their implementation and development at local level 11 p 256 thus the aim with the utopiaproject was to help unions translate their social values regarding the job skills quality of work and quality of products into new computer hardware and software for the printing industry its participants held a strong belief that technology largely shaped working conditions the underlying notion of technology being deterministic led them to argue that it was crucial for workers to develop and control alternative technologies altering notions of technological change the concept of technological determinism ruled during the postwar period however as pointed out by david edgerton we should distinguish it from the notion of technology as autonomous as outofcontrol an important theme in western thought during the 1950s and the 1960s 1213 thus the trade unions and the utopiaproject questioned the inevitability of technological change not the technological determinism in social change per se on the contrary utopia presupposed a soft technological determinism 14 p 2 the point of departure for the project was that technology largely shapes the workers conditions in the following the paper will examine the governing social democrats and the labor movements approach to technology and technological change during the postwar period already in the arbetarrörelsens efterkrigsprogram from 1944 a joint labor movement program set up by the social democrats and the swedish trade union confederation a growing technological optimism could be sensed it was through technological progress that material and social welfare should be reached the socalled rigoletto conference organized by the social democrats in 1955 with participating scientists technicians and politicians as well as representatives for trade and industry received public attention it resulted in the publication tekniken och morgondagens samhälle and manifested an optimistic belief in technology and science 15 this belief was established as a supreme ideology an ideology above all other ideologies an ideology that unified all the existing political ideologies it was also reflected in the discourse on the death of ideologies that took place in the western world during the mid1950s 16 the notion of technological change as autonomous was strong thinking in the inevitability of technological progress there was no need for considering alternative directions there was only one way to go the overall strategy was total adaptation to the demands of the assaulting technology people understood that technology determined social change thus both the belief that technology is autonomous and the belief that technology is largely deterministic in its character existed side by side trade unions largely shared this approach for example the trade union confederation adopted a rationalization friendly approach ie a strategy of adaptation towards technological change 17 p 355 in the aftermath of the boom years of the 1950s and the 1960s came the crisis of the 1970s technology changed from a promise to a threat the rationalization that followed technological change did not produce prosperity to the same extent as before instead it increasingly made workers redundant and ultimately led to unemployment a broad spectrum of political organizations and interest groups began to question the inevitability of technological change it was almost as a discovery technology is political instead of adapting ourselves to the inevitable technological progress they argued we should choose technology thus choose our future we should take control over technology in order to take control over work etc 18 a very strong labor movement expanded its ambitions from wage negotiations into changing work organization and eventually technology 19 for instance the trade union confederation established a committee for computing in 1976 the workers educational association it conducted courses on the role of computers in social change the social democratic party presented an action program on computers and politics 20 21 22 23 24 25 they movedin their own words from a defensive to an offensive strategy instead of being the passive object of automation they argued that the worker should be an active subject in shaping technological change tage erlanders computer symposium became an important political manifestation of this new posture the symposium took place in 1980 at the social democratic residence bommersvik and resulted in among other things the publication datorerna och samhällsutvecklingen this labor movement summit conference consisted of participants such as the social democratic party secretary sten andersson the president of the swedish confederation of professional employees lennart bodström the member of the social democratic party executive kjellolof feldt the secretary for the swedish trade union confederation rune molin hans gustafsson anders ferm as well as the social democratic icons such as former prime minister tage erlander and former minister for finance gunnar sträng 26 the wellknown finnish philosopher georg henrik von wright opened the symposium with a reflection over man technology and the future he drew the attention to the profound social consequences of modern technology and thus addressed the overall themes of the conference what social consequences does technological change have of special concern at the conference were the effects of technological change on employment given the profound consequences of technology who influenced and controlled technological change was it possible to control the progress of technology or was humanity forced to adapt itself to this development different visions and strategies for confronting technological change were suggested the participants from trade unions such as rune molin emphasized that trade unions had to take command over technological change another participant demanded offensive decisions in short the employees needed to create their own alternatives 26 thus during the 1970s it is possible to discern a shift in the notion of technological change from a belief that it was autonomous and outofcontrol towards a belief that it is controllable however the notion that technological change determined social change was as strong as before it also was a very important incentive for the trade unions to take control over technological change it is in this vein that we should understand the attempts of the scandinavian labor movement to take control over work organization and technology and consequently projects such as njmf demos due and above all utopia industrial democracy reborn henry fords assertion that democracy stops at the factory gates strikingly illustrates a problem that gained attention during the 1920s in connection with the wave of democratization that swept through europe after world war i it dealt with the employees influence in companies after the seminal saltsjöbaden agreement in 1938 between the swedish trade union confederation and the swedish employers confederation the question gained renewed attention the socalled swedish model was established during the 1930s and the 1940s and it became a role model manifesting technological optimism during the boom years of the 1950s and the 1960s 2728 the social conflicts that arose at the end of the 1960s politized the industrial rationalization and the swedish model was questioned by the trade unions who protested against the overprofits made by corporations which they claimed did not sufficiently reach the employees as a response the powerful social democratic party carried through a number of legislations during the 1970s that considerably strengthened the position of the employees in private companies for instance a law concerning the right of participation in decisionmaking the codetermination act was legislated in 1976 and in the wake of these many reforms the question of industrial democracy called for attention once again 20 pelle ehn utopias project leader rephrased fords assertion as democracy stops at the office door and the factory gate 29 the attempts to revitalize the question of industrial democracy had important parallels in other scandinavian countries norway was pioneering with its program for industrial democracy during the 1960s and a number of experiments in work organization were completed similar attempts took place in denmark where several experiments in industrial democracy were conducted between 1969 and 1973 it should be noted that this trend is also discernible outside scandinavia and particularly in west germany which among other things carried through a similar codetermination act in 1976 3031 in conjunction with passing the codetermination act the swedish parliament decided in june 1976 to establish a research institute with the purpose of bringing the research community and trade unions together the work environment fund 2 based on a wage tax paid by all employers financed the swedish center for working life 32 one of the aims of the center was to promote democracy in working life and the concept of industrial democracy so to speak was built in its regulations 33 p 9 p 13 furthermore it edited the international quarterly journal economic and industrial democracy published by sage publications starting in 1980 the center for working life carried out three big research projects dealing with trade unions and development of technology and organization demos utopia and front 34 in the statutes of the center for working life it legislated that the research conducted should not consist of traditional reflective analytic social science instead it should take the form of action research where the researchers contribution as well as the reporting should be highly dependent on the actions of local parties 33 p 12 the argument supported by the center for working life was that trade unions needed to develop independently knowledge in order to shape technology and work organization actively the center took a seminal role in the demos and utopia projects 33 to conclude this section the 1970s and the first half of the 1980s was a period when powerful trade unions made several attempts to realize the old dream of economic or industrial democracy through a number of governmental decisions several new institutions with affinities to the labor movement such as the work environment fund and the center for working life took place on stage and quickly gained in strength a statesupported complex giving voice to the demands of the labor movement was established and it became an important prerequisite for projects such as demos and utopia democracy by design a technology laboratory where researchers and workers worked closely together was established at the swedish center for working life the american robert howard reviewed utopia for the mitbased journal technology review and was amazed at what he saw when visiting the laboratory he reported that it could be a research department at any hightech manufacturer instead the lab belonged to the governmentfunded swedish center for working life in stockholm and he described the scene where graphic workers and computer scientists sat side by side as an intriguing experiment in technology development 1135 one of the more important results was the publication of requirement specifications in 1983 the requirement specifications acted as guidelines for what workers should require of new technologies or organizations when introduced and they were used in collective bargaining and local negotiations 36 the utopiaproject presented its results at a conference in may 1984 at the social democratic youth leagues residential study center bommersvik 11 p 259 the choice of place symbolized and manifested the strong connections with the labor movement during the latter half of the twentieth century the bommersvik residence was a political and cultural center for the swedish labor movement should the utopiaproject be evaluated as a success or as a failure according to the researchers the project led to a successful conclusion as a single demonstration example it demonstrated that alternative technological and organizational solutions for newspapers could be developed which gave possibilities for graphic workers to improve their skills and keep their jobs the participating researchers nurtured a dream that the project would contribute to a new scandinavian model for technological development however as they later pointed out the lack of trade union cooperation put an end to this dream 6 11 p 260 nevertheless as a project on participatory design it must be considered seminal it gave rise to the socalled scandinavian school of system development where the users participation in system development has become a key element 37 moreover quite interestingly an observer noted in 1990 that graphic workers in sweden had managed to keep their occupations to a considerably higher extent than in the p lundin anglosaxon countries 28 to sum up the counterstrategies against a computerbased wave of rationalization developed by the nordic trade unions differed fundamentally from those articulated by trade unions in the anglosaxon countries

by using the utopiaproject as an example this paper highlights the role of the nordic labor movement in technological change and underlines that there are different incentives for technological change while corporations developing technology usually pursued increased efficiency in production the utopiaproject aimed at other alternative goals such as translating social values regarding job skills quality of work and quality of products into new computer hardware and software for the graphic industries in the larger context the utopiaproject can be seen as an attempt by the labor movement to revitalize and realize the old dream of industrial democracy by designing computing technology

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introduction the ministry of education and culture in indonesia offers higher education affirmation scholarships through the governments affirmation of education program these scholarships are part of the governments affirmation of education program which aligns with constitutional programs and initiatives aimed at ensuring equal educational opportunities under the supervision of kemendikbud the adik program specifically targets high school graduates from frontier outermost and lagging regions with the goal of enabling their participation in higher education by providing financial support and access to educational resources the adik program strives to empower students from these regions and bridge the educational gap between different parts of the country the implementation of the affirmation of education program aims to ensure the participation of racial and ethnic minorities in higher education it requires an academic environment that is tolerant of minority groups and academic achievements that enhance the quality of resources among minority groups this program is expected to improve education standards and quality of life thereby accelerating equitable development particularly in the papua region and the 3t areas which have faced challenges in accessing education and competing with other regions papua island and the 3t areas have been the focus of the papuan education affirmation program due to various challenges these challenges include geographical obstacles underdeveloped infrastructure and limited economic capacity all of which demand significant human resources these regions also face issues such as poverty unemployment and social conflict which are exacerbated by the low quality of education consequently high school students from papua and the 3t regions find it difficult to compete with students from other areas on the snmptn and sbmptn pathways resulting in limited access to higher education especially in state universities while the adik papua and 3t region programs have successfully affirmed over 3000 students in various educational institutions throughout indonesia from 2012 to 2018 several challenges have emerged for the students enrolled in the program it is evident that many of these students require assistance to adapt to the academic environment experience low motivation and are prone to academic stress which often leads to requests for study program changes or even discontinuation of studies these issues indicate that migrant students particularly affirmation students encounter various obstacles that hinder their academic achievements numerous studies have highlighted the problems faced by migrant students including mental health issues academic stress difficulty adjusting limited social interactions low selfconfidence and financial challenges social support plays a crucial role in student wellbeing academic achievement adaptability and social relationships given the significance of the higher education affirmation scholarship for indigenous papuans and the aim to increase equity in access to quality education improve human resources and enhance the quality and empowerment of papuan students it is crucial to address the financial barriers faced by these students the provision of scholarships to assist financially constrained students in completing their studies is essential as many papuan students possess strong academic abilities but come from lowincome families and resort to additional work to cover their expenses the scholarship program lasting until students complete their college education enables students to focus on their studies without financial concerns thereby promoting timely graduation this commitment by the government which has gained attention from the governor of papua lukas enembe reflects efforts to develop the papua region this research aims to investigate the relationship between the level of social support and the wellbeing of students enrolled in the adik program and from the 3t areas at the university of indonesia understanding this relationship is essential as affirmation programs are seen as inclusive processes that offer opportunities for participation however it is equally important to examine how students actively engage in the academic environment after being accepted into college therefore the central question of this research is how does the level of social support relate to the wellbeing of students enrolled in the adik program and from the 3t areas at the university of indonesia literature review social support and student wellbeing several studies have examined the relationship between social support and student wellbeing lee et al conducted a study on high school students in chicago and found that those who received high levels of instrumental and emotional social support achieved better academic outcomes lee et al conducted a study on high school students in chicago and found that students who received high levels of instrumental and emotional social support achieved better academic outcomes this finding was supported by maslihahs research conducted at smpit assyfa boarding school in subang west java which revealed a positive impact of instrumental and emotional support from the school on student academic achievement these studies demonstrate the influence of social support on wellbeing specifically in terms of academic performance moreover oreilly et al investigated the experiences of american students studying at larga irist university and concluded that social support particularly social acceptance facilitated students ability to adapt to their new environment sullivan and kashubeckwest highlighted the importance of social support for students in the midwestern united states who faced stressors that hindered their social interactions social interaction with the community plays a vital role for migrant students as it fosters emotional and psychological comfort these findings emphasize the impact of social support on wellbeing in terms of adaptability and social relationships moreover aprianti emphasized the significance of social support for firstyear students psychological wellbeing and their active participation in college activities similarly demary stressed the importance of social support in shaping students interactions and gaining social acceptance in the learning environment additionally govaris et al revealed that social support particularly from teachers enhances student satisfaction in the learning process these studies highlight the influence of social support on wellbeing specifically in relation to students sociopsychological conditions furthermore stewart and suldo emphasized the role of social support including support from parents teachers and friends in fostering life satisfaction and positive mental states with adequate social support and good mental wellbeing students exhibit resilience which includes the ability to balance academic commitments with other responsibilities maintain a good gpa overcome educational obstacles and manage stress these findings further illustrate the impact of social support on wellbeing particularly in terms of students mental conditions student wellbeing several factors influencing wellbeing have been identified by the center for education statistics and evaluation including a safe environment connectedness learning engagement social and emotional learning and a whole school approach moreover according to the ottawacarleton district school board student wellbeing is connected to having a positive sense of self and the capacity to make constructive choices that promote learning and achievement the ocdsb emphasizes that an improvement in student wellbeing leads to enhanced participation in social activities furthermore the ottawacarleton district school board highlights the association between student wellbeing and a positive sense of self as well as the ability to make constructive choices that facilitate learning and achievement the ocdsb emphasizes that enhanced student wellbeing enables individuals to actively participate in social activities furthermore fraillon highlights the importance of the social context within schools in shaping student wellbeing as it provides a framework for social conditions that significantly impact students student wellbeing is often defined by the school community in terms of a sense of belonging participation influence values and shared experiences based on these definitions it can be concluded that student wellbeing encompasses a positive selfperception and the ability to achieve educational objectives particularly within the school environment it is important to note that academic success alone does not determine student wellbeing it also includes the capacity to establish positive relationships adapt collaborate and actively engage in various activities to support learning objectives in research student wellbeing is often assessed using the three dimensions proposed by the ottawacarleton district school board physical wellbeing socioemotional wellbeing and cognitive wellbeing furthermore mental wellbeing is an essential aspect to consider given students vulnerability to mental health issues social support in measuring social support researchers differentiate social support into five forms according to schaefer et al namely emotional support esteem support network support information support and instrumental support emotional support is defined as a form of communication to meet affection needs that contain expressions of empathy and concern appreciation support is defined as a form of communication to uphold individual confidence regarding their ability to handle problems obtain positive responses to ideas handle and solve problem and task properly network support is defined as a form of communication that characterized by being able to integrate oneself with many other people information support is defined as a form of communication to provide information and support lectures meanwhile instrumental support is defined as a form of communication in the form of material assistance in addition each form of social support is seen as based on the parties involved and has a relationship with student recipients of the program such as parents central government local government academic advisors universities student organizations and college friends analysis models figure 1 analysis model diagram the diagram highlights the various forms of social support that contribute to student wellbeing emotional support characterized by expressions of empathy and concern plays a vital role in meeting students affectionate needs esteem support on the other hand focuses on upholding students confidence and providing positive responses to their ideas and problemsolving abilities network support emphasizes the integration of students with a diverse range of individuals fostering a sense of belonging and a strong social network information support involves the provision of relevant and helpful information to support students academic endeavors lastly instrumental support refers to material assistance that aids students in overcoming financial and resourcerelated challenges the analysis model diagram serves as a comprehensive framework for the research enabling an exploration of the intricate relationship between social support and student wellbeing it considers the specific factors and dimensions that impact the wellbeing of students enrolled in the adik program and originating from the 3t areas at the university of indonesia by understanding this interconnectedness the research aims to shed light on the role of social support in promoting student wellbeing and inform potential interventions to enhance the educational experience of these students method this quantitative study examines the relationship between social support and the wellbeing of migrant students enrolled in the affirmation education program in papua and the 3t region it adopts a crosssectional design to explore the impact of social support on student wellbeing within a specific timeframe a comparative analysis with similar studies is not included the research was conducted at the university of indonesia where the affirmation education program is implemented the study population comprised active students from the 20122017 classes who were enrolled in the adik program in papua and the 3t region during the odd semester of the 20172018 academic year a nonprobability sampling method was employed to select a sample of 34 active students ensuring representation from each generation data collection occurred from january to march 2018 utilizing surveys and indepth interviews the survey questionnaire consisted of closedended questions capturing information on respondent characteristics and their perceptions of the variables under investigation the survey was administered to the selected 34 students and the collected data were analyzed using spss indepth interviews were conducted with six students purposively chosen based on their location and ethnic background these interviews aimed to provide deeper insights into the survey findings and were carried out in person following interview guidelines the interview transcripts were subjected to coding and narrative compilation for analysis to ensure data validity a pretest was conducted on the questionnaire instrument prior to data collection the instrument demonstrated reliability and validity with a cronbachs alpha score exceeding 060 and the data exhibited a normal distribution according to the kolmogorovsmirnov test these results affirm the statistical processability of the data in summary this study employed a nonprobability sampling method to select a sample of 34 active students from the population of migrant students enrolled in the adik program in papua and the 3t region at the university of indonesia data were collected through surveys and indepth interviews and analyzed using spss the questionnaire instruments reliability and validity were confirmed through a pretest results the objective of this research is to explore the correlation between the level of social support and the welfare of students enrolled in the adik program and originating from the 3t area at ui in order to achieve this goal a comprehensive data collection process was conducted encompassing various variables these variables included the year of college entry the gender of the respondents the geographical area from which they originated their respective faculty affiliations and their places of residence moreover the study also took into account the student achievement index which served as an indicator of academic performance as well as the identification of different dimensions of welfare and social support variables to analyze and interpret the gathered information regression tests were performed upon analyzing the collected data it is evident from the diagram that the respondents consisted of individuals from the 2013 to 2017 batches notably the largest proportion of respondents were from the 2015 and 2016 batches comprising approximately 3550 of the total sample following that the 2017 batch constituted 1470 of the respondents while the 2013 batch accounted for 880 comparatively the 2014 batch had the smallest representation with only 590 of the respondents originating from this group it is worth highlighting that the sampling process ensured a distribution of participants across multiple academic years capturing a comprehensive representation of the student population in summary this research explores the relationship between social support and student welfare in the context of the adik program and the 3t area at ui through a meticulous data collection process including the examination of various variables the study aims to provide valuable insights into the experiences and wellbeing of students enrolled in the program 3240 6760 male female figure 3 respondent distribution by gender according to the data presented in figure 3 the majority of respondents were female accounting for 6760 while males constituted only 3240 of the total sample this distribution highlights a clear gender disparity among the respondents the skewed distribution highlights the need to explore and understand the potential implications of this gender imbalance in the context of the study being conducted 4 the distribution of respondents varied across different provinces the province with the highest number of respondents was nanggroe aceh darussalam accounting for 2350 papua had the secondhighest number of respondents at 1470 followed by east nusa tenggara with 1180 three provinces namely west kalimantan maluku and west sumatra each contributed 8800 of the respondents additionally banten southeast sulawesi and north sumatra accounted for 580 of the respondents while the provinces of west papua and the riau islands had the lowest representation with only 290 each in this analysis it is important to note that the distribution of respondents across provinces provides insights into the geographical representation of the participants in the study however the focus of this research lies in examining the impact of the adik program on indigenous papuans and students from the 3t areas rather than analyzing regional differences therefore while the distribution of respondents offers contextual information the main objective remains to explore the relationship between social support and wellbeing among students enrolled in the adik program at the university of indonesia 290 1180 1470 3240 1470 880 290 590 590 figure 5 respondent distribution by faculty the analysis of respondent distribution as depicted in figure 5 reveals that participants were selected from various faculties at the university of indonesia the highest representation comes from the faculty of engineering accounting for 3240 of the respondents following closely are the faculty of mathematics and science and the faculty of economics and business each with 1470 of the participants the faculty of dentistry comprises 1180 of the respondents while the faculty of public health faculty of nursing and faculty of pharmacy account for 880 and 590 each respectively the faculties with the lowest participation rates are the faculty of medicine and the faculty of computer science both at 290 it is worth noting that the absence of respondents from other faculties was primarily due to the lack of active students during the research period and the limitations imposed by the studys timeframe to further understand the living arrangements of the respondents figure 6 presents a diagram illustrating their distribution based on their place of residence during their time in college the diagram reveals that the majority of the respondents accounting for 5290 lived in student dormitories at the university of indonesia on the other hand approximately 4710 of the respondents resided in boarding houses this distribution sheds light on the varied housing situations among the participants which may have implications for their college experiences and social interactions the distribution of respondents based on the student achievement index is illustrated in figure 7 the diagram reveals that the majority of respondents accounting for 5290 have a student achievement index ranging from 301 to 350 additionally 3820 of respondents fall within the 251300 range while 590 achieve a gpa between 351 and 400 furthermore a small percentage of students approximately 290 demonstrate a student achievement index of 151200 the diagram presented in figure 7 provides valuable insights into the distribution of student achievement levels based on their gpa the results indicate that a significant portion of respondents falls within the 301350 range suggesting a relatively consistent academic performance among the student population this finding could have implications for various stakeholders involved in the educational system one notable implication is that educators and policymakers should focus on maintaining and improving the performance of students who fall within the 301350 range while their achievement is commendable efforts should be made to further enhance their academic abilities and foster an environment that encourages continuous growth by providing additional support resources and tailored interventions educational institutions can contribute to the overall educational advancement of these students another implication arises from the relatively lower percentage of students achieving gpas above 350 this finding highlights the need for targeted interventions to support highachieving students and provide them with opportunities for advanced learning and enrichment by nurturing and challenging these students educational institutions can ensure that their full potential is realized leading to broader intellectual development and potentially bridging the achievement gap between different groups of students conversely the relatively small percentage of students scoring below 300 raises concerns about academic underachievement this finding suggests a need for interventions and support systems to assist students who may be struggling academically by identifying and addressing the factors contributing to their lower gpa such as learning difficulties or lack of access to resources educators can provide targeted support and interventions to help these students improve their academic performance and overall wellbeing based on the data presented in figure 8 which was obtained by the researchers it can be observed that students receiving the affirmation program generally have a good quality of life and academic support during their studies as indicated by the average wellbeing score of 647 further analysis of the measurements reveals that each dimension of wellbeing shows relatively similar scores however it is noteworthy that the mental wellbeing dimension had the lowest score of 550 indicating a more severe condition compared to the other dimensions namely physical wellbeing socioemotional wellbeing and cognitive wellbeing this study also examines the various forms of social support provided to students including emotional support appreciation network support information support and instrumental support by analyzing these forms of support the researchers have identified the parties responsible for fulfilling this social support figure 9 presents the data collected from the survey conducted the data in figure 9 obtained by the researchers highlights the significant dependence of student social support on the specific forms of support and the parties involved in providing that support among the five types of social support received by students network support emerges as the most prominent with a score of 713 in contrast the other forms of support received slightly lower scores emotional support award support information support and instrumental support the implications of this research are twofold firstly it sheds light on the overall wellbeing of students enrolled in the affirmation program indicating a generally positive quality of life but with room for improvement in mental wellbeing these findings emphasize the need for targeted interventions and support systems to address mental health challenges faced by these students secondly the analysis of social support indicates the importance of network support in assisting students highlighting the significance of fostering strong social connections and community engagement within the educational environment in conclusion this study provides valuable insights into the wellbeing and social support experienced by students enrolled in the adik program by identifying areas that require attention educational institutions and policymakers can develop strategies to enhance the overall wellbeing of these students and promote their academic success the regression test conducted in this study reveals a constant value of 89217 furthermore the significance and beta values are as follows table 1 relationship test according to the research findings a 95 confidence level reveals that student wellbeing is influenced by three variables emotional support network support and informational support however the remaining variables reward support and instrumental support did not demonstrate a significant effect the statistical analysis indicates that emotional support network support and informational support play crucial roles in shaping student wellbeing the significance levels of 0003 0005 and 0017 respectively highlight the strong influence of these variables on student wellbeing it is important to consider these findings in the context of the broader implications the results suggest that providing emotional support fostering strong social networks and ensuring access to relevant information are key factors in promoting student wellbeing therefore educational institutions and policymakers should prioritize initiatives that enhance emotional support systems encourage the formation of supportive networks and improve the availability of valuable information for students moreover the nonsignificant effects of reward support and instrumental support suggest that these variables may have limited impact on student wellbeing future studies could delve deeper into understanding the underlying reasons behind these findings and explore alternative approaches to support students in these areas in conclusion the research underscores the significance of emotional support network support and informational support in fostering student wellbeing by recognizing the importance of these variables educational stakeholders can develop targeted interventions that promote a positive and supportive environment for students ultimately enhancing their overall wellbeing and academic success independent variable betas sig emotional discussion this quantitative study aims to investigate the relationship between social support and the wellbeing of migrant students enrolled in the affirmation education program in papua and the 3t region by adopting a crosssectional design the study seeks to examine the impact of social support on student wellbeing within a specific timeframe while a comparative analysis with similar studies is not included in this research the implications of the findings are twofold firstly the study sheds light on the overall wellbeing of students enrolled in the affirmation program indicating a generally positive quality of life but also highlighting the need for improvement in mental wellbeing the findings of the multiple correlation test analysis reveal the relationship between the level of social support and the welfare of students receiving the adik program in the 3t area at ui prior to conducting the multiple correlation test a collinearity test is performed to examine the presence of multicollinearity which refers to the linear relationships between independent variables in multiple regression analysis the collinearity test using tolerance and variance inflation factor values as collinearity statistics shows that there is no collinearity between the independent variables namely emotional support esteem support network support information support and instrumental support this suggests that each variable contributes uniquely to the analysis and strengthens the validity of the results moving on to the multiple correlation test which focuses on the relationship between the level of social support and student wellbeing the coefficient of determination and adjusted coefficient of determination are used as measures of goodnessoffit for multiple linear regression models the obtained rvalue of 0884 indicates the significance of social support in influencing student wellbeing furthermore the r square value of 0781 indicates that the level of social support can explain approximately 7810 of the variation in student wellbeing while the remaining 2190 is attributed to other factors not related to social support these findings underscore the importance of considering additional variables such as religiosity and the students religious group network in understanding student wellbeing religiosity has long been recognized as a significant determinant of happiness wellbeing and better mental and physical health for many individuals in this study observations indicate that migrant students tend to participate in religious groups such as islamic study forums or christian and catholic communities participating in these religious groups provides a sense of routine and comfort for students as well as opportunities for regular social interactions these findings are consistent with previous studies highlighting the positive influence of religiosity on personal wellbeing and life satisfaction moreover the study suggests that the students religious group network and religiosity serve as additional variables that contribute to explaining student wellbeing the influence of religiosity on wellbeing is further supported by research on western religions and traditional religions which shows that religion can both positively and negatively affect an individuals wellbeing the study also reveals that spiritual belief and participation in religious rituals are positively related to academic achievement especially for african american students these findings highlight the mediating role of religious practices in the relationship between religiosity and wellbeing analyzing the specific dimensions of social support the study finds that emotional support has a moderate strength influence on student wellbeing this suggests that higher levels of emotional support contribute to higher levels of wellbeing for students previous research has also emphasized the positive effects of emotional support on wellbeing and health independent of its impact on selfesteem in this study emotional support primarily comes from parents and friends who are identified as the main providers of social support to the students this finding has important implications for student wellbeing as emotional support plays a significant role in facilitating selfmanagement academic achievement and resilience furthermore network support is found to moderately influence student wellbeing the study reveals that students with extensive networks during their college years tend to have higher wellbeing these networks are formed through connections with fellow students in their study programs friends from the same residence regional community friends and religious groups building these networks provides students with a sense of belonging and support allowing them to interact adapt and thrive in the academic environment consistent with previous research the ability to interact and establish social connections positively impacts social acceptance and facilitates students feelings of security and comfort interestingly information support is found to have a negative influence on student wellbeing contrary to the researchers initial hypothesis that higher information support would increase wellbeing this unexpected finding indicates that lower levels of information support are associated with higher levels of wellbeing for the students students perceive formal sources of information such as academic supervisors as too rigid and focused solely on academic matters on the other hand students feel more comfortable when information is conveyed in a concise and straightforward manner however the abundance of information from various sources such as study programs academic supervisors friends student organizations and media sometimes leads to confusion when there are discrepancies in the information provided this finding suggests the need for improved coordination and consistency in disseminating information to students ensuring clarity and minimizing confusion in the larger context the findings of this study contribute to the understanding of the wellbeing of migrant students in the affirmation education program in papua and the 3t region by examining the relationship between social support religiosity and the students religious group network the study highlights the multifaceted nature of factors influencing student wellbeing these findings have important implications for educational institutions and policymakers in designing interventions and support systems that promote the overall wellbeing of migrant students recognizing the positive influence of religiosity and the importance of social support networks educational institutions can foster an inclusive environment that encourages religious participation and facilitates the formation of strong social connections furthermore ensuring effective communication and information dissemination can alleviate confusion and contribute to students wellbeing in conclusion this study provides valuable insights into the relationship between social support and the wellbeing of migrant students in the affirmation education program the findings emphasize the importance of emotional support network support and the role of religiosity and religious group networks in influencing student wellbeing additionally the unexpected negative impact of information support on wellbeing suggests the need for improved information coordination the studys novelty lies in its examination of the unique context of migrant students and its comprehensive exploration of various factors that contribute to their wellbeing the implications of this research extend beyond the immediate study population highlighting the significance of social support and religiosity in promoting student wellbeing in a broader societal context conclusions this study addresses a significant research gap by examining the impact of social support on the welfare of migrant students receiving affirmation scholarships in papua and the 3t region of the university of indonesia the findings shed light on the crucial role of emotional support networking and information in enhancing student welfare interestingly reward and instrumental support were not found to have a significant effect these results emphasize the need for affirmation education programs to go beyond merely offering opportunities and support during the learning process to ensure program success moreover the study underscores the importance of providing emotional support and facilitating networking opportunities as these factors have shown a moderate positive impact on student wellbeing it also highlights the valuable contribution of religious group networks and the influence of religiosity in shaping welfare outcomes however it is important to acknowledge the limitations of the study such as the small sample size and unmeasured variables which may restrict the generalizability of the findings to overcome these limitations and further advance the field future research should delve into the cultural factors that influence social support and wellbeing among affirmed scholarship migrant students by doing so a more comprehensive understanding of the intricate dynamics at play can be achieved ultimately this study emphasizes the significance of providing comprehensive support to students in order to attain the desired outcomes from affirmation education programs the results of this research have substantial implications for policymakers educational institutions and practitioners working in the field of migrant education by recognizing the pivotal role of social support particularly emotional support and networking they can design and implement interventions that better address the unique needs of affirmed scholarship migrant students additionally the findings underline the importance of fostering religious group networks and considering religiosity as an integral aspect of student welfare overall this study makes a noteworthy contribution to the larger area of study by elucidating the importance of comprehensive support in achieving the desired outcomes of affirmation education programs it offers valuable insights and practical implications that can inform future research and guide the development of more effective strategies to enhance the welfare and success of migrant students

migrant students face unique challenges and obstacles in their educational journey particularly in terms of social support and overall wellbeing this study aims to examine the relationship between social support and the wellbeing of migrant students participating in the affirmation of education program adik in papua and the 3t regions using a quantitative approach data was collected from a sample of 34 active students through surveys and indepth interviews the study employed nonprobability sampling ensuring equal opportunity for 66 eligible students the collected data was analyzed using spss and the instruments reliability and validity were established through pretesting the results indicated that migrant students wellbeing scores were particularly low in the area of mental wellbeing regression tests revealed that emotional support network support and informational support significantly influenced student wellbeing while reward support and instrumental support showed no effect additionally the network of religious groups and student diversity were found to play a role in determining student welfare these findings underscore the importance of social support interventions targeting emotional support networking and information to enhance the wellbeing of migrant students in the adik program in papua and the 3t regions future programs and policies should prioritize the development of these aspects to improve the overall welfare of migrant students this study contributes to our understanding of the challenges faced by migrant students and emphasizes the need for inclusive educational initiatives that address their social support needs and promote their wellbeing

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introduction one of the main goals of modern primary education is the formation of abilities and social qualities of individuals the modern world needs proactive sociable people who can actively participate in public life and after graduating from school adapt to rapidly changing living conditions however experience shows that in various educational systems children are left without the appropriate level of support and attention as school education is often not ready to meet the individual educational needs of everyone in the conditions of globalization and religious education in school could be a strong tool for it the main goal of the research is to analyze the content problems and effective methods of organization of religious education in swedish primary schools to determine the learning degree of problems an analysis of scientific publications since 2000 was carried out it was supported by the research system söderscholar this made it possible to search 256 databases including scopus web of science and sage the search was conducted in two languagesenglish and sweden due to specifics of the chosen topic religion education in sweden and history of education for sustainable development in sweden the keywords were determined according to the goal of the research work and related to finding out the way of developing education for sustainable development during religious education in swedish primary schools 13 classes there is a short analysis of articles that deal with different aspects of research below there were a few separated directions of research in which there were illustrations 1 dealing with teachers preparation for esd  teachers interests and instructional practices to actionorientation in education for sustainable development survey results showed that teachers are little interested in actionoriented esd they teach their students how they should behave in their everyday life in relation to sd issues or they engage them into actions towards sd issues 1  comparative analysis of system of preparing teachers for esd in different countries scotland canada australia 2 and germany 3 it makes available insights into problems arising internationally implications for teachers education for sustainable development and suggestions learnings for other countries 2 content methods and tools for esd  displaying ideas of esd in curriculum for different types of swedish schools 4 or comparative practice of it 5  role of digital tools for implementation of esd ideas in learning process 3 practice of esd in primary school  functions of teachers for implementation ideas of esd in primary school 7  practice of teachers to implementation esd in different countries 4 swedish practice of esd  how the international practice of esd is adopted hybridizing with local sociocultural tradition  practice of esd in different areas of teaching and in primary schools also 1011  implementation ideas of esd during extracurricular pupils activities 12 5 features of religious education including in sweden  teachers preparation for religion education 13  background of the question 14  swedish pupils attitude to religious education 15 so as it could be noticed that there is much research dealing with problems of religious education religious education in primary schools and educational potential of religious education for implementation ideas of esd in primary schools but there is no founded scientific research dealing with the history of religious education for pupils sustainable development also the important question is what are the problems with teaching religious education in primary schools religious education in modern primary schools is a very important constituent of the swedish education system and it has the educational potential to form the spiritual moral social and cultural aspects of a pupils personality 16 experts in religious education and primary school education in sweden crain 17 hartwick 18 kortt and drew 19 puskás and andersson 20 jackson 21 sitompul 22 and hakim and ritonga 23 identified lots of issues in this area but five of the main problems were 1 insufficient preparation by teachers misunderstandings and a lack of effective teaching methods 2 ineffective planning in the educational process 3 poor access to educational resources 4 a lack of connection to religious education and context in other subjects and 5 a lack of a proper system for assessing students knowledge and skills findings what is religious education in swedish primary schools the steering document curriculum for the compulsory school preschool class and schoolage educare available from the swedish national agency for education outlines that teaching in religion should aim at helping the pupils develop knowledge of religions and other outlooks on life in their society and other parts of the world using teaching pupils should become sensitive to how people with different religious traditions live and express their religion and belief differently teaching should in a balanced way illuminate the role that religions can play in society both in the pursuit of peace and resolving conflicts to promote social cohesion and as a cause of segregation 24 in other words during religious education pupils should be given opportunities to develop their ability to analyze christianity other religions and other outlooks on life as well as different interpretations and use of these analyze how religions affect and are affected by conditions and events in society reflect on life issues and their own and others identity reason and discuss moral issues and values based on ethical concepts and models search for information about religions and other outlooks on life and evaluate the relevance and credibility of sources 24 also based on the study program content we should notice that few directions provide an adequate educational process level for primary school studentsreligions and other outlooks on life religion society identity and life issues and ethics if students try their best while studying religious education they will have very good knowledge of christianity and the other world religions and show this by explaining and showing the relationship and general patterns in key ideas documents and concrete religious expressions and actions within the religions pupils can also apply welldeveloped and balanced reasoning about how questions of life are depicted in different contexts and how identities can be formed by religions and other outlooks on life in a way that carries the reasoning forward and deepens or broadens it pupils can search for information about religions and other outlooks on life and use different types of sources in a useful way and apply welldeveloped and wellinformed reasoning about the credibility and relevance of their sources 24 primary school teachers should aim to explain the role of religion and faith in daily life and help pupils understand who they are ie identify themselves which leads to understanding basic universal concepts and being tolerant of other peoples beliefs the national syllabi for the swedish school system state that teachers should offer religious education to 79yearold students on topics such as religions and other outlooks on life  key ideas and documents in christianity and the distinctive features of the three main orientations of christianity protestantism catholicism and orthodoxy  key ideas and documents in the world religions of islam judaism hinduism and buddhism  varying interpretations and practices in world religions in modern society  the main features in the historical evolution of world religions  new religious movements new religiousness private religiousness and how this is expressed  secular outlooks on life such as humanism religion and society  the relationship between society and religion in different times and places  the role of religion in some political events and conflicts from a critical perspective  conflicts and opportunities in secular and pluralistic societies such as over issues concerning freedom of religious expression sexuality and views on gender equality identity and life issues  how different life issues such as the purpose of life relationships love and sexuality are depicted in popular culture  how religions and other outlooks on life can shape peoples identities and lifestyles  rites such as baptism and confirmation and their function in forming identity and a sense of community in religious and secular contexts ethics  daily moral dilemmas analysis and argumentation based on ethical models such as consequential and deontological ethics  views of the good life and the good person are linked to different kinds of ethical reasoning such as virtue ethics  ethical questions and the view of people in some religions and other outlooks on life  ethical concepts which can be linked to questions concerning sustainable development human rights and democratic values such as freedom and responsibility 25 modern education offers effective approaches for effective work with primary school students during their learning which could be used during religion classes there are a few didactic models for the organization of students learning which could be used by teachers of religion in primary schools  varkmodel learning which was proposed 26 in 1987 involves the presentation of didactic materials taking into account ways in which humans have learned new information visual auditory read or write and kinaesthetic 27  kolbs model suggested dividing students into four groups accommodation diverging assimilating and converging  david kolb also named four stages of learning 1 concrete experiencelearners encounter a concrete experience 2 reflective observation of the new experiencelearners reflect on the new experience in the light of their existing knowledge 3 abstract conceptualizationreflection gives rise to a new idea or a modification of an existing abstract concept 4 active experimentationthe newly created or modified concepts give rise to experimentation 28  bells model 29 is a fivestep cycle which consists of 1 prior knowledge 2 presenting new material 3 challenge 4 feedback 5 repetition 29 using one of these models could make the learning process more effective and accessible for children also if all these models are generalized its obvious that the effective educational process has three main stages sensory perception generalization of information comprehension and verification by practice the first stagea perception of the educational materialis very important but difficult teachers must remember the golden rule of didactic and try to make the educational environment as accessible as possible the golden rule of didactic by ya a comenius says that everything should be presented to the external senses as far as possible namely visible to sight heard to hearing smelled to smell tasted to taste tangible to touch but if something can be simultaneously perceived by several senses then imagine this object simultaneously to several senses 30 research on improving firstgrade students sensory sphere is based on the achievements of wellknown classic pedagogical scientists 31 32 33 34 35 36 37 retrospective analysis of their creative heritage allows us to state that scholars have identified the important role of perception in the pupils learning and general development paid attention to the formation of sensations many types the leading of which are recognized as visualspatial auditory and tactile there was no clear scientifically sound system for younger pupils sensory education but the accumulated information formed the necessary theoretical and practical basis for the study of psychological pedagogical and methodological ways of organizing the process of perception this knowledge is very important for organizing religious education in primary schools there are ways to control students sensory activities and enrich them printed and electronic textbooks and manuals which are widely used as a powerful resource for the diverse development of perceptions and ideas of pupils changing the external organization of perceptual processes during religious education personalityoriented and competencybased approaches that is why during religious education in primary schools teachers should use a variety of learning tools for example meetings with representatives of different cultures and religions using different pictures and photos excursions to local houses of worship and presentations of artifacts teachers could affect all senses by playing music experimenting with smell considering icons creating symbols by hand and tasting special foods these methods for teaching about different religions are the most suitable for 79yearold children at this stage students get information according to the curriculum of religion in primary school through their senseseyes ears skin nose and tongue the second stage is the generalization of information pupils at primary schools need to analyze information and establish cause and effect interaction between some facts before they can use them in practice at this stage students try to understand new information and connect it with their previous knowledge the third stage of religious education is practice this stage has two phases 1 students participating during classes 2 students using their knowledge and competencies outside school the result of religious education is knowledge and practical skills which they can use in ordinary life if we talk about religion classes students have to not only know about different religions and cultures but show their understanding of the role of moral spiritual and social values in daily life with their family friends classmates and so on the religious education process could be present as a scheme for more effective perception the process of religious education in primary schools is flexible and gives teachers an opportunity for activity and creativity if teachers want to organize an effective process the results will be knowledge about different religions and peculiarities of different cultures the ability to use knowledge and skills in practice and daily life and the forming of flexible and tolerant attitudes to surrounding people and the environment as for components of the effective educational process that must always be present in primary schoolsthe pupils knowledge the influence of family the school and the pupils broader social environment at the same time tolerance of attitudes between pupils is a necessary condition of their socialization what teachers could do for improving the educational process when talking about the educational process in primary schools we must consider the psychological pedagogical and age characteristics of pupils primary school children like to dance listen to music and sing songs draw pictures mold plasticine invent and tell different stories a variety of different types of paints colored pencils plasticine sand and other materials provide a wide range of possibilities for making the educational process more relatable for pupils there are examples of some educational exercises that teachers can use in different lessons and the realization of the main goals of religious education in primary schools 38 task 1 guess who technique drawing what you need an a4 sheet of paper and colored pencils task choose one of your classmates and draw their portrait action pupils draw abstractsymbolic or metaphorical portraits of one classmate imitate them and then everybody tries to figure out who it is then the author of this portrait tells a little about something new about their classmate without naming him and the end the classmate who was in the portrait expresses his opinion about it and adds some facts about himself such exercises help students understand each other better and become more tolerant this is among the most important methods for strengthening bonds within a group which improves the environment for the educational process tasks 2 we help each other to know technique thread drawing what you need different color threads an a0 sheet of paper and watercolor paints task create a collective thematic panel with a thread drawing action the task is carried out in a collective format for various topics about different religions and cultures at first each pupil has readymade schemes for working then he needs to lay it out with the thread after that they put it in the area of the general object and they have to see some religious or cultural objects which they pick up together their homework could be to prepare some information about it this kind of educational task helps teachers set more interesting homework helps pupils discover something new about different cultures and religions and communicate with each other during the didactic process task 3 create it by yourself technique monotype what you need watercolor paints glass an a4 sheet of paper a sponge and cotton buds task make a monotype of a cultural object in the native city action with the help of a sponge apply paint to the surface with a smooth ball paint the little ones with a cotton swab on top lay the sheet of paper and take it if necessary add details such exercises provide space for pupils imagination and encourage pupils to find out more about cultural objects in their native city task 4 flexible world technique moulding what you need colour modeling clay a picture of earth task create a collective work from plasticine about world culture action accompanied by flute or harpsichord music pupils close their eyes and imagine cultural objects that they can make from plasticine and what exactly they want to see in their world it is necessary to work with eyes closed so that pupils can express feelings and thoughts during modeling when the molded object is finished each pupil places it on a preprepared panel next to the objects of the other pupils similar exercises make it easier for pupils to get knowledge about the worlds cultures and religions and understand their relation to them tasks 5 listen what do you hear technique music expression what you need recordings of music from different cultures task show me what you hear action pupils listen to short excerpts of music from different cultures one of the pupils tries to show this music using their body and then all the other pupils try to copy the moves after each excerpt teachers reveal some interesting facts about the music for example its origin music exercises like this not only allow pupils to get to know the music traditions of different cultures and religions but also have a positive effect on the autonomic nervous system of pupils stimulate thought processes and stabilize communicative relations between adults and children task 6 let me tell you the story about … technique storytelling what you need childrens imagination and a topic for discussion task make up your own story about a person or events from a different culture or religion than your own action for homework pupils make up stories about interesting facts or an interesting person from another culture or religion each pupil should present his story as he wishes illustration of a story from their imagination is a very positive moment visualization of characters helps a pupils imagination therefore pupils should invent a story and illustrate it it should be emphasized here that teachers could mix different techniques such as storytelling and drawing for example when teachers talk about tolerance and communication they could offer the beginning of the story ask pupils to finish it and include further tasks it could be something like once upon a time there lived a little mouse and he had two brothers and three sisters the little mouse was very inquisitive he was interested in everything why are the leaves on the tree green why are the trees tall why is the sky blue and why and how every morning mother mouse going to the field for food for the little mice said that it was forbidden to leave the burrow by yourself but one day after the mother mouse left the little mouse did not listen and decided to leave the burrow alone to see what the world outside was like tasks 1 finish the story about the little mouse 2 why do you think the little mouse decided to leave the burrow 3 are there other animals around who help the little mouse in your story 4 choose and draw some of the things that happen in your story explain why you chose to draw those parts of your story there are many ways to make religious education in primary school more interesting and effective a lot depends on teachers creativity and their level of training limitation of the study the findings of this research should be interpreted with some limitations first of all the article contains the results of the authors analysis it means that it is a subjective view of the problem it means the next stage of research could be to analyze the views of the educational process participantsgovernment school administrators teachers children and their parents secondly the analysis of the material is quantitative and the results of qualitative analysis will complement the study and make it complete discussion and conclusion we have defined the role and main peculiarities of swedish religious education for pupils spiritual and moral development we showed the content of it a teaching model but there we showed only one of the effective methods that help make lessons of religion more accessibledidactic exercise we find out that other ways of it could make research more complete and make the process of learning more effective this study presents the authors opinion about the role of religious education in swedish primary schoolsits peculiarities and its potential for pupils spiritual development there are a few important conclusions of this research firstly there are a few principal problems in primary religious educationteacher training the didactic and methodical content of lessons etc secondly the process of selfeducation the influence of the family school classmates and the surrounding societyall of these factors should be recognized for the successful organization of religious education in primary schools thirdly teachers must consider the individual and age characteristics of primary schoolage children fourth the best way to organize a correct and effective process of religious education is when designing a lesson to take into account stages of educational materials perception generalization of information and practice religious education is an effective tool for moral development in primary schools and is very important especially in modern society this postulate has been experimentally proven by afifa khanam zafar iqbal and qudsia kalsoom khanam et al 39 make a conclusion that with growing age public school students left behind the out of school children and that of madaris at the mid years of 711 school going students exhibited better moral reasoning than that of madrasa students and children without education however at the age of 1115 the students having madrasa education exhibited the best increase in moral development than their competitors the results of this research could encourage other researchers to find new effective ways of religious education improvements and solve the problems of modern religious education that were highlighted by leading experts such as 1 teachers professional training 2 more effective planning in the educational process 3 poor access to educational resources 4 a lack of connection to religious education and context in other subjects and 5 a lack of a proper system for assessing students knowledge and skills

primary school religious education is important and understudied in modern educational practice classes on religious education are used to impart knowledge to pupils about the worlds main religions knowledge about specific religions or how to collaborate with representatives of different religions is mostly absent unfortunately teachers of religious education often do not use their classes as a tool for their students moral and spiritual development it is also one of the problems for swedish schools and it has to be solved because sweden is a very multicultural country with representatives of many religions and one of the tasks of modern schools is to show how to be tolerant of others this research aims to highlight problems and develop ways of teaching religious education in primary schools through theoretical literature analysis on the research topic also we provide didactic exercises which teachers can use during religion lessons to diversify them and make it more accessible to students

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introduction rapid developments in technology are fueling an influx of handheld wearable technologies engineered to collect realtime localized data about individuals and their immediate surroundings one increasingly relevant example of these technologies is lowcost portable air quality sensors the rapid and decentralized evolution of these technologies has resulted in a variety of affordable sensors with different mechanisms for data collection that have uncertain data quality measure different air pollutants and possess a variety of design attributes including how readings are presented or interpreted the developers of these technologies are varied including traditional air measurement technology companies crowdfunded startups large information technology corporations and community organizations while this technology is proliferating research to inform the translation of air sensor data into information that might guide an individuals decisions about daily activities remains limited despite these uncertainties the potential demand for sensor technology is high driven by widespread concern about air pollution as well as an interest in reducing personal exposure the adoption of lowcost air quality sensors by both public and private sectors for a diverse set of applications portends expansive use and widespread circulation of sensorbased air quality data further research is needed to elucidate how air quality sensors and their data are being used and to better understand the groups and individuals who use them to fully grasp the potential impact of the ubiquitous availability and public use of air pollution sensor technology it is important to understand 1 how communities of sensor users grow and are sustained 2 the drivers behind individual and communitylevel air sensor use and data collection 3 the behavioral sociopolitical and ethical implications of introducing sensors into communities 4 how sensor data is communicated within and across communities and 5 how crowdsourcing capabilities can be harnessed to achieve greater benefits of community sensor networks gaining understanding in these areas will require application of social science theories and methods currently there are few studies that evaluate social or economic implications of lowcost air quality sensors a recent article reviews the use of communitybased participatory research approaches to study air pollution in communities however the article focuses on communities as researchers and sensors as objects of research rather than on the motivations for nonresearch use of sensors or the social context of introducing sensor technologies into communities theories of risk governance and responsible research and innovation provide useful context for considering how the development of air quality sensors and their subsequent introduction into communities can impact individual and group level decisions there are well established health risks from exposures to air pollution that can potentially be mitigated through use of air quality sensors and also potential risks to health and community welfare that can arise from the introduction of sensors into communities for example if poor quality data leads to behaviors that increase exposure government processes that shape policy for new technology determine the potential action pathways for groups and individuals conversely individuals and groups interactions with new technology from the initial introduction of an innovation to relegation of obsolete technologies to marginalized communities often influence the policy process vulnerable or overburdened communities that face multiple social or environmental stressors may have different responses to new technologies and the interpretation of expert versus local knowledge experts are defined here to be individuals with formal education and professional experience in a relevant scientific field citizen scientists are members of the general public who are involved in scientific research and activities citizen scientists and engaged community members with local knowledge often engage in scientific studies or analyses using scientific methods or local experiential knowledge to better understand local environmental conditions and risks both experts citizen scientists and engaged community members contribute to the overall understanding of environmental quality and risks in local communities better understanding of the effects of such a knowledgeenabling technology as air quality sensors particularly when adopted by communities vulnerable to marginalization can lead to identification of opportunities for collaborative policy solutions and reduced environmental health burdens the process of engaging in monitoring of local air quality conditions can help to increase environmental literacy in communities and build capacity of communities to engage both in partnering with academic researchers and in developing local actions to reduce air pollution exposures and improve public health in this commentary we discuss the limited literature on application of the social sciences in the area of air quality sensors we identify opportunities for interdisciplinary research that brings together concepts and methods from a range of social science disciplines with environmental science engineering and user interface user experience design communities that are developing testing and deploying air quality sensor technologies we lay out the nature of the challenges associated with sensor data generation interpretation and analysis we identify opportunities for collaboration with communities and organizations to better understand how and why sensors are being used and how technological innovations may be able to improve the ability of communities and individuals to reduce exposures to air pollution and improve individual and public health discussion multiple social science disciplines have addressed the development and adoption of environmental technologies and have provided theoretical frameworks for the examination of these processes in this paper we choose to make use of the complementary conceptual frameworks of risk governance and responsible research and innovation this is not the only conceptual framework that can guide thinking about how individuals and communities respond to the availability of lower cost sensors pritchard and gabrys use a framework of perceptive and affective problematics to discuss how interactions among individuals communities and technology coproduce knowledge and mobilize publics towards certain political objectives this is a useful construct for thinking about the specific question of how relationships between individuals and communities can affect how sensor information is collected and used both in generating knowledge and in effecting political change for the purposes of this inquiry we find the framework of risk governance and responsible research and innovation to be applicable to a wide variety of potential impacts of air quality sensors and thus adopt that framework for our discussion the concepts of responsible research and innovation focuses on the democratic inclusive governance of new sciences and technologies including but not limited to air quality sensors there are four dimensions to the framework anticipation reflexivity inclusion and responsiveness anticipation asks researchers to think of future uses and scenarios for the science or technology they are developing and related risks closely related reflexivity challenges researchers to recognize the limits of their knowledge and to directly reflect on the morality of their work inclusion focuses on the substantive input of stakeholders while striving to identify and dissolve barriers precluding those who may not typically be involved in such innovative processes finally innovation must be able to respond to the challenges provided by increased anticipation reflexivity and inclusion conversely while responsible innovation focuses on the early innovative stages of a new technology inclusive risk governance focuses on the risks posed by established technology specifically risk governance addresses the various ways in which individuals and institutions manage risks that are surrounded by uncertainty complexity and ambiguity the development and deployment of air quality sensor technology is currently undertaken by a diversity of organizations on one end of the spectrum is the aircasting airbeam sensor technology that was developed by a community organization and designed to be open source as well as streaming all data from users into a common platform to develop a crowdsourced air quality map the variations of the design include multiple air pollutant sensors biometric sensors and noise data capture from android phones meanwhile on the other end of the spectrum are emerging sensor networks implemented in major cities by larger organizations with data made available to the public in the latter case some larger organizations have conducted information sharing sessions to seek public input on where to locate the technologies which may help build trust and engagement of the community an example of this is the minnesota pollution control agency planning process to implement sensors in a number of locations in minneapolis st paul the mpca held five open houses to allow the public to hear about the project and provide input on sensor locations the availability of lowercost air quality sensors may change the nature of risk governance by reducing uncertainty but can also increase ambiguity and complexity and add new dynamics related to who owns or has rights to knowledge about air quality the overall impact of these changes on how individuals and institutions interact with each other to understand and manage air pollution risks is ripe for study air pollution is a systemic risk due to ubiquitous sources mobile and heterogeneous exposed populations and varying exposures due to meteorology topography the build environment and population activity patterns however individuals and institutions are likely to respond to air pollution risks in different ways according to their own risk constructs and images when there are multiple sources of data available from official government monitors sensor networks implemented by private or academic institutions as well as community or individual air quality sensors ambiguity may result regarding the nature of the risks and the appropriate ways to manage those risks review of the literature on social and behavioral aspects of sensor use to date there are few research applications where social scientists have directly considered social implications of introducing air pollution sensors into communities there are almost no quantitative studies of sensor use by different types of users and only a few qualitative surveybased assessments of how and why users are employing air quality sensors the citisense project evaluated how 16 participants responded to having instant feedback about the air quality in their vicinity the project team provided an online mapping tool that allowed the users to view their past and current air quality based on measurements from a sensor node connected to a smart phone participants were interviewed to understand their experiences using the sensor device and how the available data influenced their behaviors over the course of the study participants had few issues with using the sensors but voiced concerns regarding data interpretation and knowing how to react to information provided by the sensor for example they felt that historical data was needed to more fully interpret current air quality participants also wanted more gradations of air quality than provided by the epa air quality index to help distinguish their immediate air quality participants utilized social media to share their measurements with coworkers and friends they also found that access to personalized air quality information was useful both in revising prior beliefs about air pollution and learning how their activity patterns and behaviors affected their exposures willett et al adopted a slightly different approach relying on structured interviews with several dozen community members who were engaged in collecting measurements with personal air quality sensors nitrogen dioxide and ozone the authors explored how improved design of mobile air quality monitoring systems could enhance the process of knowledge production such as combining information from sensors with individual knowledge of emissions sources and experiences with health impacts based on their findings the study authors developed a system called the common sense community to facilitate community analysis of air quality data collected by sensors key aspects of the design of the analysis system include a focus on personal exposure or hotspots use of local data and knowledge and avoiding use of technical jargon and information overload the authors evaluated their communitybased system in an area with known air quality problems and found that the system was useful to participants to understand local pollution and communicate insights to policy makers and others in their community oltra et al evaluated changes in perceptions and knowledge of air quality for two small groups of study participants in barcelona one group received personal no 2 sensors and collected air quality readings over a oneweek period the other group passively received information on air quality and health using videos press clippings and information pamphlets using focus groups they found that the participants who used the no 2 sensors had a more quantitative understanding of pollution levels compared to those receiving general information this gave them a sense of knowing when the air was highly polluted however compared to the group that received general air quality information which included information about health effects the group using no 2 sensors became more focused on the quantitative readings and expressed less concern about health effects except when readings were very high both groups reported low levels of selfefficacy believing they could do little to avoid the harmful effects of air pollution and indicated limited willingness to engage in protective behaviors due to concerns about costs convenience or esthetics recent literature on environmental health literacy indicates that by educating individuals and communities and raising awareness of environmental risks and strategies to reduce those risks feelings of selfefficacy can be increased these increases in selfefficacy can in turn lead to improved decision making at the individual and community levels to reduce adverse health outcomes the current array of published commentaries were mostly published prior to the recent influx of lowcost air quality sensors but addressed some of the potential social implications of citizenbased air monitoring that are highly relevant today in brief they conclude that public sampling of environmental contaminants has resulted primarily in increased community awareness of air pollution and responses with the potential in some cases to impact broader policy actions and change industrial processes they also identify the potential for sensors to transfer responsibility for risk reduction from the polluters and regulators to the vulnerable populations themselves potentially exacerbating health disparities and reducing feelings of empowerment in affected areas in addition they note the legal and administrative hurdles faced by citizen scientists including getting data they collect accepted for use in official decisionmaking about environmental issues the need for data quality and peer review protocols considerations of data privacy issues and rules for introducing evidence into legal proceedings and enforcement actions the recent article by commodore et al notes that cbpr and citizen science efforts related to air quality monitoring were driven in part by community concerns about disease burdens and living in a toxic environment due to proximity to roadways and industrial emissions sources as well as a desire to know more about air quality in their community and a desire to reduce health burdens due to air pollution exposure english et al reporting on a community monitoring effort in imperial county california highlight the importance of engaging community members in all aspects of monitoring air quality when establishing a community wide air monitoring network noting that the process of engaging community members as citizen scientists builds trust and can address concerns about scientific validity and sustainability of the monitoring network community members can serve in multiple roles during a monitoring research effort helping to identify appropriate monitoring locations develop effective communications plans and translate research findings into actions to address sources of air pollution and exposures research opportunities 1221 growing and sustaining physical and virtual communities of sensor usersgiven the spatially and temporally dynamic nature of air pollution there is significant value in combining numerous individual sensor data sets collected by individuals or groups into a larger database informing communitywide air quality however sustained participation in the endeavor is essential to the task investigative mechanisms that incentivize sustained participation may be helpful to groups planning sensor deployment campaigns study participants are generally more willing to participate when research produces actionable results in addition individuals may be more likely to initiate and sustain participation if wellknown community organizers or key community members endorse the campaign the complexity involved in interpreting air pollution trends along with the potential technical barriers for sensor use may be a limiting factor for community use of air quality sensors understanding potential limiting factors as well as catalysts such as developing local citizen technical experts is important to understand how sensor technology may be adopted and used epa has supported the advancement of community member experts by launching the community air monitoring training and air sensors toolbox online suite of resources for citizen scientists research that improves understanding of the expert within the community can be helpful to organizations seeking to employ communitybased air quality sensors qualitative methods such as oneonone interviews or focus groups can be very useful tools to understand how different communities and individuals view the role of experts within their specific social or cultural context such research could help assess whether citizens with greater technical knowledge may be able to serve as points of contact between academic scientists environmental groups and communities and act as liaisons to train and maintain broader groups of citizen scientists english et al emphasize that sustaining a community monitoring program after a directly funded research effort has concluded will require training citizens to maintain monitors and interpret and communicate collected data in appropriate and useful ways maximizing knowledge generation through crowdsourced air quality sensor data will require evaluating the most effective ways to organize the community of data producers analysts and users this may require additional research into the nature of power dynamics that determine who collects data the quality constraints on sensors used for different purposes as well as who controls the flow storage and access to sensor data pritchard and gabrys note that citizen sensing can challenge the established truth provided by traditional monitoring which can lead to tensions between communities and government agencies that have previously controlled air quality knowledge communitycollected sensor data may be a catalyst for increasing individual and community awareness of air quality and causes of pollution events and developing strategies to reduce pollution exposure social scientists using a variety of methodological tools and techniques can help elucidate the social context in how sensor data are collected analyzed and presented which may result in either collaborative solutions or conflict between citizens polluters and community governance in addressing air quality problems for example a mental models methodology could be utilized mental models are ways of explaining how people understand information or knowledge application of a mental models approach would involve the examination of knowledge and value gaps in the collection analysis and communication of sensor data between scientists and community partners understanding drivers behind individual and communitylevel air sensor use and data collectiontheories of responsible research and innovation address the role of the responsiveness of innovation to meeting the needs of the public and the responsibility for results of the innovation given uncertain and unpredictable consequences within this context understanding of the nature of individual and community experiences with air pollution and the perceived need for additional air quality information can help to evaluate how well existing air quality sensors are meeting the needs for innovation in addition evaluations of current uses of air quality sensors including who actually uses sensors and how sensor awareness and use relates to underlying demographics and socioeconomic status can help determine which types of needs are currently being addressed through sensor innovations for example environmental justice communities may view sensors as a way to document a previously identified environmental problem concerned communities may want to have full ownership over the sensor technology to ground truth external air quality information sources which may build or erode trust in their relationships with government and academic investigators a potentially useful research question applicable to individuals is to what extent are sensors employed to affirm predetermined perceptions or goals eg comparing against an air quality benchmark to adjust activities versus the development of open questions or hypotheses eg if i change my bike route will i see a change in my exposure to pm it is also important to improve our understanding of how the motivational and confirmation biases of citizen scientists may affect their views of sensor data motivational biases arise when selfinterest or social pressures distort judgements and decisions confirmation biases occur when individuals selectively interpret new data to confirm a preexisting belief questions that arise related to motivational and confirmation biases about sensor data include how does the strength of prior beliefs impact the abilitywillingness to update those beliefs based on sensor data to what extent do individuals tie success in using a sensor to findings of high variation in or high concentrations of air pollution how does discordance between exante perceptions and expost sensor measurements affect trust in sensors and scientists and policy makers commodore et al review a number of cbpr efforts and note that air monitoring results which reveal low levels of measured pollutants may be less well received compared with results that are more confirmatory of suspicions they note that for cbpr acceptance of results of air monitoring by all participants can be enhanced by making sure the research focused on an air quality issue of concern to the community the communities are engaged throughout the design and implementation phases of the research and that results are disseminated by the community to date the value of sensors has been appreciated mostly in terms of the data they produce as measurement devices as the cost of sensors declines individuals and communities may begin using them to do their own assessments of exposures in some cases with the goal of confirming perceived exposures in other cases using the data to modify behaviors or activities to reduce exposures or using the data to inform health studies whether these behavioral and social changes actually occur as sensors begin to be more widely available is ripe for scientific inquiry studies such as the columbia university biking and breathing study are being designed and implemented to evaluate personal exposures measured using sensors but evaluations of how behaviors are modified by sensors or how community decisions are affected by low cost sensors are not yet widespread sensors vary in quality performance and ease of use and individuals or community organizations will benefit from easy to understand evaluations of different sensors that can guide the selection and use process several recent studies have evaluated low cost sensors and found that while promising may available sensors suffer from inaccuracy and require frequent calibration although for some pollutants the readings are still useful for coarser statements about air quality eg high vs low pollution levels and can help communities understand local air quality understanding how individuals view their role as citizen scientists in both understanding local air quality and related health consequences will become increasingly important as communities seek to engage with policymakers to address their health concerns in communities with historically higher exposures to contaminants the level of trust in policymakers and the information on air quality provided by experts or the government may be lower and those communities may seek to use air quality sensors to interrogate traditional sources of scientific information on air quality understanding whether communities fully understand limitations of sensors and their potential applications can help direct resources toward better engagements with communities 1223 behavioral sociopolitical and ethical implications of introducing sensors into communitiesthe introduction of sensors and sensor data can have a wide range of impacts on individuals and communities given the substantial variance in sensors currently available on the market varying in pollutant types measured how data are presented to the user whether personal actions are suggested there is substantial uncertainty in how individuals or communities and their resulting exposure may be modified by sensor technology for example people may change their commuting patterns or bike and pedestrian routes to avoid areas with apparent higher air pollution exposures but there are many other potential impacts across health wellbeing and social dimensions these impacts may be either positive through reduced individual exposures or better understanding of times and locations with high pollution or negative if they result in less physical activity higher levels of anxiety or worsened disparitiesinequality in the event of incomplete or inaccurate information on air quality from sensors misinformation may drive behaviors that result in greater rather than lesser exposure to air pollution though there is a large public health literature on behavior change and incentivizing healthy behaviors relatively few studies have examined how individuals and communities translate environmental data into behavior change or otherwise make decisions in accordance with environmental data a general question is how does access to personalized exposure information impact thoughts attitudes and decisions more specifically would provision of expert advice on possible choices to reduce exposure provide confidence in making better decisions one important social dimension related to sensors is how they might change the dynamics between polluted communities polluters and regulators availability of air quality sensors can change perceptions of responsibility for air pollutionrelated exposures and research would be useful to understand these changes in perceptions in both affected communities and in those authorities traditionally responsible for reducing air pollution burdens sensor campaigns that convey either explicitly or implicitly that individuals are now responsible for any health effects that occur can paradoxically reduce the sense of empowerment for individuals who are not able to engage in protective behaviors or move away from adverse conditions conversely collaborative approaches can increase public trust by engaging the public in the collection of environmental data and generation of environmental knowledge beyond concepts of inclusion from the responsible innovation and risk governance frameworks it is important to recognize how the representation of traditionally marginalized groups in the development and use of sensors can be hindered by interlocking systems of oppression based on structural inequities such as race class and gender this systemic oppression can often create a wall between these communities and developers researchers and regulators considering this observation it is important that the inclusion of these groups goes beyond tokenism and recognizes that there is significant heterogeneity within vulnerable populations in a recent collaborative effort the us epa worked with the ironbound community corporation in newark new jerseyto test an air sensor toolbox for citizen science the icc is a recognized environmental justice community as indicated by the epas ejscreen tool which shows a population with relatively high minority proportion low education and income and relatively high environmental indicators the project successfully built a collaborative environment where community members worked alongside epa scientists to characterize air pollution exposures in the community through this effort the team together generated a mutual understanding of the strengths and weaknesses of the air pollution data collected with the lowercost sensors the potential uses of the data and cases where the data would not be useful calls for responsible innovation suggest the importance of including community voices in the development of a data collection protocol such as the one implemented in newark a key finding in this study was that the community members consistently sought to derive personalized meaning from the data through the lowercost sensors this is consistent with the theory of inclusive risk governance in that individual actors respond based on their own understanding of risk and therefore will seek to understand risk by how air quality data can impact their own circumstances one of the key principles of risk governance is communication and inclusion and the challenges of data interpretation highlights the need for twoway communication between the air quality monitoring experts and community members the us epa is working to address some of these challenges by developing methods to translate sensor readings for ozone and pm 25 into scales that relate to the aqi and provide guidance on behavioral responses when sensor readings are elevated those entities producing new knowledge through data acquisition and analysis for example are often those that are perceived as voices of authority sharing in the collection of air quality observations and cogeneration of air quality knowledge can change the dynamics of interactions between citizens and institutions and lead to comanagement of risk the relationships between traditional knowledge generators and citizen knowledge generators will need to evolve and will require understanding the different perspectives of each group while experts may be most concerned about the quality of the data used to generate knowledge it will be informative to also study how nonexpert individuals and groups view data quality and uncertainty regarding sensor data how important to individuals and communities is the participatory nature of sensor data collection versus the higher risk of inaccurate data lastly the introduction of sensors may have profound ethical implications powell notes that the ability of new data generating technologies to improve the lives of citizens depends on several factors these include the relationships between individuals and institutions economic factors shaping technology development and distribution and shared values for openness and transparency it is still uncertain as to whether availability of lowcost sensors either alleviate or exacerbate disparities in health or economic status among population subgroups of varied incomes ethnicity or race lowcost sensors provide opportunities for marginalized communities to engage with new technologies and build knowledge about local air quality conditions and potentially the local sources that are contributing to poor air quality this feeds new knowledge into discussions with state and local air quality planners to address local air quality concerns and improve community health for lowincome or ej communities however availability of sensors does not guarantee these outcomes the basic nature of this problem is that while biomedical and environmental knowledge and technology creates the capacity for individuals and communities to improve their personal health it can also exacerbate disparities in health outcomes between different populations this paradox holds true for health outcomes attributable to air pollution exposures as well for example low income vs high income populations have different access to knowledge and technologies if sensor technologies are still too costly for low income communities to use or if the level of education and expertise needed to use the sensors is too great sensors can benefit higher income higher education populations to improve their exposures while lower income lower education populations do not receive the same benefit leading to increased exposure and health disparities certain social factors such as the ability to afford these technologies time and willingness to engage or technical and scientific proficiency play a role in determining who has access to lowcost air quality sensors and the information they help generate if the resulting information leads to a greater awareness of exposure to poor air quality conditions and opportunities to reduce those exposures then those who are excluded from this process lose out on important healthrelated benefits the idea that observed patterns of disease and death are affected by the social context of a population has been termed social shaping and research into this phenomenon presents an opportunity to introduce social science insights and methods into air quality and health science marriage of these sciences can bring about a better understanding of how the risk of disease and death reflects the interface of environmental and biological stressors with awareness and access to information and technologies and can help identify the most effective types of interventions to alleviate health disparities for example programs that provide access to lowcost sensors coupled with opportunities to engage with individuals or groups with a range of professional or academic backgrounds related to sensor technologies environmental public health and air quality policy could increase equality in knowledge of local air quality in lowincome areas and result in localized programs to reduce exposures or policies to reduce emissions from sources contributing to locally elevated ambient air pollution as another example recognition of language barriers in communities with high proportions of nonenglish speaking populations could inform development of sensors with instructions displays and outputs in the community language this can enable these communities to more actively understand local air quality conditions and engage with air quality planners to address sources and exposures of concern for their communities assessing methods for communicating sensor data there are a number of potentially important research approaches that can lead to more effective communication and improved understanding of how people respond to the availability of individualized continuous air quality information several of these approaches involve consideration of how evidence is framed in risk messages what are the most effective ways to communicate measurements obtained with air quality sensors measurements delivered as visual representations or as health messages may be more or less effective in altering individual behavior such that subsequent potentially harmful exposures are reduced whether messages are framed as improving health or preventing health damages can affect behavioral responses the direction of the impact may be dependent on the nature of the behavioral response with gainframed messages likely to positively impact behaviors to prevent an exposure and lossframed messages likely to positively impact behaviors that identify when an exposure has occurred visual approaches may differ in their effectiveness based on the desired application eg should sensor results be communicated in different ways depending on whether they are used to achieve health risk reductions or for identification of emissions sources evaluations of the effectiveness of communication strategies should evaluate what is actually communicated to recipients rather than just what is nominally displayed on a screen at the same time research is needed beyond initial messaging to ascertain how people can be encouraged to make checking air quality a habit so they can realize long term benefits research on the phenomena of attention fatigue or information fatigue that can identify ways to reduce this fatigue will hopefully reveal technologies and tools to increase meaningful persistence of use that result in positive behavioral responses it would also be useful to understand how behavioral responses to sensor data differ over time ie in the shortterm sensor data may drive changes in daily personal activities and transportation choices while over a longerterm people may geographically relocate seek political action or make investments in perceived health protection such as purchasing home filtration units understanding the persistence and effectiveness of longterm behavior changes will be important in informing the benefits of introducing lowcost sensors into communities the effectiveness of communication methods for sensor information likely varies with the intended audience measurable demographic and socioeconomic characteristics may help to explain utilization of sensorbased data and associated risk information and can be used to shape the messaging to different populations research is needed on the optimal translation in some cases simplification of messages and data either by the sensor itself or by experts simplifying the message may make sensor data more comprehensible but also less interesting and less useful users may have different levels of numeracy and decisions about the level of numerical information provided can shape the ultimate use by the community users may prefer apps that provide behavioral choices eg different movement pathways rather than prescription of activities eg staying indoors there is an extensive literature on communicating health risk information that may be informative to future research on sensorbased messages on the other hand consistent with todays informationoverloaded society additional data may not be appreciated by some individuals research into the impact of continuous provision of air quality information on individual and community wellbeing or happiness can help guide decisions on how and when to deliver air quality information eg does continuous data increase worry or enhance peace of mind the health communication literature has reported that information fatigue or information overload can be detrimental to decisionmaking and cause stress and anxiety or lead to ignoring of relevant risk information little is known about these relationships with regard to air quality but as sensors further penetrate into personal use their importance will become more evident mixed methods may be appropriate to address these questions including use of online and mobile appbased surveys focus groups and interviews the types of communication may also depend on how users want to employ sensor data for example some individuals may be primarily concerned with exceeding identified health benchmark levels while others may simply want to reduce their own personal air pollution exposures research is needed to understand the extent to which individuals can use sensors to customize their own air quality goals sensitive individuals eg asthmatics heavy outdoor exercisers children have the potential to use sensor data to determine where and when they have higher exposure or more severe responses to air pollution and may want to know how to minimize those exposure and outcomes evaluating how much confidence the sensor user has in indices and associated messaging like the aqi may guide his or her interpretation of sensor messages related to perceptions of local air quality conditions epa has been cognizant of the emergence of sensor data at high time resolutions and has currently responded in two ways 1 communicating that the official aqi should only be used as intended for specific data sets and at averaging times matching the national ambient air quality standards and 2 providing a proposed alternative color scale and data messaging that would be appropriate for high time resolution sensor data additionally better understanding of how the success of different communication approaches is affected by levels of social vulnerability and behavior within groups is also needed are individuals and communities less likely to employ air quality sensors when they perceive the information provided is less actionable ie there is nothing i can do about it a reading of poor air quality can cause alarm but if there are no appropriate mitigation options for an individual or community to address exposures and risks individuals may become disinterested or develop a sense of powerlessness that may increase anxiety and reduce wellbeing environmental health literacy is also critical to effective use of sensor data consideration of approaches to ensure that environmental health literacy is maintained in communities as new residents enter the community and over time as children become adults and raise their own families developing messages based on sensor data that are targeted to sensitive populations such as children and the elderly and those with preexisting heart and lung disease can improve the likelihood of behavioral changes that reduce exposures for these populations harnessing crowdsourcing capabilitiesas communities begin to crowdsource the analysis of their sensor data social scientists can help to understand how different communities organize to sharegenerate knowledge from sensor networks social media or other webbased platforms open the possibility for individuals and communities to share their own analyses of sensor data other outlets for dissemination of data and results could include local sporting events community events religious events etc these data may have been personally collected or perhaps have been publicly provided by others these options raise new challenges and opportunities for knowledge generation a key question that results is how do different user groups analyze and utilize sensor data compared with how scientists use the data taking into account timing delays interpretation and dissemination social scientists can help to understand the role of social analysis of data eg crowdsourcing community contextual analysis team model building etc to better understand fundamentals of sensor use and those factors that enable exposure and risk reductions investigation into the extent that these types of social analytical tools engage stakeholders expand their use and aggregate as well as leverage results over temporal and spatial scales will enhance the improvement of advanced analytical tools for communities efforts in this regard have begun the common sense community air quality data analysis platform is an example of a system specifically designed to allow novice citizen scientists to analyze visualize and annotate data collected from sensors within a collaborative software environment epa has introduced the real time geospatial data viewer webbased tool for visualization and analysis of sensor data another example is habitatmap that allows users to upload measurements from the airbeam sensor and pinpoint air emissions facilities in nyc and alert public officials to potential environmental concerns conclusions emerging air sensor technologies may significantly shape how individuals and communities perceive and respond to information about their air quality given the complexity of the science of air pollution layered on the uncertainty in sensor data quality and interpretation the downstream impacts of this technology on individuals and communities are uncertain the spectrum of social sciences provides an array of metrics for judging human responsesat many levels of organization to technologies and interventions the social sciences can contribute to a better or more refined understanding of individual and community perceptions attitudes behaviors and what determines various levels of engagement around and trust in air quality sensors and sensor data application of social science methods and tools to evaluate how sensors are entering the social arena and the resulting impacts is an area with high potential to enhance the quality of individual and community life the sensor itself is only the beginning of the process of understanding communicating and responding to air pollution other steps include processing and translating the sensor data collecting ancillary information that might explain unusually high or low readings data aggregation and sharing visual and statistical analysis and visual display and communication social or other virtual networks can be a potentially valuable tool for users to compare combine and interpret sensor data gathered across a community they can also foster data verification through group inquiry and group communication to regulatory and health officials in the end data collected through sensors can influence positively or negatively public attitudes and ultimately help inform policy decisions about air quality management engaging in monitoring efforts can also increase environmental health literacy which can lead to greater efficacy of interventions to improve community public health and can deepen the expertise that community members have in areas typically considered to be the realm of academicallycredentialed or technicallytrained experts the ironbound community successfully learned how to assemble install operate and troubleshoot the air quality sensor pods throughout the course of the epa research study these skills are transferrable to future studies and raises the communitys capacity for understanding their own air quality beyond the technical skills the community also gained knowledge of spatial and temporal variability of pollution as well as potential pollution sources with the information gained they plan to collaborate with researchers on future studies to further explore pollution sources levels and exposures in their community the imperial county community air monitoring network project also led to increased capacity in the community to operate and maintain air quality sensors however they point to the continuing need for partnerships with government agencies and researchers recognizing the important roles that each plays in ensuring credible reliable and meaningful analyses and due to the potentially high costs of maintaining large sensor networks and the low available resources in many vulnerable communities the integration of social science and technology development which builds from the experiences of those engaged in citizen science and those working in academic and government social and natural science communities will augment the value of air quality sensor information and the likelihood of developing successful solutions to public health problems posed by air pollution social sciences can contribute to the understanding of all elements of sensor design and use

background lowercost air quality sensors hundreds to thousands of dollars are now available to individuals and communities this technology is undergoing a rapid and fragmented evolution resulting in sensors that have uncertain data quality measure different air pollutants and possess a variety of design attributes why and how individuals and communities choose to use sensors is arguably influenced by social context for example community experiences with environmental exposures and health effects and related interactions with industry and government can affect trust in traditional air quality monitoring to date little social science research has been conducted to evaluate why or how sensors and sensor data are used by individuals and communities or how the introduction of sensors changes the relationship between communities and air quality managers objectives this commentary uses a risk governanceresponsible innovation framework to identify opportunities for interdisciplinary research that brings together social scientists with air quality researchers involved in developing testing and deploying sensors in communities discussion potential areas for social science research include communities of sensor users drivers for use of sensors and sensor data behavioral sociopolitical and ethical implications of introducing sensors into communities assessing methods for communicating sensor data and harnessing crowdsourcing capabilities to analyze sensor data conclusions social sciences can enhance understanding of perceptions attitudes behaviors and other human factors that drive levels of engagement with and trust in different types of air

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introduction how could interventions for lifeand careerconstruction contribute to a development that would be ecologically sustainable socially just and based on decent work activities to answer this question this paper started from an observation although for some 50 years anthropologists have underlined the serious threats that our mode of development poses to the human species the still dominant conception of interventions for lifeand careerconstruction do not ask any question about the future towards which people should be helped to direct their lives a reference to analyzes of active life by hanna arendt accounts for this paradox while active life has three dimensionslabor work and actionmost current interventions focus on just one work they only consider active life as a development by individuals of their skills interests values etc through their work within current work systems in doing so these interventions ignore the other two fundamental questions guiding the construction of an active life that relating to laborhow can i ensure my survivaland the other referring to action what can i do to contribute with others to a collective life that is good and just some studies have already underlined these limitations of the currently dominant models of career counseling and vocational guidance in particular the psychology of working by david blustein the model of counseling for work and relationship in the social world by mary sue richardson or the dialogues of construction of active lives by jean guichard et al the sharp worsening in recent years of the anthropocene crisiswhich the un general secretary and the ipcc reports constantly underline and which is now brought to bright light by covid 19implies going much further in this direction this path is explored in the third part of this text first by specifying the fundamental principle and the political legal and ecological requirements of actioninterventions the purpose of which would not be to include individuals in the world of work and economic exchanges as they function today differently it would be to allow them defining future perspectives that answer the question asked at the opening of this text that of the forms of active life contributing to a development that would be ecologically sustainable socially fair and based on decent work activities interventions based on this principle and these requirements must therefore be developed the broad outlines of two such interventions are then presented a key question remains what conditions are required for interventions for lifeand careerconstruction undergo such a metamorphosis this question is dealt with in this articles conclusion that focuses on two requests that of a renewal of the conceptual field on which these interventions are based and that of the setting up of public or community services for their delivery to the population an issue ignored by most current interventions for lifeand careerconstruction towards which future should people be helped to direct their active lives on november 21 2008 the council of the european union and the governments representatives of the member states agreed to give an official definition to lifelong career guidance it is referring to a continuous process that enables citizens at any age and at any point in their lives to identify their capacities competences and interests to make educational training and occupational decisions and to manage their individual life paths in learning work and other settings in which those capacities and competences are learned andor used guidance covers a range of individual and collective activities relating to informationgiving counselling competence assessment support and the teaching of decisionmaking and career management skills the following year a group of researchers who were working together for several years has made this approach in a way more radical in proposing to replace expressions such as vocational or career development by the concept of life designing career problems are only a piece of much broader concerns about how to live a life in a postmodern world shaped by a global economy and supported by information technology managing interactions between different life domains has become a paramount concern for the many peripheral workers whose employment is contingent freelance temporary external parttime and casual a major consequence of the interconnectedness between the different life domains is that we can no longer speak confidently of career development nor of vocational guidance rather we should envision life trajectories in which individuals progressively design and build their own lives including their work careers not only adolescents will encounter the big question what am i going to make of my life this question is at issue for everyone as they negotiate a series of major transitions in their lives occasioned by changes in health employment and intimate relationships these two approaches differ somewhat the european union one emphasizes occupational careers and the training of the skills required to be able to give direction to a life centered on a professional trajectory for its part the analysis in terms of life designing considers on the one hand that not all working lives can be thought of in terms of trajectory and on the other that work is only one element among others contributing to a life construction beyond their differences these two conceptions proceed from a neoliberal vision considering that individuals are autonomous beings responsible for the direction they give to their life courses in both cases interventions supporting clients in such endeavors consist in helping them project themselves into a certain future that gives meaning to their present existence but in both cases an issuefundamental both 1 3 international journal for educational and vocational guidance 22581601 for the individual and the communityis left in the dark for heading towards which future over the past decades however this issue has gradually come to the fore under the impetus of movementsand large international organizationsconcerned about the extreme worsening of demographic ecological and social justice problems the covid19 pandemic has given this concern an acuteness that it had never had before as for example underlined by frédéric keck director of the social anthropology laboratory of the french national center for scientific research in an interview published by the newspaper le monde on march 27 2020 since the 1970s all indicators have shown that our mode of development produces more harm than good especially the emergence of infectious diseases transmitted by animals under the effect of anthropic changes climate change warnings have been scarcely heard whilst a health alert forces governments to take swift decisions to prevent emergency deaths lockdown an unprecedented measure to manage a health crisis produces a mixture of accelerating signs of ecological change and slowing down of economic activity which is conducive to fundamental reflection on our mode of development for professionals helping people design their lives and careers this concern is accompanied by another question how to help individuals and groups to head towards which other mode of development hanna arendts analyzes of the concept of active life seem able to offer a solid basis for providing answers to this double question designing ones life giving a future perspective to ones active life active life labor work and action in 1958 hanna arendt published the human condition as indicated by the title of this book german editionvita activait shows that active life is the mode of existence of human beings active life is no longer seen as an optional mode of life to be chosen among many and to be assessed as an end or a good it is the condition of all human existence which has always been and can only be active because of this condition active life is made of three dimensions labor work and action each of these can be understood to describe amore or less importantcomponent of the todays various jobs trades professions professional functions and unpaid workings the first of these dimensions is labor labor refers to a kind of activity that human beings must do for sustaining their lives this is the activity required for our survival as animals both as individuals and as a species it needs to be always started again without leaving the trace of any made works food searching and caring for children are prototypical examples of labor this concept applied to todays working activities makes clear that some of them are essentially labor for example jobs of immigrants harvesting fruit and vegetables those of people cleaning at night at the headquarters of large companies those of employees taking care each day of different elderly dependent people or those of people making home meals deliveries besides most unpaid activities traditionally assigned to housewives are equally labor the second dimension of active life is work it refers to the making of relatively durable goods for example the development of a first plow the production of such goods allows the human species to free itself to a certain extent from its animal condition by transforming its conditions of existence through work human beings construct a certain human world in which they construct themselves work is an activity in which each person can get involved because they can identify with the object of their production they relate to themselves as capable of beings who develop and construct themselves through their activities the intellectual and artistic professions and all craft trades are examples of working activities in which work is predominant in todays world of work the creation of derivative products in banks or of softwareas the uber eats one that organizes the labor of their delivery employeesare examples of jobs implying work action is the third dimension of active life action is the human collective agency that allow ustogetherto face the problems we encounter as a group and to give a certain direction to our world and therefore to our existences in this world the designing of laws fighting the global warming that human activities produce is a prototypical example of action action refers to the wholeproperly humanacts consisting in making together a world by initiating something new through the mediation of reasonably acting using the vocabulary of eric weil we can say that action is this doing characterizing the life of this being of which no definition can be given because men as species are the beings who are not since they are essentially their own becoming and this becoming is not a natural and describable becoming but their own selfmaking1 and this selfmaking is action a power to act on ones own making without the faculty to undo what we have done and to control at least partially the processes we have let loose we would be the victims of an automatic necessity bearing all the marks of the inexorable laws which according to the natural sciences before our time were supposed to constitute the outstanding characteristic of natural processes if left to themselves human affairs can only follow the law of mortality which is the most certain and the only reliable law of a life spent between birth and death it is the faculty of action that 1 3 international journal for educational and vocational guidance 22581601 interferes with this law because it interrupts the inexorable automatic course of daily life the life span of man running toward death would inevitably carry everything human to ruin and destruction if it were not for the faculty of interrupting it and beginning something new a faculty which is inherent in action like an everpresent reminder that men though they must die are not born in order to die but in order to begin action refersin particularto the collective organizational activities that are required as a consequence of the ongoing generation by labor and work of something more than their immediate results this more is something new which has usually not been forecasted coping with this unexpected outcome requires collective decisions for example home meal deliveries create large amounts of packaging waste solving this problem requires organizing collectively should some regulation be enacted should we reorganize the collection and sorting of garbage and how and in the longer term how to recycle it in other words action stresses that active lives lead to such transformations of the world that they make it imperative to organize collectively failing which humanity would run to its destruction this organization is never definitively established since the active lives of human beings constantly produce unexpected outcomes some people have active lives in which action dominates politicians ngo leaders organizers of collective actions certain journalists and intellectuals etc the three questions of active life designing arendts analyzes make it possible to differentiate the main types of questions that today individuals may ask themselves about their active lives some human beings are in such an economic and social situation that they can only ask one question what kind of labor can i immediately engage in to ensure my daily life survival this question is frequently asked by immigrants or women living in areas in economic decline other questions relate to the work what working life would allow me to become who i expect to be this type of questioning is that of people who relate to themselves as skills holders most often they have succeeded in their initial education and detain a capital of socially valued qualifications some people finally focus their thinking on the dimension of action they ask themselves what active life would allow me to contribute with others to the resolution of certain problems that we are facing such a question is at the basis of the thinking of citizens who enter into the social and solidarity economy it is also the bedrock of climate demonstrations organized under the impetus of figures like greta thunberg in summary each of the three questions encompassed into a life designing questioning can be summarized as follows • how can i ensure my survival • what working life could give me a good life • what can i do to contribute to a collective life that is good and just this threedimensional breakdown of peoples questions about the designing of their active lives leads to underlining the limits of the support interventions that are usually offered to them and more over to outlining ways to help them head towards a human equitable and sustainable future as summarized by the above quoted european definition of vocational guidance it usually aims to help clients give direction to their occupational career on the basis of an analysis of their actual and potential skills of their expectations of their interests and of their values such support refers exclusively to the second dimension of the active life it only considers it as work seen as the sole source of human construction as mary sue richardson wrote the discourse of vocational choice and the technology of matching persons and occupations based on interests and abilities that was the foundation of vocational guidance did not acknowledge that many people had to take whatever jobs they could get with no opportunity to engage in an idealized matching process thus the paradigm and discourse of vocational choice masked the ways in which choice was in fact very limited or even nonexistent for some this reductive approach to active life is still the premise of most research on career development and guidance in his last book mark savickas summarized it as follows as agent directing their own life through motivational schema and adaptation strategies individuals implement their selfconcept by constructing activity preferences or selecting workroles in which to pursue their career goals but as observed by david l blustein the notion of career is deeply embedded in a sociocultural framework that is relevant to only a minority of individuals around the globe this is why he has developed a psychology of working that seeks to embrace work that is engaged in for survival and work that is engaged in as a means of expressing ones interest in the world in other words not ignoring the first dimension of a questioning about active lifewhat labor to engage in for my survivalis a matter of great importance this is all the more so since as numerous studies underlined it more and more 1 3 international journal for educational and vocational guidance 22581601 jobs are labor a succession of piecemeal tasks endlessly started again and having no other purpose for the person who performs them than to earn a living charlie chaplin gives an image of such jobs in modern times if most theories of career development and vocational guidance ignore the vital questioning of a person who must engage in a labor in order to survive it is because they only consider active lives as working lives lives by which people construct themselves through the mediation of a development of their skills their interests their values etc but the role of skills interests values etc is very weakeven nilin entering a labor thus this syrian graduate male nurse a refugee in europe has had no other solution than laboring as a night watchman in a shopping center or again this young single mother holder of a beautician diploma living in an area in economic decline has as only possible source of income a repetitive and poorly paid labor of coding images for artificial intelligence software along with blusteins and richardsons analyzes the approach of life design dialogues for selfs construction is another exception to this usual reduction of the concept of active life to that of professional career these dialogues aim at helping individuals define future prospectsnot necessarily career relatedthat give meaning to their lives and commit themselves to see these prospects through to completion these dialogues refer to a model of identity construction that considers any individuals subjective identity as a dynamic system of identity forms identity is not seen as a monolithic substance but as an ongoing process of structuring and unifying various forms each of these forms corresponds to a life domain in which individuals act in certain ways and relate to themselves to others and to objects in specific ways these forms and the system they make evolve over time this identity dynamism originates in all phenomena that mark a life course as well as in the ways in which an individual makes sense of them this understanding of subjective identity as a dynamic process of unifying a system of identity forms highlights that one of these forms usually holds a central place in the systems organization at any given time this identity form then plays a major role in defining a future perspective by which a person gives hisher active life a meaning thus this nurse a refugee from syria who labors as a night watchman can set up with compatriots an organization aimed at facilitating their integration into european society likewise the young beautician coding images for artificial intelligence programs can devise with members of her community a local system for exchanging goods and services such activities are actions as hanna arendt understands this term acts by which a person seeks to contribute with others to the resolution of problems which affect them collectively this dimension of active lifea central dimension in some peoples construction of their subjective identitiesis generally not considered by the usual forms of lifelong guidance and counseling however it seems to have a bright future as shown by the growing number of young people who wonder with fear about what life will be like on earth when they are in the middle of their existence towards a shift to support action the observations that have just been recalledthe growth of labor the pending questions about our model of economic and social developmentlead to a same conclusion lifelong guidance and counseling as limited supports to careers construction of workers cannot cope with the challenges of todays world facing them supposes not to ignore the two other dimensions of any active life andmore particularlyto develop supports to action that aim to cope with the threedimensional crisis to which humanity has been confronted for more than three decades this crisiswhich is worsening from year to yearindeed combines three aspects first a critical problem of demography and social justice second major ecological issues and thirdly serious degradation of labor work and employment combined with these three dimensions is the current global pandemic that appears to be as noted just another manifestation of this global crisis it is now of such magnitude that the un general assembly adopted unanimously on september 25 2015 a plan of action to deal with it this resolution is entitled transforming our world the 2030 agenda for sustainable development many analysts illich castoriadis gorz serge moscovici bourg arnsperger etcconcluded that this deleterious state of affairs is the result of the current organization of the world economy solving this crisis requires therefore to profoundly transform our economic and social model and to question the current relations between mankind and nature how could life designing interventions become supports to action contributing to such transformations this is the core question of the works by the unesco chair for lifelong guidance and counseling and by the unescounitwin project life designing intervention for decent work and sustainable development that brings together about 20 universities around the world on the basis of a seminal principle and in relying on three major imperatives this chair and this network have outlined sketches of interventions supporting action towards such changes 3 international journal for educational and vocational guidance 22581601 seminal principle and imperatives of interventions supporting an action life designing an active life based on a founding principle the imperative of responsibility the founding principle of interventions supporting an action life designing is hans jonass imperative of responsibility the imperative of a sustainable economic development that is socially just the main objective of such interventions cannot therefore be that of an inclusion into the world of work as it is now differently it consists in helping clients think about their future in connection with targets such as those defined by the un in 2015 whilst bearing in mind the imperative of decent active lives for all as in lifelong guidance towards work and careers the reflection induced by the interventions supporting action life designing is about the knowledge knowhow interpersonal skills interests or values that the client intends to develop but their final interpretant what active life could stir their developments and give my existence a meaningis not the current world of work jobs functions careers unpaid labor etc their final interpretant needs to be progressively constructed by pondering first the various possible forms of organizing activities producing such good or service secondly the diverse possible forms of exchange of this product and thirdly the life form that each option would imply for the client and its consequences for other people these issues hark back to a single question which of these forms seem to best contribute to a sustainable and socially just development that equitably distributes the share of labor this issuereferred to a personcan be stated even more simply what direction could i give to my life so that by 2050 around 10 billion human beings can have a truly human life in a world of limited resources in order to allow everyone answer this question this support to an action life designing aims to contribute to the achievement of three imperatives implementing a universal labor law as it is known since the end of world war i the international labor organization s mission is to define regulations and standards guaranteeing decent working conditions everywhere in the world but the ilo only has an advisory role if it can think about the basic principles of a universal right to decent work it cannot enforce such law around the world however the current global ideological contextdominated by the belief in the benefits of economic competition that no principle of law should hinderis such that labor law far from developing is gradually being called into question in most countries gradually measures favorable to employees are deleted because they increase production costs and consequently place the companies subjected to them in a situation of unfavorable competition compared to those of other countries where the labor laws are more lax or nonexistent the different states are thus engaged in a competition with each other in the direction of an increasing fading of labor laws these changes have had the consequence of a development of modes of work organization and forms of employment which corrode the character cause mental attrition trigger burnouts induce occupational diseases and accidents at work and push certain employees to commit suicide in their workplace this is the reason why the implementation of a universal right to decent and human work is a priority imperative this implies that all citizens of the world are made aware of it and demand the inforcement of this right committing to the achievement of the un 2030 agenda for sustainable development given the ecological dimension of the current global crisis the imperative of establishing a universal labor law must be combined with that of equitable and sustainable development the above mentioned agenda adopted by the 2015 un general assembly details an action plan centered on 17 major goals and specifies targets corresponding to each of them a total of 169 targets to be achieved by 2030 are set for example goal 12 reads as follows ensure sustainable consumption and production patterns the third target under this goal states by 2030 halve per capita global food waste at the retail and consumer levels and reduce food losses along production and supply chains including postharvest losses achieving this action program involves political and economic decisions but it also supposes that each citizen reflects on herhis active life asking herhimself how shehe could contribute to the attainment of one or another of these goals this implies that everyone become sufficiently aware of these goals and targets in order to selecting those they will place at the core of their personal reflection reducing the human ecological footprint each year the global footprint network shows that mankind is living more and more beyond its means in terms of consumption of natural resources and the production of waste and various pollutions2 this phenomenon is mainly the result of the forms of life of the richest fractions of the world population the most affluent humans must therefore shift towards new lifestyle to quote the title 1 3 international journal for educational and vocational guidance 22581601 of the first part of the sixth chapter of the encyclical letter laudato si of pope francis of which paragraph 203 specifies since the market tends to promote extreme consumerism in an effort to sell its products people can easily get caught up in a whirlwind of needless buying and spending compulsive consumerism is one example of how the technoeconomic paradigm affects individuals the gadgets and technics forced upon him by the patterns of machine production and of abstract planning mass man accepts quite simply they are the forms of life itself this paradigm leads people to believe that they are free as long as they have the supposed freedom to consume but those really free are the minority who wield economic and financial power amid this confusion postmodern humanity has not yet achieved a new selfawareness capable of offering guidance and direction and this lack of identity is a source of anxiety for about thirty years economists have emphasized that reducing the ecological footprint implies to reterritorialize production and trade this means thatfor certain goodsshort circuits of production and trade replace world trade and that processing industries be developed near the places where natural resources are harvested therefore a world economy based on a principle of territorial subsidiarity needs to be created it consists in giving an all the more high priority to productions organizations and exchange systems than their ecological footprints are lower this principle leads to distinguish on the one hand goods that can only be designed manufactured and traded in a globalized trade system and the other productions that can be local regional or interregional depending on their immediate and longerterm ecological footprints it is therefore essential to develop local systems of production and exchange of goods and services forming the basic level of such an economic organization but as stressed by azam et al this requires a profound reform of the international monetary fund the world bank and the world trade organization which bear a heavy responsibility in the current crises therefore a transformation is needed of the underlying principles both of the organization of world trade and of global and intraeuropean trade treaties as a consequence supports to action life designing must both make citizens of the world aware of this imperative and help each of them specify the kind of active life shehe could design in order to reduce herhis ecological footprint two preliminary intervention projects supporting an action life designing based on this principle and in line with these three imperatives interventions supporting an action life designing have been outlined they are on the one hand an education for an active life designing aimed primarily at young people and on the other counseling workshops and dialogues mainly intended for adults designing decent and human lives acting for sustainable and fair world this remodeling of career education would include two parts • a learning about the essential role of active life of the modes of organization of labor work and action and of their forms of exchange in the construction of a common world and of each persons subjectivity this learning could be based on an adaptation to the levels of knowledge and reflection of the various groups of young people of works such as those of bergson arendt gorz dejours et al supiot linhart ilo etc this learnings goals would be to make participants aware of the role of the different forms of organization of labor work and action and of their exchanges in the development of individual talents of certain modes of relating to self and others and of representations of self and others and in the transformations of the world as a whole the objective would be to make young people aware of the deleterious consequences of some forms of work labor and action and of their exchanges and as a consequence of the fundamental importancefor individuals and the human communityof a universal right to decent and human work and labor • a reflection of each person on herhis future active life in view of contributing to the achievement of the goals and targets defined by the un 2030 agenda this reflection implies that the participants become aware of these different goals and targets that each of them selects those to which shehe would like to commit that shehe reflects on the forms of working likely to best contribute to the achievement of these targets that she he becomes aware of the talents shehe needs to develop in order to engage in such or such form of working and that shehe selects the best ways for developing these talents constructing active lives that minimize the ecological footprint and contribute to solidarity economy this intervention would be aimed first at adults wishing to think about the forms of active lives in which they couldcollectively or individuallyengage in order to minimize their ecological footprint and contribute to solidarity economy it would include a collective component and an individual moment international journal for educational and vocational guidance 22581601 • the objectives of the collective workshops would be to make participants aware of the need to reform the global system of organization of the production and exchange of goods in order to reterritorialize certain productions and to organize short circuits and to reflect collectively on the possibility of developing together in a certain geographical area a local system of production and exchange of goods and services • onetoone counseling dialogues would aim to help everyone think about their own active life on the basis of the imperatives of minimizing its ecological footprint and of contributing to solidarity economy in which working to engage for producing which durable and tradable goods or services and satisfying which human needs in what types of work organizations and exchange systems does the person have the opportunity and wish to participate in the organization of a local trading system etc conclusion two required conditions for constructing and implementing life designing interventions aiming at a sustainable equitable and human development as we have just seen lifelong career guidance refers back to only one of the three dimensions making active life which were distinguished by hanna arendt work as a result the future implicitly postulated by that guidance is that of functions considered skilled in current work organizations inserted into todays economic exchange system however the imperative to face the triple global crisis which has been worsening for more than three decades implies to develop interventions basedthis timeon the action dimension of active life interventions that help clients to designwith othersactive lives that head towards an economically sustainable and socially just future through the mediation of decent and human active forms of life two sketches of interventions of that kind nature have been outlined both are only outlines that deserve to be developed tested evaluated and no doubt revised before being offered to larger populations these sketches are based on the work of academics jurists and economists all of whom conclude that the current global crisis cannot be resolved without the institution of universal labor law and without radical reform of world trade organization such interventions aim on the one hand to sensitize addressees to the need for such reforms but on the other hand they take notice that as long as these reforms have not become effective all human beings will not be able to construct their future active lives within such a fair and sustainable future it is in this sense that this support is an action life designing an activity which by connecting human beings together creates a space for public debates and gives faith in and hope for a new beginning of the world these sketches of interventions are only examples other methodologies have already been constructed in addition developments are underway however in order for interventions supporting the designing of active lives fully contribute to resolving the current global crisis two conditions must be met on the one hand a development of systematic research programs and on the other hand the implementation of institutions offering these interventions to the public such research programs will first have to construct the concepts on which to base these new interventions leads have already been opened in this direction the concept of working has already been mentioned but other seminal works cannot be ignored for example the developmental contextualism model by vondracek et al the hermeneutical studies of lives in context by richard young and audrey collin the concept of goaldirected action by richard young and ladislav valach and those of constructing lives through working and relationship and of agentic action in context by richardson etc for its part the analysis model of activities forming the heart of a life by jacques pouyaud opens another avenue which starting from the notion of decent work has developed it scientifically within the frames of clinic of activity by yves clot and of psychology of personalization by jacques curie the concept of form of life should also find a central place in the renewal of this research domain form of life held a core role in the developmental psychology of the early twentieth century but throughout that century it underwent a series of devaluations which first has transformed it into types of men before giving birth in psychology to a quite different conception the typology of john holland updated the concept of form of life is now at the center of many works in philosophy sociology and political science and along with serge moscovici we can only plead for its regaining the place it should have never lost in psychology indeed the cornerstone of ecology is to create a new form of life the goal of ecology and it is indeed the role of the movement that must do these things is to create to think and to experience in order to get to new form of life more generally this research will need to undertake a radical critique of concepts that wereand still areat the core of current lifelong career development interventions indeed these conceptslike all those used for the government of self and others are outcomes of a triangulation a todays examination by a person of herhis various experiences and behaviors past and present from the perspective of the standards of a certain future state to be reached and of the required behaviors for achieving it in the case of current lifelong career development interventions the third pole of this triangulationthe future state to be reachedis the world of work of yesterday and today and the resulting concepts bear its mark career adaptation interest values etc are conceived from the point of view of such a future perspective it is therefore not surprising for 1 3 international journal for educational and vocational guidance 22581601 example that sprangers religious life form underwent a radical transformation to become a john holland type and that core values of sustainabilitysuch as solidarity dont appear in the repertoire of work values can such research be undertaken in the current context where the bulk of research funding often comes from contracts with various agencies and private companies nothing is less certain nor is it guaranteed that services and schemes supporting people towards equitable and sustainable development will created the report coordinated by anthony watts and colleagues in 1993 on educational and vocational guidance services in the european community unveiled a dividing line between a german model of organization of these services and an english project the german organization was that of public offices employing staff trained in a dedicated university whose missions were linked to the realisation of constitutionally rooted rights including protection of human dignity free development of personality equality of opportunity protection of family and the right of free choice of occupation place of work and place of training the british project consisted in transforming public career services into structures competing with each other in a quasimarket this organizational model was the correlate of an ideology considering that the sole purpose of support to career construction was to providing companies with the workforce they need to face economic competition guidance and counseling were thus seen only as a preparation of individuals for hiring processes over the past 30 years as a consequence of the power of neoliberal ideology in europe forms of organization of career construction services close to the english view were gradually set up in most european countries it is doubtful whether such servicesthe objective of which given their mode of financing can only be that of rapid integration of their clients into training or employment in todays world of workcould offer them interventions contributing to the development of fair and sustainable economy in an interview given on the occasion of the 2019 un general assembly antónio guterresits general secretarysaid recognize that we are not on track and then take the decisions necessary in investment in policies in changes of different forms of cooperation also at the international level or with the businesses the civil society the local authorities in order to come together more effectively to make sure that agenda 2030 is successfully implemented therefore today less than 10 years from the term in the context of the current pandemic we need more urgently than ever more investment more political action more priority to those aspects that are described in the goals that we have fixed to have a fair globalization to have a development that is simultaneously sustainable and inclusive in the field of supports for the construction of active lives such political action would consist in setting up schemes and public services helping people to direct their lives towards sustainableand socially justdevelopment and in providing researchers and practitioners with required means for developing ad hoc rigorous methodologies will the current pandemic be the wakeup call for such political action or as economist coriat thinks will it take recurrent pandemics for changes to occur publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations jean guichard is emeritus professor of psychology at the national conservatory of applied technologies former director of the national institute for the study of work and career development he is honorary chairman of the unesco chair in lifelong guidance and counseling at the university of wroclaw and unescounitwin international network life designing interventions for decent work and sustainable development

how could interventions for lifeand careerconstruction contribute to a development that would be ecologically sustainable socially just and based on decent work activities most career interventions today generally only aim to include individuals into the current systems of work and economic exchange without questioning the role that these forms of organization play in the terrible anthropocene crisis in fact these interventions only consider one of the aspects of active life distinguished by hanna arendt work they ignore labor and action dealing with this crisis therefore implies an indepth renewal of interventions for lifeand careerconstruction so that they become sources of action towards equitable and sustainable development by means of decent working activities transforming these interventions in this way supposes to base them on the principle of responsibility defined by hans jonas and to take into account certain political legal and ecological requirements renewed intervention methodologies have already been outlined however an actual development of such actioninterventions implies an indepth review of the conceptual field on which support to lifeand careerconstruction is based and the setting up of public or community services delivering them to the population keywords career development interventions • sustainable development • work résumé de lorientation professionnelle à la conception de vies agir pour un développement juste et durable comment les interventions daccompagnement à lorientation pourraientelles contribuer à un développement écologiquement soutenable socialement juste et reposant sur des activités décentes de travail les interventions daccompagnement à lorientation aujourdhui les plus courantes ne visent généralement quà insérer les individus dans les systèmes actuels de travail et déchanges économiques sans mettre en question le rôle que jouent ces formes dorganisation dans la terrible crise actuelle de lanthropocène en fait ces interventions ne consid jean guichard

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introduction inequalities in mortality have been observed in sweden for the last 50 years 1 and reducing them has been on the political agenda for more than 30 years 2 yet incomebased inequalities in mortality increased substantially in sweden during the 1990s and the early 2000s 3 4 5 6 similar trends have been observed in other nordic countries 5 7 8 and during the 2010s social inequalities in life expectancy continued to increase in sweden 9 10 less is known about recent trends in the shape of the incomemortality association and whether mortality in any specific part of the income distribution contributes to widening social inequalities in mortality a multitude of interrelated and complex processes that occur as intertwined processes across the life course contribute to the association between income and health 11 12 the most obvious processes are those related to social causation such as poor material conditions 13 reversed causation pathways where health impedes the ability to fully participate in the labour market and thus negatively affects a persons income 14 and various health behaviours for example smoking and alcohol consumption 15 in addition personal characteristics that are important to succeed on the labour market both cognitive and noncognitive confound the association between income and health 16 17 all these processes contribute to the often found nonlinear association between income and health the gradient tends to be stronger at lower incomes and weaker at higher incomes 5 1820 income and other socioeconomic assets have been suggested to be flexible resources that can be used to avoid health risks and to mitigate consequences that follow health strengths and limitations of this study ► total population register data allow for descriptions of trends that are representative of the population including older persons ► by analysing allcause preventable and nonpreventable mortality we can speculate about the causes behind increased health inequalities ► no information in the population registers on personal characteristics and behaviours limits further investigation of individuallevel mechanisms open access problems this is at the core of the theory of fundamental causes that posits that resources are potentially beneficial for health no matter what specific health risks are prevalent in a given context at any given point in time 21 22 however health risks can only be actively avoided or mitigated when knowledge on how to do so is available attempts to test the fundamental causes theory have been made by categorising causes of death according to how preventable they are if socioeconomic position is in any way causally related to mortality then deaths from causes that are less preventable should exhibit a smaller socioeconomic gradient and causes that are considered more preventable should exhibit a larger socioeconomic gradient in support of the theory studies often find stronger social gradients in preventable causes of death 21 2325 the relationship between income and mortality changes across the life course 26 and the importance of the contributing processes may change as the individual ages for example exposure to poor socioeconomic conditions during childhood and working life possibly has lasting effects on health throughout the life course 27 28 29 studies that have examined the association between income and mortality in different age groups have generally found smaller relative inequalities in old ages compared with young ages 5 30 fewer studies have examined absolute inequalities in different age groups however those that do generally find persistent or widening absolute inequalities in older age groups 31 32 except among the oldest old where income inequalities in mortality have been shown to converge 26 diverging trends between absolute and relative measures of inequality are commonly observed 33 both absolute measures and relative measures tend to be sensitive to the prevalence of the outcome this makes it difficult to compare inequalities in mortality across groups with large differences in absolute level of mortality for example when overall mortality is reduced in a population relative inequalities tend to be stable or increase while absolute inequalities tend to decrease 33 due to these properties it has been suggested that both relative and absolute measures of health inequalities should be reported 34 35 yet king et al 36 showed that of studies on health inequalities published in public health journals in 2009 only 7 reported both absolute and relative measures while 88 only included a relative measure based on previous evidence we expect that the incomemortality gradient has continued to widen since the 1990s and 2000s 4 5 7 9 moreover previous studies that examined trends in the incomemortality association primarily focused on workingage populations therefore we do not know whether the development has been similar among older persons finally if incomebased inequalities in mortality are widening due to increased social causation or social selection we expect that this increase is mainly driven by mortality from causes that are considered preventable aim in this study we investigate the development of the incomemortality gradient in 19951996 20052006 and 20162017 in sweden in three age groups more specifically we aim to investigate how the incomemortality gradient has changed between 1995 and 2017 if this change has predominantly occurred in any specific part of the income distribution if changes have been similar in all age groups and whether the development has been similar for causes of deaths that are more preventable versus less preventable we assess mortality inequalities between income groups using both absolute and relative measures methods data and participants the data used in this study were compiled from various swedish population registers and included the total population above age 30 years who were living in sweden during the years 19951996 20052006 and 20162017 in total 8 084 620 persons were observed across these three time periods many individuals were observed at more than one time point and the total midyear populations used for calculating death rates numbered 17 044 027 observations patient and public involvement the population register data used in this study are collected for use in official statistics and figures and for administrative purposes we did not involve patients or the public in the design conduct reporting or dissemination of our research statistical analyses allcause mortality was measured by agestandardised mortality rates per 100 000 personyears using the 2013 european standard population 37 age standardisation was performed to lessen the effect that changes in the age structure might have had on the incomemortality association between measurement points asmrs were calculated for three periods in 2year intervals for three age groups and by income deciles we repeated the analysis using the same age categories but without applying age standardisation observing similar patterns we classified causes of death as either preventable or nonpreventable this classification was adopted from mackenbach et al 24 and was similar to the classification that phelan et al 23 open access average was measured for the 5 years preceding mortality followup measuring the average income over 5 years reduces the impact of shortterm fluctuations in income that might occur during 1 year and lessens the impact that health complications can have on employment and income in the year preceding death 38 39 to make income comparable across different household compositions disposable household income was divided by the square root of number of household members income inequalities in mortality were assessed on a relative and an absolute scale by comparing mortality in the top and bottom three income deciles to the total mortality within each age group the relative difference was assessed by the ratio between the top or bottom three income deciles with the total mortality in the same group both the ratio and the natural logarithm of the ratio are presented to ease the interpretation of the nonsymmetrical properties of the ratio scale above and below 1 the absolute difference was assessed by the difference in number of deaths per 100 000 personyears locally estimated scatterplot smoothing was used to smooth the data in the visual presentations of mortality by income deciles 40 the loess method is nonparametric and fits multiple regressions that are weighted toward the nearest neighbour observation the underlying data and nonsmoothed plots are presented in online supplemental table 2 and figure 1 sensitivity analyses showing the shape of the incomemortality association using finer age categories and stratified by sex were performed results table 1 presents descriptive statistics for the analytical sample in this study in total 8 084 620 individuals contributed with 17 044 027 observations and 540 303 deaths during the study period most observations in the data were in the age group 3064 years and most observed deaths were in the age group 80 years previous research and routine data collection of incomes in sweden have shown increased income levels and inequality since the 1990s these trends were observed in the analytical sample the gini coefficient of the averaged incomes between 1990 and 1994 was 0213 and for incomes between 2011 and 2015 the gini coefficient increased to 0297 an increase in income inequality was observed in all age groups 1a the curve flattened between decile three and five with an earlier and a more pronounced inflection of the curve in 20162017 compared with 19951996 and 20052006 between 1995 and 2006 the largest mortality reduction was seen above decile four in 20162017 mortality was reduced across the complete income distribution absolute inequalities in the age group 3064 years were stable between 1995 and 2017 showing around 200 more deaths per 100 000 personyears in the bottom three income deciles compared with the average mortality rate in the sample in the top three income deciles there were around 100 fewer deaths per 100 000 personyears compared with the average mortality rate the combination of an overall reduction of mortality and only a slight decline of absolute inequalities resulted in an increase of relative inequalities among those aged 3064 years relative inequalities increased from 66 higher mortality in the bottom three income deciles compared with the average mortality in the sample in 19951996 to 104 in 20162017 similarly the top three income deciles showed 32 lower mortality compared with the average mortality in the sample in 19951996 this difference increased to 49 in 20162017 increased relative inequalities were thus driven by changes in both the upper and lower part of the income distribution expressed on the logarithmic ratio scale the estimates showed that this increase was slightly larger in the upper part of the income distribution a linear pattern in the incomemortality association was observed for those aged 6579 years in 19951996 during 20052006 and 20162017 tendencies towards nonlinear patterns were observed the incomemortality gradient was stronger below income decile four furthermore in the age group 6579 years mortality was reduced in all income deciles the decrease in the top three income deciles was 347 deaths per 100 000 personyears between 1995 and 2017 whereas the corresponding reduction in mortality in the lowest three income deciles was 197 consequently both relative and absolute inequalities increased substantially in this age group the bottom three income deciles showed an 18 higher mortality rate compared with the average mortality rate in the sample in 19951996 this difference increased to 55 in 20162017 similarly the top three income deciles had a 17 lower mortality compared with the average mortality in 19951996 this difference increased to 35 in 20162017 the logarithmic ratio scale confirmed that the relative increase of inequalities was constant across the income distribution increased inequalities in mortality among those aged 6579 years were thus driven by reductions in mortality that were substantially larger in the upper part of the income distribution compared with mortality in the lower part of the income distribution in the oldest age group the mortality pattern across income deciles shifted during the study period in 19951996 a nonlinear pattern was observed open access with a stronger gradient at low incomes while in 20052006 the incomemortality gradient was overall weaker and more linear in 20162017 again a nonlinear gradient was observed which in figure 1c was somewhat obscured by the large overall reduction in mortality in this age group a reduction in mortality occurred in the lowest and the highest income decile groups between 1995 and 2006 in 20162017 mortality had decreased substantially in all income decile groups in the oldest age group both relative and absolute inequalities thus remained stable at rather low levels during the entire observed period table 3 presents differences in mortality rates between the top three income deciles and the bottom three income deciles compared with the average mortality in the sample for preventable and nonpreventable causes of death in the age group 3064 years relative inequalities were substantially larger in preventable mortality compared with relative inequalities in nonpreventable mortality an increase in relative inequalities occurred in both preventable and nonpreventable mortality between 1995 and 2017 driven by changes across the whole income distribution similarly in absolute terms inequalities were larger in preventable mortality due to the large reduction of overall preventable mortality however absolute inequalities in preventable mortality decreased in contrast absolute inequalities in nonpreventable mortality did not change open access in the age group 6579 years relative inequalities were again larger in preventable mortality however the difference in inequality between nonpreventable and preventable mortality was small in 19951996 this gap grew during the observed period and relative inequalities in preventable mortality increased more than relative inequalities for nonpreventable mortality absolute inequalities were larger in preventable mortality in 19951996 20052006 and 20162017 compared with absolute inequalities in nonpreventable mortality despite reductions in mortality in both preventable and nonpreventable causes of death absolute inequalities increased in both groups in the oldest age group relative inequalities were at similar levels for preventable and nonpreventable mortality in 20162017 relative inequalities in preventable mortality widened somewhat compared with previous periods this change was mainly driven by lower absolute mortality in the upper part of the income distribution to test whether there were variations within the age groups that we choose we present crude death rates in 5year age groups in online supplemental figure 2 in the first seven 5year age groups the shape of the association was similar to the extent that it showed curvilinear associations at the three time periods across similar income deciles in the youngest age group the association deviated somewhat compared with the other age categories with much stronger associations in the lowest two income deciles and no association at higher income deciles in the age group that included the open access younger old all 5year age groups showed more linear trends in 19951996 and 20052006 and more curvilinear patterns in 20162017 among those aged 80 years and over there were somewhat more varied patterns but with similar tendencies in all included 5year intervals analyses stratified by sex are presented in online supplemental figures 3 and 4 as expected mortality was lower for women at all observed periods and income levels in the age groups 3064 years and 6579 years the overall shape of the associations was similar in the oldest age group the shapes between men and women were similar in 20052006 and 20162017 in 19951996 the shape was somewhat more curvilinear for women than for men discussion the results of this study showed that relative inequalities in mortality by income increased in sweden in the age groups 3064 years and 6579 years and that absolute inequalities increased in the age group 6579 years during the period from 1995 to 2017 relative and absolute inequalities in the oldest age group were low but showed increasing trends that were driven by increasing absolute inequality in the upper part of the income distribution the commonly observed curvilinear shape of the incomemortality association 5 1820 41 was most pronounced in the age group 3064 years in the age group 6579 years the shape of the associations shifted from linear in 19951996 to a more curvilinear shape in 20162017 in the oldest age group varied shapes were observed and in 19951996 the shape was more curvilinear for women than for men several studies have previously observed growing incomebased health inequalities since the early 1990s in sweden 3 4 5 6 hederos et al 3 examined how specific causes of death contributed to life expectancy changes and mortensen et al 5 studied the shape of the association in four nordic countries in 1995 and 2003 fors et al 6 showed that income differences in life expectancy increased also among older persons up to 2015 the current study contributes to a more comprehensive understanding of time trends in income inequalities in mortality using more recent data than has been previously available we examine both absolute and relative inequalities in mortality and present time trends in the shape of the income gradient in different age groups including older persons our results are consistent with previous research that has found smaller relative health inequalities among older persons compared with younger age groups 5 30 during the study period however relative income inequalities in mortality in the age group 6579 years increased substantially and were in 20162017 more similar to the levels in the age group 3064 years than they were in 1995 fewer studies have examined trends in absolute inequalities in mortality our results showed that in 19951996 absolute income inequalities in mortality were largest among persons aged 3064 years this changed in 20162017 absolute inequalities were at this time by far largest in the age group 6579 years these results show that health inequalities in sweden persist in older ages and if these trends continue future cohorts of older persons will experience similar or even higher levels of health inequalities compared with workingage persons age variations in the shape of the incomemortality gradient highlight the importance of considering agespecific processes these are shaped by agestratified institutions that individuals age in and out of such as the educational system the labour market and the tax and pension systems the organisation of these institutions may have consequences for the functional form of the incomemortality association in part since it affects income inequality the distribution of income is an important component in the incomemortality association we observed substantial increases in income inequality measured by the gini coefficient in all age groups increased income inequalities in sweden have been driven by higher top incomes 42 and in the 2000s by stagnation of benefits and reduced taxes on earnings that led to a growing gap between insiders and outsiders on the labour market 43 the latter changes are intentional consequences of political decisions several earned income tax credits were introduced between 2007 and 2019 as activation measures which meant that income from work was taxed significantly lower than other types of incomes including pensions moreover the universal guaranteed pension distributed to persons with no or low earnings during their working life is indexed to prices unlike the major earningsrelated pensions which are indexed to the real growth among older persons who aged into retirement during the late 1990s and 2000s this was reflected by increased income inequalities and growing relative poverty rates which may have contributed to the growing incomemortality gradient that we observed in the age group 6579 years in two different ways first the growing income differences between insiders and outsiders on the labour market are likely to have disproportionally affected the finances of people with poor health and traits associated with poor health resulting in a larger clustering of people with poor health at the bottom of the income distribution second to the extent relative poverty has a negative causal effect on health the increased rates of relatively poor retirees may have aggravated these health inequalities further along these lines the increasing income inequalities among workingage adults and older persons suggest that the distribution of pension incomes may be increasingly important for health inequalities as current and future cohorts enter retirement we observed the incomemortality gradient in both preventable and nonpreventable mortality however consistent with previous research the gradient was more pronounced in preventable mortality 21 23 24 between 1995 and 2017 income inequalities in mortality increased for open access both preventable and nonpreventable causes of deaths in the age groups 3064 years and 6579 years if social causation or social selection was the main driver for the increased inequalities in mortality that were observed we would expect a larger increase in inequality in preventable mortality based on the hypothesis that socioeconomic resources can be more effectively used to protect individuals against causes of death that can be prevented the results on the income gradient in preventable and nonpreventable mortality therefore suggest a more complex explanatory model where social causation social selection and health selection may all contribute to increased health inequalities 11 population register data do not offer direct measurements of respondents behaviours and subjective assessment of their situation this limits further investigations on how specific mechanisms influence the incomemortality association such as health behaviours or cognitive abilities we tried to overcome this by dividing mortality into preventable and nonpreventable causes of death however the conclusions that we can draw from these results are limited to only speculating what the underlying mechanisms might be conclusions the reduction of health inequalities has been on the swedish political agenda for more than 30 years 2 contrary to this goal the results from this study showed that in all age groups except among those aged 80 years relative inequalities increased over the last 30 years with no indication of slowing down one argument against a sole focus on relative inequalities is that they tend to be stable or increase when overall rates of morbidity and mortality are reduced in a population 33 it has therefore been suggested that absolute measures of inequality are better metrics to focus on in contexts of declining mortality rates 44 45 we showed that absolute inequalities declined only slightly in the age groups 3064 years were stable among persons aged 80 years and increased in the age group 6579 years in terms of health inequalities this development can hardly be considered a success contributors jr oö sf and jf contributed to the study conception and design data collection was done by oö data analysis was performed by jr the first draft of the manuscript was written by jr all authors commented and contributed to all iterations of the manuscript all authors read and approved the final manuscript jr is responsible for the overall content as guarantor competing interests none declared patient and public involvement patients andor the public were not involved in the design or conduct or reporting or dissemination plans of this research patient consent for publication not required ethics approval the use of data for the purposes of this study was granted by the swedish central ethical review board provenance and peer review not commissioned externally peer reviewed data availability statement data may be obtained from a third party and are not publicly available the data used in this study were collected from swedish administrative registers these data can be requested for research use from statistics sweden and the national board of health and welfare to apply for the data an ethical permit is needed which can be obtained from the swedish ethical review authority supplemental material this content has been supplied by the author it has not been vetted by bmj publishing group limited and may not have been peerreviewed any opinions or recommendations discussed are solely those of the author and are not endorsed by bmj bmj disclaims all liability and responsibility arising from any reliance placed on the content where the content includes any translated material bmj does not warrant the accuracy and reliability of the translations and is not responsible for any error andor omissions arising from translation and adaptation or otherwise

objective we investigate recent trends in income inequalities in mortality and the shape of the association in sweden we consider allcause preventable and nonpreventable mortality for three age groups 3064 6579 and 80 years design and setting repeated crosssectional design using swedish total population register data

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psychological development during the transition from childhood to adulthood happens within the context of an expanding network of social relations the details of which depend on cultural and historical context socialization environments and material affordances one of the most striking aspects of the socialization environment in western cultures in the early part of the 21st century is that adolescents and emerging adults have a variety of communication technologies at their disposal to manage quickly and efficiently very large webs of social connections nowhere is this expanse of social connections more clearly articulated than on social networking sites such as facebook the most popular social network in the united states and the fourth most visited website on the internet from a sociocultural and historical perspective on human development it is not hard to imagine that the prominence of facebook as a cultural phenomenon in the lives of college students in the united states would frame and shape developmental issues salient to them certainly the current generation of college students has experienced an adolescence permeated by online peer interactions estimates are that 90 of undergraduates on the majority of college campuses and 90 of high school students use social media sites creating online profiles of themselves and adding other users to their lists of friends on the network as they build these social networks college students collect large numbers of facebook friends a recent study finds the median to be 300 and numbers sometimes reach into the thousands the trend for large networks raises questions about the changing nature of friendship for the new generation of digital natives namely does facebook engender an orientation toward popularity and large numbers of friends at the expense of reliable social support from close friends and the development of skills for intimate relations in order to begin to understand the nature of facebook friendship and its implications for social development during the transition to adulthood we examine the anatomy or friend composition of college students facebook networks and its implications for social interactions life satisfaction and perceived social support close relationships and intimacy development in emerging adulthood learning how to maintain close intimate relationships has long been considered a central developmental task during emerging adulthood defined broadly by sullivan as closeness intimacy has been operationalized as disclosure of private information requiring high levels of trust and confidentiality between partners intimacy begins to appear in friendships during early to midadolescence but does not advance to more mature levels until late adolescence and emerging adulthood the period that is the focus of the present study intimacy in relationships is just one of the social resources that quality close relationships can provide during the developmental period spanning from adolescence to adulthood friendships grow as a source of companionship and support for selfesteem and as a source of instrumental support in complement to familial social support research with emerging adults shows that those who report an increase in social support over the course of emerging adulthood show increases in psychological wellbeing whereas low perceived social support among college students is related to depression and loneliness to what extent and in what way is intimate selfdisclosure transferred to an online social networking site how does the nature of the online social network and the nature of online communication relate to a sense of social support these are some of the questions addressed in the present study developmental tasks projected online as the internet becomes increasingly integrated into the socialization contexts of youth salient developmental tasks such as identity and sexual development are projected literally and metaphorically onto computer screens for example in the area of identity development myspace facilitated a heightened focus on selfconstruction for college students when it was a popular social networking site other studies have supported these findings another developmental task salient during emerging adulthood intimacy development seems to be refracted in two different directions as it is transferred onto the screens of social network sites depth and breadth both appear to be important to healthy development during emerging adulthood intimate close relations are widely regarded as conducive to psychosocial wellbeing and breadth in social relationships is integral to the process of expanding social circles as young people experience broader horizons in their development toward adulthood evidence for depth in online interactions comes from surveys indicating that facebook is used in the general population to maintain ongoing communication with close rather than distant relations social networking sites create opportunities for young people to nurture friendship intimacy in one college sample more intense facebook use was associated with higher perceptions of emotional support in another 20 asserted that myspace brought them closer to their friends perhaps having multiple modes of communication media multiplexity enables continual steady contact with close others which could increase intimacy college students also capitalize on social network sites to acquire breadth in social relationships ellison and colleagues found that the more intensely college students used facebook the more they perceived that they were integrated into their university community and the more confident they were in their ability to secure support from distant high school and hometown relationships recent studies showed that the strongest association with the intensity of facebook use is the accumulation of informational forms of social support from distant kinds of contacts this finding suggests that facebook is particularly conducive for maintaining large networks of weak ties because the technology allows for cheap easy and efficient maintenance of these relationships a prevailing and unresolved question is whether these expansive social networks might present a socialization context that encourages superficial relationships more than close connections as college students facebook networks have grown larger over the past few years the association between intensity of facebook use and perceived emotional support seems to have disappeared in the present study we examine the relationship between network size and perceived social support to see whether the growth of social networks has led to dissociation between facebook use and a sense of social support from close relationships we also look at the anatomy of the friendship network to consider whether other kinds of online relationships are associated with a sense of social support another possibility is that only reciprocal and direct exchanges with close others on facebook are associated with feelings of social support decreased loneliness and higher life satisfaction this finding suggests that type of facebook communication matters for a sense of social support and wellbeing we explore this issue in the present study particularly focusing on the distinction between private and public communication modalities one important question is whether intimate selfdisclosure is becoming more public through status updates broadcasted to ones entire network of contacts and whether this kind of selfdisclosure is associated with perceived social support among college students facebook in the context of sociocultural change in the current study we consider the influence of facebook on emerging adults social development through the lens of sociocultural and historical change this point of view provides important perspectives on how humans adapt to culture change through socialization and psychological development it also raises questions about what is enduring in humans social and emotional architecture and what characteristics shift in response to new social circumstances greenfields theory of social change and human development suggests that societal change in the direction of increasing urbanization structural complexity wealth commerce or technology shifts socialization toward increasing individualism and social relations toward an increased number of relationships many of which are both evanescent and with complete strangers in smallscale rural low technology environments strangers are rare or nonexistent and family cooperation is necessary for survival in sharp contrast lifestyles in complex urban hightech environments require adaptations that feature independent values and behaviors as well as instrumental relations with strangers indeed manifold instrumental relations with strangersfor example the clerkcustomer relationshipis a documented effect of the shift from urban to rural residence the theory predicts that technology like urbanization will enable manifold instrumental relations with relative strangers or superficial acquaintances data suggest that not only are wealthier countries more individualistic than poorer countries but also that individualism in the united states is increasing as a function of the growth of technology for example uhls and greenfield have observed a correspondence between the rapid growth in internet penetration in the united states and a sharp increase in narcissistic personality among college students after the year 2000 one facet of individualism this correlation supports greenfields theoretical assertion that technology is currently the motor driving increasing individualism performing for an audience is one aspect of narcissistic personality another component of which is inflated selfesteem both are individualistic traits because the possibility of a large number of friends on facebook facilitates performing for an audience the theory would predict a correlation between network size and estimated audience size as well as a correlation between estimated audience size and selfesteem these predictions were tested in the present study if social networking sites are truly transforming the nature of social relations we can go one step further and ask whether facebook is a socialization context that drives college students toward deriving feelings of wellbeing and perceived social support from having large networks of connections and receiving attention from them this question was explored in the present study the theory of social change and human development also predicts that technology will shift networks of social relationships away from a smaller number of relationships serving less differentiated functions toward a larger network of relationships serving more differentiated functions the logic behind this prediction is that as technology affords more opportunities to connect easily and efficiently with expanded networks of social relations human psychology adapts by increasing network size and creating specialized functions for different network members because of the limitation on the number of genuinely social relationships an individual can have we predict that friendship networks on facebook will grow predominantly by adding instrumental relations rather than emotionally close relationships to examine these issues we designed a survey study of college students that could address the following hypotheses and questions current study and analytic plan research hypotheses and questions are broken down into three main topics anatomy of the facebook network relationship between anatomy and communication behaviors and psychological implications of facebook use the first set of analyses quantitatively describes the anatomy of college students facebook networks and how anatomy changes with increasing network size next using linear regression we look at how proportions of particular types of friends and network size relate to facebook communication behaviors finally we use hierarchical linear regression to examine what kind of network composition and what facebook communication behaviors predict life satisfaction and perceived social support through facebook because we were interested in examining whether particular uses of facebook would predict greater life satisfaction and higher perceived social support beyond the positive effects of selfesteem we controlled for selfesteem in these regression analyses hypotheses anatomy of the facebook network 1 in line with greenfields theory we predict that friendship networks will be composed primarily of acquaintances activity contacts onlineonly contacts and strangersrelatively superficial and instrumental relations close and maintained connections will be in the minority 2 we predict that relative to close relations networks will grow by adding a disproportionate number of superficial relations communication behaviors and network composition 3a we predict that emotional selfdisclosure an important feature of intimacy will predominate in status updates thus transforming from private forms of expression to more public forms of expression 3b based on greenfields theory we predict that having larger networks of social connections on facebook translates to perceptions of larger audiences for status updates if this is the case and if status updates are used primarily for emotional selfdisclosure then it follows that facebook is transforming the nature of intimacy in the individualistic direction of public performance 3c we hypothesize that higher estimates of the audience size observing ones status updates will occur in networks including a greater number of distant social connections 4 in line with the traditional nature of intimacy we hypothesize that private messages will be used more when friendship networks comprise a higher proportion of close and maintained connections 5 conversely we hypothesize that the more public modalities of communication will be used more when friendship networks comprise a higher proportion of more distant relations psychological implications of facebook use 6 based on greenfields theory we predict a positive correlation between selfesteem and audience size deriving self3 anatomy of facebook network esteem from attention to the self is a psychological adaptation in a highly individualistic socialization context 7 do higher proportions of close connections on the network or larger networks filled with more distant kinds of relations predict college students life satisfaction the former is in line with traditional notions of the importance of a few trusted friends for young people the latter in line with greenfields theory would suggest that sources of psychological satisfaction are changing to adapt to the potential for using facebook to collect large networks of connections comprised primarily of more superficial relations 8 does having more private communication exchanges public communication exchanges larger audiences for ones status updates or larger proportions of facetoface contacts on the facebook network predict life satisfaction in other words does facebook help emerging adults meet enduring needs for close intimate relations or does it help emerging adults meet individualistic psychosocial needs will using facebook for close intimate exchanges be most associated with life satisfaction or alternatively as greenfields theory would predict does facebook emphasize individualistic experiences of friendship such that college students derive more life satisfaction from facebook when the tool is used to gain garner attention from ones facebook public 9 do higher proportions of close friends on the network or larger networks filled with more distant kinds of relations predict perceptions that one has available social resources through facebook in other words do emerging adults seem to find social support through depth or breadth on facebook 10 which activities and network structures are associated with perceptions of facebook as a tool useful for acquiring social support private communication exchanges and larger proportions of facetoface contacts the more traditional source of social support alternatively in line with greenfields theory is it public communication exchanges and larger audiences for ones status updates that better predict higher perceptions that facebook is a useful tool for social support method participants eightyeight undergraduate students from university of california los angeles participated in this study the ages of the 67 female and 21 male students who participated ranged from 18 years to 28 years there were 39 juniors 23 seniors 16 sophomores and eight freshmen ethnic makeup was 36 asiansoutheast asian american 27 european american 19 latino american 8 middle eastern american 2 pacific islander american and 8 mixed ethnicities combining asian european and african ancestries current access to a social network account was required to participate in this study because 95 of participants actively used facebook the studys label was switched from being a general social networking site study to a facebook study procedure participants upon online sign up received a link to survey monkey participants were given a series of questions including demographic data and general facebook routines while having their facebook profile open they were also asked about their general facebook activity most central to the study they were asked a series of questions for 20 friends in their network including how they would classify the friend how often they communicate with this friend via various facebook applications and whether they see this person in their offline worlds the next section describes the method used for unbiased selection of the 20 friends lastly participants filled out psychological measures sampling the friendship networks while our original intention was to ask questions about participants entire social network the large size of most social networks made that procedure too long and tedious hence we asked participants to sample 20 friends from each network a number that was doable by participants and convenient for calculating percentages participants were instructed to make this selection with their facebook open to their profile and to use the friend list that displayed their entire network in order for participants to select 20 friends without bias a systematic selection method was devised and included in the instructions when the data were collected in 2009 there was only one option on facebook for viewing a list of friends on the network all of the users friends were listed alphabetically by first name we did not ask participants to take the first 20 friends on their friends list because consistently sampling friends from the beginning of the alphabet could have introduced bias into the selection process therefore participants were asked to take their total number of friends divide that number by 20 take the answer and round it down to the lowest whole number lastly participants were asked to count by that whole number down their friends list providing information for each friend at whom they stopped until information for 20 friends had been filled out for example if network size was 160 and they divided by 20 their final number would be eight they would then provide information for every eighth friend which should bring them to the end of their friends list we piloted this procedure with 10 participants who were able to follow the directions quite easily as a consequence of this procedure we sampled a different proportion of friends for participants with different sized networks for smaller networks the sample of 20 friends was a higher proportion of the total network for larger networks the sample of 20 friends was a lower proportion of the total network however if we had instructed each participant to use the same percentage of his or her network we would not have been able to equate the absolute sizes of the samples of friends across participants it is intuitively clear that equating percentages would have yielded samples that were too small for those with small networks or samples that were too large and unwieldy for those with large networks in contrast a sample of 20 seemed large enough to include various categories of friends but small enough to be 4 manago taylor and greenfield manageable by the participants given that there were multiple questions asked about each friend selected measures network size participants reported the size of their network by looking at the number of friends listed on their profile page nineteen participants did not report network size and therefore were removed from analyses that used network size categories of friends participants were asked to check only the most accurate and intimate option describing their relationship with each of the 20 friends that were sampled from their networks according the following categories family member current boyor girlfriend best friend very good friend good friend roommate teammate classmate fraternity brother or sister fellow club member coworker high school friend past romantic partner friend of a friend acquaintance floormate casually dated met in a different country met only once online friend only band or musical artist do not know this person and other participants were given the instruction that participant bs best friend can also be considered as a high school friend however she clicks the option for best friend since this is the most accurate and intimate choice to describe the nature of her relationship with this friend to simplify the distribution of types of friends we categorized the reported types of relationship in the following way close ϭ best friend very good friend good friend current boyor girlfriend family member or roommate acquaintance ϭ friend of a friend acquaintance floormate casually dated met in a different country or met only once activity ϭ teammate classmate fraternity brother or sister fellow club member or coworker maintenance ϭ high school friend or past romantic partner online only ϭ online friend only or band or musical artist stranger ϭ do not know this person and other ϭ other decline to answer to obtain a percentage of these friend categories we divided total number of friends in each category by 20 to estimate absolute numbers in each category we multiplied percentage of friends in each category by participants reported number of friends in their network to simplify analyses we then combined acquaintance and activity friends into one category superficial communication with facebook friends participants were asked to estimate how often they communicate with each of their 20 selected friends publicly they were also asked how often they communicate with that friend privately participants characterized exchange frequency on a 0 7 scale the overall average of public communication with this random selection of 20 friends was created by averaging the frequency of exchanges of wall and photo posts across 20 friends the overall average of private communication with these 20 friends was created by averaging the frequency of private messages sent and received through facebook across 20 friends in addition participants indicated whether they had facetoface interactions with each of the 20 friends we divided total number of people with whom participants reported facetoface interaction by 20 to estimate proportion of people in the network with whom participants had offline relationships status updates the status update is a facebook feature that allows users to post messages that automatically go to the news feed portion of every profile in ones entire network of facebook friends participants were asked to indicate how they typically use their status update by selecting all that applied from the following categories listed here in the order they were presented keep people updated on where you arewhat you are doing voice your opinion on a current event convey your current emotional state vent frustration satire or other then they were asked how many people they estimate are looking at their status updates by selecting one of these categories 1 ϭ 0 10 2 ϭ 1130 3 ϭ 3150 4 ϭ 5180 5 ϭ 81100 and 6 ϭ more than 100 life satisfaction the students life satisfaction scale was adapted to assess global life satisfaction participants rated agreement on a 5point likert scale for nine statements selfesteem the rosenberg selfesteem scale is a 10item selfreport measure of global selfesteem each item is scored on a 4point likert scale half the items are positive half are negative and are reverse coded perceived online social support a measure of perceived online social support was adapted from the interpersonal support evaluation list a multidimensional inventory used to evaluate perceived availability of social support a subset of questions was adapted from the subscales of companionship support emotional support and instrumental support for example there are several people i trust to help me solve my problems was adapted as there are several people i trust on my friend list to help me solve my problems and when i feel lonely there are several people i can talk to was adapted as when i feel lonely there are several people online that i can talk to using a social networking site on the internet participants indicated the extent to which they agreed with the statements on a 5point likert scale results anatomy of the facebook network network composition size of network reported by participants ranged from 29 friends to 1200 friends the most common network size as indicated by 20 of participants fell in the range between 200 friends and 299 friends the mean was 440 and the median was 370 analyses with network size include only participants reporting network size figure 1 shows on average reports of the specific friend categories comprising the networks out of each participants 20 friends on average 27 were acquaintances 24 were activity connections 21 were close connections 18 were maintained connections 4 were strangers 2 were online connections and 4 were classified as other the distribution of friend types confirms hypothesis 1 that close contacts and maintained contacts are in the minority among facebook friends together constituting just 39 of the network multiplying participants percentages of friends for each category by their reports of total network size yielded an estimate of the absolute number of friends in each category on average participants reported having within their networks 123 acquaintances 120 activity connections 80 close connections 77 maintained connections 17 strangers 16 others and 7 online connections all of the types of friends except for close connections and maintained connections are superficial types of relationships or strangers these data further demonstrate that college students use facebook primarily to collect large webs of superficial connections the relationship between network size and network composition absolute number of superficial connections correlated closely with network size r ϭ 90 p ϭ 0001 absolute numbers of close connections also increased significantly with increasing network size r ϭ 43 p ϭ 0001 however as suggested by the smaller correlation this expansion occurred at a slower rate as reported network size increased the proportion of friends participants labeled as close connections decreased significantly r ϭ ϫ33 p ϭ 006 while the proportion classified as superficial connections increased significantly r ϭ 35 p ϭ 003 these data confirm hypothesis 2 networks grow on facebook primarily through relatively more distant kinds of relationships whereas close contacts also expand with increased network size they do so to a lesser extent absolute number of strangers was significantly correlated with network size albeit relatively weakly r ϭ 25 p ϭ 040 while proportion was not r ϭ 03 p ϭ 815 hence while the number of strangers does increase as networks grow larger it does so at a lower rate than superficial connections but at a higher rate than close connections in summary college students with large facebook networks are expanding those networks primarily from their involvement in extracurricular activities and acquaintances secondarily through adding strangers and thirdly by adding close contacts communication behaviors associated with facebook use and network composition overall participants reported spending on average a little over an hour a day on facebook they reported checking into their accounts quite frequently 80 report logging on to facebook multiple times a day and on average they reported updating their status a few times a week table 1 shows the correlations between communication variables network size and categories of friends status updates the most frequent use of the status feature reported by participants is to convey ones current emotional state this confirms hypothesis 3a that emotional selfdisclosure a key feature of intimacy estimated audience for status updates we predicted that a larger network translates to perceptions of larger audiences for ones status updates the most common estimate of audience size was 10 50 people 50 percent of participants estimated that between 10 and 50 people are looking at their status updates 24 estimate over 50 people are looking at their status updates 23 estimate that less than 10 people are doing so indeed the larger ones network the more people college students perceive are looking at their status updates r ϭ 405 p ϭ 001 this correlation between the size of the network and the size of the estimated audience for status updates supports hypothesis 3b users with larger networks are aware of their friendship network as audience for the self to explore what network anatomy is associated with audience size for status updates we conducted a regression analysis entering absolute numbers of each kind of friend to see which kind of friend predicted larger estimated audiences for ones status updates we entered absolute numbers of close connections maintained connections superficial connections onlineonly connections and strangers as independent variables into the regression model according to hypothesis 3c numbers of superficial connections onlineonly connections and strangers should be significant predictors while the overall model was significant only number of close connections and strangers emerged as significant predictors in the model these results differ from the predicted pattern they suggest two routes to perceiving that one is receiving attention and feedback for expressing oneself via public status updates having many close friends on the network and having a relatively large collection of unknown others as potential onlookers or fans private communication to explore what type of friendship network is associated with use of private communication modalities on facebook a regression analysis was conducted to explore which categories of friends would predict more frequent private communication exchanges this analysis was based on participants reports of private communication via messages on facebook with the 20 selected friends we entered proportion of close connections maintained connections superficial connections onlineonly connections and strangers as independent variables into the regression model variables in the model are summarized in table 3 the overall model is significant and proportion of close connections drives the model it is the only category of friend significantly predicting reports of frequency of private communication hypothesis 4 is partially confirmed the more intimate modality of private messaging on facebook is more frequent when friendship networks comprise a higher proportion of close but not maintained connections public communication to explore what type of friendship network is associated with the use of public facebook modalities a regression analysis was conducted to identify which categories of friends would predict more frequent reports of public communication with the 20 selected friends again we entered proportion of close connections maintained connections superficial connections onlineonly connections and strangers as independent variables into the regression model variables in the model are summarized in table 4 once again the model is significant and only the proportion of close connections predicts public communication exchanges this finding that college students are more likely to be communicating via public modalities on facebook with close connections suggests that contrary to hypothesis 5 the central feature of facebook communication public posting is generally not utilized to communicate with distant others rather facebook facilitates interactions between close relations to take place in the virtual public psychological implications of facebook use table 5 shows the correlations between the measures of wellbeing communication patterns and categories of friends relationship between audience size and selfesteem as predicted in hypothesis 6 there was a significant positive correlation between estimates of audience size and selfesteem r ϭ 24 p ϭ 018 larger audiences are associated with higher selfesteem lifesatisfaction and network composition are college students deriving happiness from intimate friendships on facebook or from expanded networks and popularity on the site to explore the kinds of facebook networks that are associated with college students life satisfaction we conducted a regression analysis entering proportions of close connections maintained connections superficial connections and network size as independent variables into the regression model with selfesteem as the covariate the variables in the regression are summarized in table 6 which shows that the model is significant after controlling for selfesteem and only size of the network predicts college students life satisfaction proportions of close connections and maintained connections show larger standardized coefficients than proportion of superficial connections however they were not statistically significant in response to question 7 these data suggest that emerging adults who take advantage of facebook as an efficient tool for collecting large networks of friends rather than using it to maintain a network more dense with close and enduring friendships are happier with their lives lifesatisfaction and facebook use next we explored what particular uses of facebook are associated with higher life satisfaction exchanges of public communication exchanges of private communication having larger audiences for ones status updates or having larger proportions of contacts in the network with whom one has a facetoface relationship we again entered selfesteem as a covariate variables in the regression models are summarized in table 7 the models were significant but it was only higher estimates of numbers of people observing ones status updates that emerged as a marginally significant predictor of life satisfaction above and beyond selfesteem answering question 8 this finding suggests that emerging adults who use facebook derive more life satisfaction from their friendships in the virtual world when they perceive they function as an audience rather than when they have more mutually reciprocal private or public exchanges or more offline relationships within their online networks social support and network composition what kind of friendship network is associated with viewing facebook as useful for procuring social support to answer this question a regression analysis was conducted entering proportions of close connections maintained connections superficial connections and network size with selfesteem as a covariate predicting our measure of social support table 8 summarizes the variables in the two models both of which were significant controlling for selfesteem higher proportions of friends labeled as maintained connections in the network and larger network size significantly predicted positive attitudes toward facebook as a tool that is useful for garnering social support those with more friends from the past on their network primarily high school friends and those with larger networks are more likely to feel social support on facebook social support and communication finally we explored what aspects of facebook useprivate communication exchanges public communication exchanges estimated audience size and proportions of facetoface relationships on the networkwould predict perceptions that facebook is a useful tool for acquiring social support again we entered selfesteem as a covariate as seen in the summary of variables in the model in table 9 the models are significant overall and higher estimates of an audience size for ones status updates is marginally significant predicting perceived social support above and beyond the effects of selfesteem the more that college students feel that they are receiving attention for their selfexpressions the more likely they are to feel that facebook is a useful tool for acquiring social resources these data together with the associations between estimated audience size and life satisfaction demonstrate the importance of attention from ones facebook public as a pathway to feeling better about ones life and ones social resources discussion network composition we confirmed our hypothesis that facebook facilitates large impersonal social networks we can put this finding in historical perspective by relating it to past research that shows networks are getting larger over time from data collected by childrens digital media center los angeles in 2006 the average network size for college students was estimated at 137 data collected in 2007 led to an estimate of 185 with the estimate rising to 225 for data collected in 2008 all three studies were carried out with college students in the same city los angeles the latter two estimates were from data collected at the same university ucla steinfield et al reported that the average number of college students facebook friends at michigan state university increased from 223 in 2006 to 339 in 2007 the present data collected in 2009 shows yet another increase now to a median of 370 and mean of 440 friends differences between the studies notwithstanding the trend toward ever larger social networks is unmistakable also in support of our hypotheses relatively superficial relations formed the majority of participants facebook networks in addition networks grew by adding disproportionate numbers of these superficial relations as networks grew larger participants also added to their stranger contacts and close connections nonetheless the significant positive correlation of network size with number of close connections also suggests the transformation of close relationships as ever increasing numbers of close connections mean that intimacy must be attenuated for any given dyad this conclusion is supported by the fact that the mean number of close connections in this sample of emerging adults was 80 communication on facebook expressing ones current emotional state dominated use of facebooks statusupdate tool a feature for broadcasting oneself to ones entire network usually numbering in the hundreds this finding indicates that selfdisclosure a hallmark of intimacy has gone public transforming the nature of intimacy development for emerging adults participants with larger networks estimated larger audiences for their status updates more specifically larger numbers of both close relations and strangers predicted larger audience estimates thus facebook appears to be a tool for transforming both close connections and unknown others into audiences for individualistic selfdisplays we also found that participants with relatively more close contacts more frequently communicated both privately and publicly on facebook the finding implies that public performance has been added to private communication transforming the nature of close relations on the one hand the persistence of private communication used with close relations suggests the enduring nature of intimacy in close relations within the socialization context of facebook on the other hand the movement of interactions between close connections into the public eye suggests a mechanism by which interactions between close friends are transformed on facebook from the exchange of emotional support to the showcasing of social skills like earlier research this study suggests that college students increasingly construct their social identities through public performances on social network sites college students public interactions with friends on myspace allowed them to demonstrate social skills and connections to large audiences and sometimes reinforced closeness between friends through the process of committing publicly to the relationship the potential to enact both selfdisplays and relationship displays on facebook may further socialize emerging adults to focus on the construction of personal and social identities for a public audience in line with greenfields theory performance for an audience is an individualistic turn in the development of emerging adults life satisfaction and social support participants reports of larger networks and larger estimated audiences for status updates predicted both life satisfaction and perceived social support proportion of close contacts did not these findings constitute evidence that emerging adults are adapting psychologically to the affordances of social network site tools whereas other studies emphasize instrumental benefits of large networks of superficial relations our study points to another potential benefit of large networks for the current generation of emerging adults more attention from dunbars estimate that the maximum number of people with whom an individual can have a genuinely social relationship is 150 researchers have posited that the remaining contacts in college students networks may serve as collections of latent ties relationships that are available but not yet activated or engaged our findings indicate that college students may derive life satisfaction and social support from these latent ties as they comprise the audiences for their selfdisplays and relationship displays indeed as predicted there was a positive relationship between selfesteem and estimated audience size we do not know whether high selfesteem leads to higher estimates of audience size or larger perceived audiences are a source of selfesteem if the latter is the case then the new possibility of large audiences created by social networking sites would tend to inflate selfesteem augmenting narcissistic personality traits this interpretation is in line both with twenge et als finding of a jump in narcissistic personality in the present decadeduring which facebook and other communication technologies have evolvedand the prediction from greenfields theory of social change and human development that the expansion of technology produces increasing individualism data concerning connections among larger networks estimated audiences for the self and measures of wellbeing suggest that one source of psychological adjustment for todays young people may be attention from an audience as they adapt to the affordances of social network sites in this way facebook may be a feature of the technological environment that is both expressing and contributing to the documented increase in narcissistic personality of todays college students driven by the rise of new communication technologies the sharp increase in narcissistic personality traits in the last decade parallels the rise of fame and fall of community feeling as values presented in popular family and preteen television shows in the united states in this same period the current study suggests that tools for public selfdisplays on social network sites may be one way young people today enact increasing values for fame and attention in line with greenfields theory of social change and human development new communication technologies augment an individualistic focus on the self another important result of this study is that college student participants who were most highly convinced of the usefulness of facebook for procuring social support were those with higher proportions of maintained connections this finding is consistent with large surveys from the general population of adults showing that large proportions of facebook social networks comprise friends from the past primarily high school friends and that facebook users have higher levels of perceived social support than do nonfacebook users these contacts from the past have been termed by ellison and colleagues as maintained social capital in fact social networking sites may be important new psychosocial adjustment tools for emerging adults in particular to adapt to the increased mobility of modern society prefacebook studies on friendship during the transition from high school to college found declines in precollege friendship quality and satisfaction and associations between concerns over losing high school friends and higher levels of emotional distress and college maladjustment on the other hand college students who are able to maintain communication with high school friends report being less lonely and better adjusted to college life electronic communication such as email and instant messaging helps college students maintain distant high school friendships even more so than do facetoface communication or phone calls in addition the ability to stay in touch with high school friends through social networking sites buffers college students emotional distress associated with friendsickness limitations and future directions the fact that we did not assess participants entire networks is a limitation although systematic sampling of the friend network while participants were online was a methodological advance other limitations in our study include a small sample a high proportion of women and the fact that participants voluntarily signed up for the study which may have biased our sample to those who are active users and interested in facebook others have found that women are more active communicators on facebook especially public communicators and thus our results may have largely been driven by womens proclivities in addition there may be other modalities not assessed in this study by which college students may be developing skills for intimacy with close friends and family the present study has limited its focus to facebooka highly popular socialization context that promotes a particular orientation toward social relationships and drives social development in a particular direction in this study we have attempted to study social change indirectly by inferring emerging adults psychological adaptation to facebook at one point in time for stronger inferences concerning social change a future investigation could study these patterns over chronological time assuming that communication technologies continue to expand and develop the prediction would be that network size would keep growing that proportion of superficial relations would increase and that the importance of selfexpression to an audience would continue to grow

is there a tradeoff between having large networks of social connections on social networking sites such as facebook and the development of intimacy and social support among todays generation of emerging adults to understand the socialization context of facebook during the transition to adulthood an online survey was distributed to college students at a large urban university participants answered questions about their relationships by systematically sampling their facebook contacts while viewing their facebook profiles online results confirmed that facebook facilitates expansive social networks that grow disproportionately through distant kinds of relationship acquaintances and activity connections while also expanding the number of close relationships and stranger relationships albeit at slower rates those with larger networks estimated that larger numbers of contacts in their networks were observing their status updates a form of public communication to ones entire contact list the major function of status updates was emotional disclosure the key feature of intimacy this finding indicates the transformation of the nature of intimacy in the environment of a social network site in addition larger networks and larger estimated audiences predicted higher levels of life satisfaction and perceived social support on facebook these findings emphasize the psychological importance of audience in the facebook environment findings also suggest that social networking sites help youth to satisfy enduring human psychosocial needs for permanent relations in a geographically mobile worldcollege students with higher proportions of maintained contacts from the past primarily high school friends perceived facebook as a more useful tool for procuring social support

19951_0

introduction within the lens of behavioral science stress was regarded as any circumstance that makes it difficult for an individual to adapt to a new environment and maintain a condition of equilibrium between him and the outside world in regards one of the psychometrically sound scales used to assess the perceived stress was the perceived stress scale which was a 14item scale based on the transactional perspective 1 this was meant to say that the pss was based on the internal perceptions of the respondents as this scale would ask them whether their lives appeared to be unpredictable unmanageable or overloaded instead of focusing on a single occurrence 2 in relation to what has been noted numerous studies have been conducted in the philippines utilizing the perceived stress scale prior to the covid19 pandemic especially in various educational institutions to assess the level of stress among filipino learners 345 one study conducted among filipino nursing students revealed that using the perceived stress scale as one of the tools for assessing stress levels nursing students suffered from stress 4 it also noted that stress related to workload assignments and patient care were the most prevalent stress factors 4 meanwhile another study conducted among filipino middle school and high school students revealed that using the perceived stress scale there was a significant relationship between perceived stress and the lifestyle choices of filipino adolescents 5 in comparison to their male counterparts female subjects were found to be significantly better able to control and manage their perceived stress as well as have a healthier lifestyle choice thus this emphasizes the need for developing and properly implementing schoolbased healthy lifestyle programs and prevention among adolescents 5 on the other hand a research conducted towards filipino medical students utilizing the perceived stress scale as one of its methods revealed that while their overall functional health and wellbeing are good mental health is less developed than physical health 3 thus it was undeniable to pronounce that college life in philippines was definitely a stressful one primarily composed of students in their late adolescent years 6 meanwhile as the world was combatting the pandemic insurgence caused by the 2019 novel coronavirus all aspects were heavily affected particularly the school settings 7 in the philippines the covid19 pandemic had a major effect on higher education institutions as a result of the increasing number of cases during the midyear of 2020 that resulted on the decision of the commission on higher education to resort for online learning 8 thus due to the social distance norms and fear of infection the typical youthrelated experiences have been interrupted or modified 9 furthermore the new normal including online classrooms and extracurricular school events restricted movement and socializing disruptions of major social functions and leisure events and an uncertain future outlook might have an impact on the students psychoemotional development 10 as a result the repercussions of the pandemic and other scenarios in 2020 might have a significant impact on college students transition to adulthood 11 moreover this study was anchored to the transactional theory of stress by lazarus and folkman 12 the transactional stress theory of lazarus and folkman is one of the theories that explores at how people adapt to stressors primary secondary stress and adaptation evaluation structures were included in the folkman transactional model the person may describe their initial assessment of the situation as either threatening or alternatively harmless meanwhile the persons course of action in relation to the situation or environment was examined in the second stage also known as the secondary evaluation the perception of risk and its severity relied on the possibilities that the individual believed they had and this is connected to the knowledge that the environment life experiences and individual traits had produced reassessing and reevaluating a persons position may be aided by new information in regards our social engagements have decreased as a result of covid19 causing psychological suffering 13 according to brodeur et al 14 the pandemic had a significant impact on our mental health and increased web searches for divorce loneliness anxiety and despair additionally other research shown that epidemic and postepidemic conditions might result in physical conditions like migraines and headaches as well as psychological issues including stress anxiety and stigma 1516171819 in regards to what has been iterated numerous studies have been conducted using the perceived stress scale to reveal the stress level among filipino learners during the covid19 pandemic 202122 thus these would be a great opportunity to undergo validation on the wellknown measure of perceived stress called the pss the pss was available in 14 10 and 4item versions and had become one of the most widely used noninvasive measures of subjective stress in psychophysical health studies 23 specifically the 4and 10item versions were subsets of the 14item scales items which were reported as reliable and as valid as the original version of the perceived stress scale 23 in retrospect the pss was also already translated into several other languages wherein its psychometric properties were assessed in a variety of populations 242526 hence considering that stress plays an essential role in the holistic development of college learners and the fact that numerous studies have been administered to assess the perceived stress among filipino learners during the covid19 situation the psychometric properties of the test that measured stress across cultural settings must be considered therefore the aim of this study was to investigate the reliability and validity of the english version of the 14item pss among samples of college students and in this case at the university of mindanao digos college an established higher education institution on mindanao island in the philippines methodology instrument in this validation study the researchers have utilized the 14item english version of the perceived stress scale from cohen et al 1 the perceived stress scale was developed to assess how stressful certain situations in a persons life the items were created to gauge how overburdened unpredictable and unmanageable the life events of the respondents these three difficulties were at the heart of the stress experience a number of questions about current levels of experienced stress were also included on the scale on a 5point likert scale target participants would grade statement items with reported significantly greater perceived stress the scales questions inquired about feelings and thoughts during the previous month in each case the respondents would be asked to indicate how frequently heshe felt or thought a specific emotion or thought a certain way with 1 being the lowest and 5 being the highest although some of the questions were similar there were some differences that one should be aware of there were seven items reversekeyed particularly item numbers 4 5 6 7 9 10 and 13 respectively items must be added in order to consolidate the final score hence each statement item should be treated as a separate question design and procedure securing permission in this validation study the researchers have ascertained to secure and consolidate the permissions of the target respondents through the provision of informed consents in these informed consents the rights of the respondents were acknowledged to have the choice to either accept or refuse to partake in the test administration the informed consent was presented in the google form in a comprehensive manner wherein the terms and conditions were completely discussed such as the purpose benefits and risks in retrospect the researchers have made sure the clarity and preciseness of the reasons in the informed consent why the validation study was needed to be conducted and the accompanying sense of urgency of administrating the study instrument distribution the distribution of the research instruments was addressed through online platform particularly in google form medium in pursuance to a safe and secured administration of the test since the archipelago was still in combat against the covid 19 the facetoface test administration was not considered hence resorting to online distribution of the instruments was the best option for this reason the google forms were sent via the social media application called messenger in each of the respondents messenger account during the working hours of weekdays the researchers have avoided delivering google forms in nonworking hours holidays and during the weekends meanwhile all queries coming from the respondents were substantially addressed which were mostly about their concerns on the instability of their internet data collation and processing as the researchers have met the standard minimum sample size of 200 responses gathered from the distributed google forms the data were then collated and arranged in the microsoft excel the demographic profiles of the respondents which served as the imposed criteria were categorized such as the names sex age college department course program and year level furthermore these categorizations of the respondents demographic profiles were accompanied by their responses on each of the 14 item statements of the english version of the perceived stress scale in a 5 pointlikert scaling format the researchers have rechecked and ascertained the finalized and irrevocable presentation of data in the microsoft excel in the pursuit of obtaining an accurate process of encoding the data were then sent to the research adviser to undergo reevaluation prior to delivering the data set to the statistician for data analysis sample size the sample size used was 200 based from the guidelines for the respondenttoitem ratio of tentimes rule 28 which posited that a minimum sample size would be determined through multiplying the number of questionnaire items by 10 in this validation study the total number of items of the scale was 14 which were multiplied by 10 to gain a minimum sample size of 140 however the researchers decided to increase the minimum sample size to 200 as this was a fair amount of sample size in contrast to 140 which was considered poor 29 furthermore kline 30 stressed that a sample size of 200 was regarded as appropriate and moderate in noncomplex researches nevertheless given the wide range of questionnaire forms in used it was also acknowledged that there were no absolute guidelines regarding the sample size required to verify a questionnaire 31 the respondenttoitem ratios were only used to bolster the justification for a large sample size when necessary statistical analyses in this validation study a statistician was designated for the data analysis in examining the psychometric properties of the pss14 in terms of its reliability and validity a software program called statistical package for the social sciences was utilized in order to statistically measure the psychometric properties of the scale through the provided data set in particular the reliability of the pss14 was evaluated through examining its internal consistency as emphasized by tang et al 32 internal consistency referred to the extent to which all of the items in a test measured the same notion or construct and thus linked to the tests interrelatedness hence the internal consistency of the items was assessed through the utilization of the cronbachs alpha which would indicate the strength of the association between items 33 finally the corrected itemtotal correlation and the cronbachs alpha if item was deleted were also reported 34 meanwhile construct validity of the pss14 was assessed through the utilization of pearson productmoment correlation to measure the strength of a linear association between variables and was denoted by r to contextualize in this validity study the calculations were done through significantly correlating each scales item to the total of each item using the pearson correlation coefficient hence one way to assess the validity of each item was through examining the value of significance the significant value obtained by the sig was compared under 005 level of confidence to determine if the item was valid 35 lastly another technique adopted to scout up the validity of items was through comparing the rvalues with respect to the critical values under pearson product coefficient at 005 level of confidence rvalues should exceed the critical values to pronounce that the scales items were valid otherwise it would indicate the opposite interpretation 3637 ethical considerations the researchers made sure to adhere to the ethical standards and protocols set in conducting the research and gathering the data from the participants in order to serve the best interest of ethical standards of this validation study the application of the following ethical principles was addressed in order to protect the human subjects informed consent was provided through google forms as an online medium towards the target test takers amidst the ongoing transmission of covid 19 in the public provision of informed consent was the most important part of any ethical process therefore the researchers have made sure that the test takers have completely understood the studys purpose benefits and risks prior to making a decision of whether they would agree or decline to partake in the test administration thus the researchers have secured the permission of the test takers without any exercise of pressure or coercion as these consents were given on their own volition and accord avoidance of any form of physical or mental damage was seriously observed and complied during the course of test administration the researchers have taken into account all the possible outcomes of the validation study and weighed the risks against the benefits moreover the nature of administering the test was through online platform to abate the risks of being infected by the existing novel corona virus in the public at the same time physical social and psychological harm as well as all other types of harm were kept to a bare minimum hence no any incident associated with harminduced by test administration was reported the researchers have ascertained that the respondents were fully aware that they had an option to optin or out of the validation study at any given time should they feel uncomfortable or violated as well the researchers have assured that the test takers were fully informed on the terms and conditions of the study prior to their decision to partake in the test administration finally the researchers made it clear to the participants that they were free to answer the survey questionnaires without any pressure or coercion the researchers took precautions to ensure that any of the subjects identifying information could not be linked to personal responses the researchers also addressed confidentiality by concealing the identities of the participants researchers have always considered the psychological and social consequences that a breach of confidentiality may have on subjects to protect participants the researchers have educated them on their rights and employed all possible coding systems that they deemed appropriate in the research study the psychometrics of the english version of the 14itemed perceived stress scale were explored in the context of filipino university students and the findings suggested that the pss14 questionnaire had potential in assessing perceived stress among filipino students the analyses in particular revealed a good report on the pss14s internal consistency moreover the pearson correlation demonstrated an outstanding relationship despite the fact that the correlations strength varied from low to strong pss14 items were still susceptible of assessing the same construct of perceived stress among students note the score of items 4 5 6 7 9 10 and 13 were reversed a response of always suggests low perceived stress pss 14 item 4 in the last month how often have you dealt successfully with irritating life hassles item 5 in the last month how often have you felt that you were effectively coping with important changes that were occurring in your life item 6 in the last month how often have you felt confident about your ability to handle your personal problems item 7 in the last month how often have you felt that things were going your way item 9 in the last month how often have you been able to control irritationsin your life item 10 in the last month how often have you felt that you were on top of things item 13 in the last month how often have you been able to control the way you spend your time results and discussion reliability cronbach alpha coefficient for the pss 14 was found to be within the acceptable range set by cronbach 34 furthermore the pss14 exhibited a highreliability coefficient that was compatible and conforming with the findings of other researchers 33 in this regard the usability and portrayal of the internal consistency of pss14 in estimating perceived stress among filipino samples coincided with the evidences from japanese samples 38 on greek samples 24 on chinese samples 39 and on malaysian samples 40 furthermore these data results suggested that the pss14 items attained strong interconnections and consistency among each other implying that they were capable of evaluating similar construct 24383940 besides when it came to the corrected itemtotal correlation only item 6 failed to qualify on the recommended correlation coefficient which meant to say that the items 1 2 3 4 5 7 8 9 10 11 12 13 and 14 were higher than the recommended correlation coefficients signifying that majority of the pss14 items were justifiably appropriate to be included in the scale 3041 on the other note cronbach alpha of the pss14 was not compromised if any items were deleted on the scale interestingly deleting item 6 would increase the cronbachs alpha from 0813 to 0814 hence deletion of item 6 could be considered to make the scale more reliable the results divulging the reliability of items in the perceived stress scale when assessed in the context of undergraduate students at um digos college during the height of the covid19 pandemic testified that the pss14 was a reliable and valid scale for measuring perceived stress among the respondents in short pss14 could measure the perceived stress among the respondents this was in line with a study by canillo et al 20 that looked at mental health and perceived stress as the key indicators of the wellbeing of selected college online students in the philippines during the covid19 pandemic it was shown that there is a strong negative correlation between perceived stress and mental health indicating that students mental health declines as perceived stress increases and vice versa meanwhile in another local study conducted by del rosario et al 22 about perceived stress as predictors of depressive symptoms among polytechnic university of the philippines academic scholars during the covid19 pandemic it was divulged that there was a significant positive relationship between perceived stress and depressive symptoms which means that as the perceived stress increases the depressive symptom increases as well these findings were also coherent with the transactional stress theory of lazarus and folkman 12 to contextualize this study the repercussions of the covid19 pandemic brought sudden unanticipated lockdowns that resorted to online modes of learning however many students including professors have spoken out against online learning for a variety of reasons the reality was that numerous higher education institutions in the philippines both private and public colleges and universities were unprepared to meet the challenges 11 therefore stress results when the demands of our internal and external environments outweigh our available resources when situational demands outweigh available resources stress can take many different forms including acute episodic or intermittent and chronic stress all of which can lead to bodily and mental problems 12 finally the pearson correlations of all the items of pss14 yielded significant values under 005 level of significance and critical values were revealed as smaller than rvalues implying that the items and scale were legitimate if the requirements specified by numerous authors were met 3637 specifically item 4 got the strongest association among the 14 items items 1 2 3 5 7 9 11 12 13 14 garnered moderate association and items 6 8 and 10 attained low to moderate association thus signifying that if each item of the scale was correlated to it summations then most of the items were considered valid however it did not disaffirm the possibility that few of the items could be revisited and revised validity the findings highlighting the validity of items in the perceived stress scale when assessed in the context of undergraduate students of um digos college at the height of the covid19 pandemic signified that the pss14 was a reliable and valid instrument in measuring the perceived stress among the aforementioned respondents thus this implied that the pss14 contained items that really measure what it purports to measure which was in this case the perceived stress of the studys respondents these findings were supported by a survey conducted by cao et al in 2020 which involved 7143 college students and discovered that 25 of them were experiencing significant anxiety as a result of the strain of online learning additionally research results suggested that the covid19 pandemic may be having psychological consequences on both learners and the wider populace including anxiety fear and worry during the covid19 crisis certain students may be more likely to experience social isolation and the emergence of mental health issues this was especially true for those who lived alone had fewer personal interactions with close family members and friends had less social support and had a more difficult time integrating into a student social network the results were also reflected in the study of guillena and guillena 21 which examined the perceived stress selfefficacy and mental health of firstyear college students in the philippines during the covid19 pandemic it was extrapolated from this studys findings that students who experienced high levels of stress would likely exhibit poor mental health these results were also supported by lazarus and folkmans 12 transactional stress theory the covid19 pandemic was already distressing for the learners which helps to put this study in context the epidemic and the switch to online learning had already had an impact on the learners mental health the results of several investigations carried out in the philippines 202122 also supported this when 000 note a pvalue less than 005 is statistically significant presented with a stressor an individual reacts with their environment according to lazarus and folkmans 12 transactional stress theory given that a persons response to the stressor changed as the stressors nature changed and as a result the persons assessment of it changed the interaction was dynamic and bidirectional consequently in this case the covid19 pandemic was the stressor that could be considered central if it was perceived to have immediate adverse effects on the self uncontrollable if it was perceived to be outside of ones own control and threatening if it wasperceived as anxietyinducing and having adverse effects conclusion the pss14 was shown to be a reliable scale with acceptable validity allowing it to efficiently quantify student perceived stress using the cronbach alpha a satisfactory reliability coefficient was obtained in this investigation item 6 got the lowest item correlation however including this item did not cause an adverse impact on the robustness of the scale in general the pss14 demonstrated strong psychometrics was easy to fill out and understand and could elicit useful information in the context of filipino university learners moreover this validation study of the perceived stress scale concluding that this instrument was still a reliable and valid scale in the context of filipino university students was valid proof that the pss14 was not just psychometrically sound to be of use during noncovid situations among academic institutions in the philippines but as well as during covid situations which were supported by a number of studies conducted throughout the archipelago withal the transactional theory of stress by lazarus and folkman 12 also affirmed the experiences of filipino undergraduate students during the insurgence of the covid19 pandemic the varied experiences of stress among the learners brought by the impact of the covid19 pandemic had taken their toll on the economic social mental and personal aspects of the individuals thus a call to action is addressed to schools mental health practitioners guidance counselors and authorities to create programs designed for improving and boosting the mental health of their learners future studies were also encouraged with this type of academic inquiry to broaden the knowledge and explore more the issue of mental health not just among the students but among other stakeholders involved in academic institutions covid 11 in the last month how often have you been angered because of things that happened that were outside of your control 1never 2almost never 3sometimes 4fairly often 5very often 12 in the last month how often have you found yourself thinking about things that you have to accomplish 1never 2almost never 3sometimes 4fairly often 5very often 13 in the last month how often have you been able to control the way you spend your time 1never 2almost never 3sometimes 4fairly often 5very often 14 in the last month how often have you felt difficulties were piling up so high that you could not overcome them 1never 2almost never 3sometimes 4fairly often 5very often consent all authors declare that written informed consent was obtained from the participants ethical approval as per international standard or university standards written ethical approval has been collected and preserved by the author competing interests authors have declared that no competing interests exist appendix a perceived stress scale cohen et al 1 perceived stress scale the questions in this scale ask you about your feelings and thoughts during the last month in each case you will be asked to indicate by selecting how often you felt or thought a certain way among the given choices appendix b

this work was carried out in collaboration among all authors authors rde and mr together with the supervision of a statistician designed the study performed the statistical analysis and managed the analyses of the study authors ar jg and ews managed the informed consent and necessary documents authors adr jjz and tkt managed the literature searches furthermore author rde organized and advised the researchers for minor changes all authors read and approved the final manuscript

19952_0

introduction despite widespread availability of antiretroviral therapy and preexposure prophylaxis in western europe and canada continuing hiv transmission remains a significant challenge with an estimated 15 782 individuals being newly diagnosed in western europe in 2021 1 unsuppressed viraemia among people with undiagnosed hiv likely accounts for ongoing transmission 2 3 4 this is strengths and limitations of this study ⇒ this is a large study of several european hiv cohorts and a canadian cohort of individuals with recently acquired hiv ⇒ few large cohorts combine quantitative and highly participatory and innovative qualitative research methods ⇒ strong patient and public involvement ensures that the study is informed and shaped by those with lived experience of hiv and represents their research priorities ⇒ recruitment of individuals close to the time of hiv acquisition reduces but does not eliminate recall bias and will allow for detailed investigation of circumstances around hiv acquisition and missed opportunities for prevention on may 6 2024 by guest protected by copyright open access of particular relevance for those with recently acquired hiv as viral load remains markedly elevated for the first year or so following seroconversion before achieving a viral set point 5 studies of individuals who have recently acquired hiv are crucial for detecting and measuring the effects of any changes in circulating virus as well as providing insights into missed prevention opportunities although guidelines recommend immediate art initiation regardless of cd4 cell count 6 7 8 9 10 there is evidence of variability in art initiation among individuals with recent hiv infection with one study reporting art initiation 6 months after diagnosis 11 this is concerning as art initiated in the first 4 months following seroconversion is more likely to lead to a rapid recovery of cd4 cell counts 12 in addition while clinical benefits of immediate art initiation are well recognised in terms of reducing aidsdefining morbidity and mortality 13 14 the association of art and of new antihiv drugs as they are introduced with longerterm outcomes is not yet known 15 16 17 evidence is needed to understand for instance the potential association between integrase strand transfer inhibitorbased art regimens which are highly efficacious for viral suppression 18 with weight gain and obesity 19 or incident cardiovascular disease 20 furthermore little is known about the outcome and experiences of people who acquire hiv at older ages who may also have to manage agerelated comorbidities and polypharmacy with most evidence to date being based on those who acquired hiv at a younger age similarly individuals who acquire hiv in their teens and early twenties may experience specific challenges with the prospect of lifelong medication finally the majority of the limited qualitative literature on recently acquired hiv predates prep and treatment as prevention and mainly focusses on circumstances around infection and sexual behaviour following diagnosis in summary there is a need for interdisciplinary work that engages with the complexities of recently acquired hiv we present the protocol for the concerted action on seroconversion to aids and death in europe study which aims to address the identified research gaps through the recruitment of individuals with evidence of recently acquired hiv infection at the time of diagnosis we will explore reasons for not using hiv prevention methods understand barriers to rapid art initiation the choice of drug regimens examine subsequent outcomes the lived experience of hiv seroconversion in the context of prep availability and use of treatment as prevention such data will inform the optimal implementation of biomedical behavioural and structural interventions to reduce the number of new hiv infections as well as optimise the health and wellbeing of those with recently acquired hiv 21 study aims cascade is a multinational collaboration of cohorts of people with recently acquired hiv that is based in western europe and canada using a mixedmethods approach we aim to explore current viral and host characteristics measure clinical and patientreported outcomes and understand the lived experiences and needs of individuals with recently acquired hiv in western europe and canada our specific research objectives are to ► describe current epidemic trends and examine the relationship between hiv incidence and use of prevention including prep and early art initiation in the population ► gain insights into new infections occurring each year and reasons for continuing hiv transmission ► explore determinants of art initiation choice of regimen and outcome ► investigate how clinical social and structural determinants impact on health outcomes and selfperception of wellbeing ► understand contextual factors that shape hiv acquisition risk and lived experiences of recently acquired hiv methods and analysis the cascade collaboration the cascade collaboration was established in 1997 with european commission funding and subsequent renewal to pool data from cohorts of individuals with recently acquired hiv 22 23 24 the current study will create a new ukbased cohort of individuals with recently acquired hiv at the time of hiv diagnosis recruited directly from national health service clinics with clinical data entered into a redcap database and bring together eight longestablished hiv cohorts study design mixedmethods research focuses on collecting analysing and mixing both quantitative and qualitative data in a single study or a series of studies 25 the underlying assumption is that it has the potential to address research questions more comprehensively than by using either quantitative or qualitative methods alone our study will use a mixedmethods convergent parallel design approach with quantitative and qualitative work and participatory photography undertaken concurrently the study is organised into four interrelated work packages detailed below wp1 epidemic trends clinical data on individuals from participating cohorts will be extracted and linked to hiv nucleotide sequences using the hiv cohorts data exchange protocol a wellestablished protocol which we had collaboratively established releasing the first version in september 2011 26 we will describe current epidemic trends and host and viral characteristics as well as viralhost interactions cd4 cell count and hiv rna value at or close to the time of seroconversion likewise we will determine whether the cd4 cell count at seroconversion has changed over the past decade or whether there are differences by person characteristics including any prior exposure to prep pooling data from the cascade constituent cohorts will allow us to examine effects with greater precision and to compare across countries wp2 hiv acquisition risk and patient wellbeing through questionnaires completed by individuals with recently acquired hiv attending participating clinics we will collect information about behaviour knowledge and attitudes to hiv prevention prior and leading up to their hiv diagnosis factors influencing art initiation experiences of taking early art selfperceptions of health and wellbeing over time and experiences of living with hiv proms data will focus on mental health healthrelated quality of life experiences of stigma and symptoms the questionnaire is informed by the theoretical framework of comb a theory of change model that understands behaviour as an interaction between the necessary conditions of capability opportunity and motivation 27 open access participants will be invited to complete a followup questionnaire between 12 and 18 months after completing the baseline questionnaire wp3 effectiveness of art using clinical data and laboratory results we will assess whether art in individuals with recently acquired hiv has the potential to restore cd4 cell count and cd4cd8 ratio to normal levels and rapidly lower hiv viral load evaluate treatment effectiveness and tolerability investigate differences between immediate and delayed art at seroconversion determine treatment durability and rates and predictors of starting and switching regimens investigate differences among drug classes in terms of virological and immunological response especially in persons with very high initial viraemia or seroconversion illness and evaluate the burden of concomitant medications particularly in those aged over 50 under 25 and those experiencing symptomatic seroconversion this wp will combine individual characteristics clinical data and laboratory test results from participants medical records and data from questionnaires wp4 qualitative investigation of experiences we will prospectively recruit 2030 participants in total from three countries in europe for ssi covering the following themes ► experiences of hiv testing ► attitudes to and experiences of combination prevention ► access to combination prevention ► barriers to and facilitators of combination prevention uptake and adherence ► access to immediate art ► barriers to and facilitators of immediate art adherence ► impact of recently acquired hiv on sexual behaviour ► lived experiences of recently acquired hiv including stigma qualitative approaches will allow us to capture lived experiences the context within which decisions are made and outcomes are reached and the motivations underlying particular health behaviours they can therefore provide a deeper insight into for example the reasons why prep and other methods of prevention were not used barriers to art adherence and why individuals choose to delay or stop art ssis will be conducted either face to face by telephone or via online video participants will be invited to a baseline ssi of approximately 1 hour and an exit ssi of the same length around 1218 months later in the intervening period participants will be asked to submit between one and five photographs or complete and submit a short writing task at 3 6 9 and 12 months photographs and writing exercises will be elicited through prompts sent by short message service text message or email towards the end of the study we will invite participatory photography participants to two 2hour online workshops during which they will be invited to share and discuss their photographs with each other and reflect on their experiences we have developed a modified version of the photovoice method 28 29 a method which has been widely deployed in health research 30 31 including hiv 32 33 34 as photovoice is traditionally conducted face to face over a short period of time the adaptation allows us to conduct the research remotely and to collect data over a longer period of time at predefined time points the exit interview will use photo elicitation meaning that participants will be asked to reflect on their photographs as a focus of discussion the longitudinal qualitative design will allow us to build rapport and explore how experiences change over time recruitment of participants pooled clinical data for wps 1 and 3 will include all those eligible and already enrolled into a participating cohort or recruited through uk clinics as well as individuals acquiring hiv in the 12month period preceding recruitment prospectively pooled clinical data will thus potentially include individuals acquiring hiv from the 1980s to 2024 for wps 2 and 4 only individuals with recently acquired hiv in the 12month period preceding recruitment are eligible due to the relatively small number of participants recruited to wp4 we will not be quota sampling by selected characteristics consent is already in place for pooling clinical data cohort leads of existing cohorts will identify individuals who meet the inclusion criteria from databases aged 16 years or over with confirmed evidence of recently acquired hiv at the time of diagnosis in the uk clinical research staff will approach potential participants to invite them to take part and those interested will receive participant information sheets and sign a consent form identified eligible participants across all cohorts will need separate consent to take part in wp2 and wp4 which will be initiated through their respective clinical centres or cohort leads cohort leads may recompense participants for their time with a gift voucher for £10 for completing each baseline and followup questionnaire and £20 for participating in interviews or photography workshops analysis plan we will analyse quantitative and qualitative data separately and where possible conduct integrated mixedmethods analyses to triangulate and contextualise the findings 35 quantitative analysis will combine data pooled for wps 13 as well as descriptive analyses we will use regression analysis to examine changes in person characteristics and trends over calendar time we will use software previously developed by the group to create analysis files of the interpretations from hiv sequences for example viral open access subtype position of mutations and drug susceptibility scores we will use logistic regression to examine the association between transmitted drug resistance mutations and year of seroconversion adjusting for confounders to examine changes in initial cd4 cell count and hiv rna values all longitudinal measurements before the initiation of art will be analysed using linear or fractional polynomial mixed models adjusting for all available potential confounders the variance of the responses and the withinsubjects correlation will be modelled through the inclusion of a random intercept term and a number of random functions of time since seroconversion on top of the level 1 errors calendar time effects will be modelled through natural cubic splines we will analyse questionnaire data using regression analysis to examine the association between several factors and outcomes including proms qualitative data will be synthesised during data collection using a modified rapid assessment procedure sheet 36 a separate rap sheet will be created for baseline ssi participatory photography and exit ssi this will allow us to identify emerging findings and facilitate consistency across settings thematic analysis of ssis using nvivo will be conducted the analysis will include the interpretation of visual materials writing tasks and workshops to achieve the mixedmethods data integration we will analyse the qualitative data thematically using a deductive organising framework derived from results from the quantitative analyses 35 this will facilitate integration of quantitative and qualitative data for instance if quantitative analyses reveal reduced access to immediate art among older people we will interrogate the qualitative dataset to explore barriers and facilitators to immediate art in this group to aid this process we will use coding matrices ethics and dissemination open access september 2022 signed consent will be obtained by all the participants participants have the right to enrol in any or none of the wps while they may not personally benefit from taking part in cascade the knowledge gained through this research will help to inform policy and improve health services data storage and security patient privacy and confidentiality will be central to the study a dataset with all personal identifiers removed will be generated for analyses care providers will not have access to questionnaire responses or to information shared through ssis pooled clinical data will be deidentified and a linking log with identifiers will be kept and stored securely by the participating cohort sites questionnaires will be submitted by participants directly into a redcap database within university college londons data safe haven qualitative data will be transcribed and pseudoanonymised before being sent to the ucl dsh via managed file transfer this study has been registered in the ucl data protection office cascade data will be archived in ucl archive facilities for a minimum of 10 years after publication in accordance with ucl research data policy patient and public involvement the involvement of people living with hiv is central to this study and takes place at several points during the project since its inception in 1997 cascade has included representatives from the community of people living with hiv as advisory group members with the launch of this new study some of the original community representatives remain closely involved as members of the cascade executive committee and the socialscience subcommittee for wps 2 and 4 community representatives are included in the latter subcommittee ensuring a range of perspectives we aim to ensure that community representatives are diverse in terms of gender ethnicity age and hiv acquisition risk community representatives attend steering group meetings review documents and contribute to analyses and papers as coauthors so far cascade community representatives have guided design and conduct of the study including questionnaire design and interview topic guide in autumn 2021 we held a series of patient public involvement meetings in france greece and the uk these comprised people living with hiv recruited by cascade community representatives who also cofacilitated these meetings these meetings further shaped the design and conduct of our work helping us to develop an approach and tools that are sensitive to the needs of people who have recently acquired hiv all our ppi work has been costed and we reimburse our community representatives at rates recommended by the uks national institute for health and care research in recognition of their time and expertise dissemination plan findings will be communicated using a comprehensive dissemination strategy we will use various forms of media to reach a diverse range of stakeholder groups and individuals at the local national and international level this will include the use of academic media and social media finally we will ask participants in wp4 for consent to share images from the participatory photography project in the form of a physical or online art exhibition this exhibition will be cocreated with cascade community representatives we have a study specific twitter account and a study website allowing us to engage with people living with hiv the academic community clinicians and the wider public we aim to produce accessible infographic summaries of key findings and will present an overview of the study and findings through a series of webinars twitter elisa ruizburga elisaruizburga shema tariq savoytruffle emily jay nicholls ejnicholls and linda wittkop lindawittkop open access nicoletta policek elisa ruizburga chris sandford bruno spire inés suárezgarcía giota touloumi alain volny anne contributors the study protocol was conceptualised by kp gt mjg cs cm and lm st ejn and fmb contributed to study design and developed the rationale and methodology for wps 2 and 4 erb wrote the first draft of the manuscript ava cc sg ij mvdv lw bs and np provided critical feedback on overall study design and manuscript all authors read revised and approved the final manuscript competing interests the funders did not participate in the study design and will not intervene in its process analysis or publication of the findings st has received speaker honoraria and consultancy fees from gilead sciences cc has received speakermoderator honoraria and advisory board fees from gilead sciences gskviiv and msd as well as an unrestricted gilead sciences nordic fellowship research grant cs has received funding from gilead sciences viiv healthcare and janssencilag for participation in advisory boards speaker panels and for preparation of educational materials mvdv has received consultancies fees for participation in advisory boards and research grants from gilead msd and viiv all paid to his institution fmb has received funding from gilead sciences ltd for preparation and delivery of educational materials ij has received teaching fees from viiv healthcare and advisory fees from gilead sciences gt has received research grants and advisory board fees from gilead all paid to her institution and mjg has received honoraria for ad hoc participation in national advisory boards of gilead merck and viiv patient and public involvement patients andor the public were involved in the design or conduct or reporting or dissemination plans of this research refer to the methods section for further details patient consent for publication not applicable provenance and peer review not commissioned externally peer reviewed supplemental material this content has been supplied by the author it has not been vetted by bmj publishing group limited and may not have been peerreviewed any opinions or recommendations discussed are solely those of the author and are not endorsed by bmj bmj disclaims all liability and responsibility arising from any reliance placed on the content where the content includes any translated material bmj does not warrant the accuracy and reliability of the translations and is not responsible for any error andor omissions arising from translation and adaptation or otherwise

cascade protocol exploring current viral and host characteristics measuring clinical and patientreported outcomes and understanding the lived experiences and needs of individuals with recently acquired hiv infection through a multicentre mixedmethods observational study in europe and canada

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introduction the increasing severity and frequency of modernday disasters is a real concern for governments and decisionmakers two phenomena are held responsible for this situation the climate change and the complexity of human settlements and development as an adaptation to this reality our understanding of disaster risk has evolved to include new concepts as vulnerability and social vulnerability disaster risk is described as the combination between the hazard and the characteristics inherent to the community or the place these characteristics are gathered under the broad concept of vulnerability the latter is associated to various underlying aspects among which the social vulnerability that gained the interest of decisionmakers and academics the importance of social characteristics can be observed before and during the hazard impact and afterward during the crisis and recovery phases the sendai framework emphasizes social aspects and places the social vulnerability as a key factor of risk management wisner defines social vulnerability as the characteristics of a person or group and their situation that influence their capacity to anticipate cope with resist and recover from the impact of a natural hazard while all dimensions directly contribute to the overall level of vulnerability social vulnerability has the particularity to trigger all the other forms by generating pressure on the community gilbert c describes the disaster as a combination between external forces and social vulnerability several conceptual frameworks dedicated to disaster risk represent social vulnerability as an aggravating condition that besides its direct impact on risk level has an indirect influence on all risk factors hence the understanding of social vulnerability is necessary in order to anticipate all conditions that may increase or decrease risk factors like exposition to hazards sensitivity coping capacity and relief capacity an effective risk reduction strategy must be founded on a comprehensi ve understanding of vulnerability and its geographical distribution this has led to an increased interest in the development of empirical measurement tools capable of producing comparable values and providing mappable results as the concept of vulnerability has evolved to encompass multiple dimensions there has been a growing need for metrics to assess each dimension among academics and risk managers however early assessment approaches focused more on structural and human vulnerability the main reason for that lies in their quantifiable nature suitable for empirical and analytical engineering approaches in contrast expressing social vulnerability in quantitative terms is more challenging consequently despite its undeniable importance social vulnerability did not initially receive significant attention in terms of empirical studies however recent efforts have been made to quantify social vulnerability using approaches similar to those employed for structural vulnerability over the past two decades a range of empirical methods have been proposed one of which is the social vulnerability index developed by the hazards and vulnerability research institute at the university of south carolina under the direction of susan cutter when it comes to empirical assessment of social vulnerability the sovi is on e of the most used and widely accepted metrics in the academic field it was initially developed in 2000 for the assessment of social vulnerability to environmental hazards in the context of the united states at the county level the sovi has since been used and tested for a variety of hazards at different contexts and scales and for various purposes the popularity of the sovi can be attributed to its numerous advantages this metric provides an objective empirical estimation enabling the classification of communities based on their level of social vulnerability and the identification of the most vulnerable areas the quantitative results generated by the sovi are highly suitable for mapping social vulnerability offering a comprehensive representation of its geographical variation within a given territory additionally the sovi proves practical in terms of data requir ements instead of requiring specific datasets this tool is designed to utilize commonly available statistical data on demographics housing and socioeconom ic conditions for most countries such data is readily accessible and regularly updated through national census operations and similar surveys this not only simplifies the data collection process but also makes the sovi a flexible metric applicable on a global scale although being initially developed for the united states data structure the sovi has been used in many countries which demonstrates its flexibility despite differences among countries the sovi can be adjusted to suit diverse contexts an d accommodate different data structures enabling comparisons of social vulnerability on a global scale vulnerability studies in algeria in algeria the situation closely mirrors the broader context of social vulnerability analysis the country is exposed to numerous natural and technological risks it experienced many disasters and adapted its prevention strategy over the years notably after two deadly disasters the floods of bab el oued in 2001 and the earthquake of boumerdes in 2003 in reaction the country followed the new trends of risk reduction and adopted a strategy oriented toward vulnerability reduction and spatial planification this transition required adapted procedures for analyzing and mapping vulnerability to support the new strategy with suitable methods various studies were conducted by both academics and government institutions however most of these studies primarily focused on physical vulnerability with limited consideration for social characteristics as aggravating factors social aspects were typically discussed in term of post disaster losses and consequences furthermore following the tradition of physical vulnerability analysis most studies concerned the urban level despite the need for vulnerability analysis at upper levels this is particularly important given the recent recommendations of the national risk management strategy which emphasizes territorial analysis at the provincial level before addressing urbanscale risk assessment and management a study conducted in the province of boumerdes explored the relationship between social and physical vulnerability using empirical methods however the indicators used in that study were derived by deductive approach from sets of variables selected for different contexts while the use of locally specific data is important to insure the relevance of the indicators to the context considering the aforementioned elements there is a compelling need to incorporate social vulnerability analysis into algerias risk management strategy in this regard the social vulnerability index offers a convenient solution due to its ability to produce comparable and mappable outcomes using readily available census data the province of chlef chosen as a case study has endured significant natural disasters and has been subject to a significant number of studies but has never undergone an indepth social vulnerability analysis the present paper explores the social vulnerability analysis in the algerian context the desired analysis aims to capture and map the geographical variation in social vulnerability it should support decisionmaking concerning disaster risk reduction the sovi is the measurement tool adopted to carry out this study considering its convenience for the objectives and the possibility of replication thus the study aims also to test the adaptability and the applicability of the sovi in the particular context of algeria more specifically for the municipalities of the province of chlef the main social factors that determine social vulnerability are identified and combined in a single value the resulting maps should give a comprehensive representation of social vulnerability distribution for the province the maps interpretation is performed based on natural and human geographical characteristics hence the interpretation becomes intuitive for knowledgeable decisionmakers as well as for the general public allowing for more awareness about social vulnerability and better risk management method and data study area the study area corresponds to the province of chlef located in the northwestern part of algeria the province counts 35 municipalities covering a total area of 4074 square kilometers its the seventh most populated province of the country with more than a million inhabitants spread over a territory threatened by several natural and humaninduced hazards the main economic sectors are agriculture and services with some industrial sites the province lies between the major mountain range of the tellian atlas in the south and the mediterranean sea in the north the territory of the province is exposed to several hazards flood landslides wildfires and earthquake hazard which represents the greatest threat because of its location in the western mediterranean region th e province is exposed to substantial seismic activity caused by the convergence between the african and the eurasian tectonic plates two major disasters testify to the threat caused by seismic activity the orleansville earthquake in 1954 with a 68 magnitude and 1500 human deaths and the el asnam earthquake in 1980 with a magnitude of 73 causing about 3000 deaths back to the antic period a seismic disaster is suspected to be the cause of the destruction of the roman city of castellum tingitanum whi ch occupied the present location of the city of chlef three major natural elements are responsible for shaping the territory and creating various geographical regions in terms of physical economic and social characteristics as depicted by the map in figure 2 first the plains region to the middle and the south crossed by the chelif river which gave the province its name this area enjoys good accessibility due to the railway line and important highways many important cities are located in this region including the chief city of chlef its characterized by a diverse economic activity agriculture due to fertile plains important industrial parks located alongside transportation axis and services near important cities second the coastal area to the north enclosed between the sea and the dhahra mountains chain despite being linked due to the coastal national road this area has moderate and mostly indirect connectivity with the rest of the province the major city of this region is tenes located at the junction between the coastal road and a national road connecting the south of the province to the coast in addition to agriculture the coastal area benefits from a commercial port and fishing resources finally the area shaped by the dahra mountains chain which is responsible for separating the middle of the province from its coastal region this area forms a band of highlands oriented eastwest with weak connectivity to the rest of the province data the sovi is calculated using general census data the most recent accessible data source is the general census of population and housing of 2008 conducted and published by the national office of statistics it covers the most of sovis common indicators by direct substitution or through calculation using appropriate equations to obtain the requested values in some cases the modification of original set of indicators is needed in order to match with the available data considering the data structure of the national census it is possible to downscale the geographical unit to the municipal level the municipality called commune in local context is the basic administrative subdivision in algeria it usually counts one or more major cities within its territory at the upper level the country is divided into 58 provinces called wilaya in each province municipalities are grouped to form the daïra that correspond to the intermediate level equivalent to the district the province of chlef counts 35 municipalities grouped into 13 districts method social vulnerability is associated to a large number of variables the sovi development starts with an initial set of variables that is then reduced using principal components analysis the last is an exploratory data analysis method that eliminates data redundancy and filters the initial set to obtain a reduced number of indicators the resulting set is sufficient to cover the characteristics that affect social vulnerability and its variability among the studied geographical units before proceeding with pca an adaptation process is carried out in order to match the variables with the context the scale and the available data structure in fact when applying the sovi outside of its original context flexibility becomes one of its main strengths the key of this flexibility lies in the selection process of the indicators the variables set doesnt need to be an exact replica of the original set proposed by s cutter al a research conducted by m schmidtlein and al examined the sovi sensitivity to changes in the following elements construction procedure scale set of variables and geographical context the study revealed that modifications in the set of indicators has little influence on the final results of the index and that it induces the same interpretation of social vulnerability despite some difference in leading components and their order for the scale changes as well the test showed a good stability for the final interpretation of the results sovi variables adaptation there is no consensus about variables that can be used to measure social vulnerability however some vulnerability factors appear in most studies the original sovi is based on a set of preselected variables grouped under a number of factors associated to social vulnerability in the present study the process of variables identification and adaptation is guided by three studies first it is based on the original set proposed for the united states at the county level the set dated 2000 is regularly updated so we assembled variables from both the original and the current sets for the selection in order to extend the list of potential variables we used as references two additional studies both conducted in association with s cutter the main developer of the original sovi the study of w chen al for the yangtze river delta in china and the study of c guillardgoncalves al for the greater lisbon area in portugal by combining the three sets used as reference we obtained an extended list of distinct potential variables the list was then compared to available data and assessed for its relevance to the local context in order to be filtered and adapted variables that dont fit to those criteria are either eliminated or replaced by alternative variables the alternative variables are selected with respect to their similarity to original variables or to their association with one of the vulnerability concepts of the sovi the concepts of race and ethnicity are omitted for both reasons data issues and context convenience actually in algerian context the link between those concepts and social vulnerability is less strong and less confirmed in comparison to countries historically known as an immigration destination nevertheless indicators related to foreign nationalities refugees and language barrier are relevant variables in local context they were omitted only because of the lack of data extreme ages are associated to vulnerability because of reduced physical and cognitive abilities and the dependency to assistance variables are selected to represent the proportion of these categories in the area in addition to the median age that gives the tendency of the age structure in the literature the higher vulnerability associated to women is justified by physiological characteristics and responsibilities within the family situations like pregnancy or infant caring may induce additional difficulties during postevent crisis education is a common concept of social vulnerability usually associated with a potential development and higher incomes but it can also indicate good cognitive skills in one way or another it reflects the ability to cope with the risk and recover socioeconomic status is associated to the ability to recover after experiencing losses it is represented by indicators concerning poverty and wealth to overcome data issues usual variables like incomes renters and ownership were replaced by variables about basic household appliances some house appliances are so affordable and democratized that their absence becomes a sign of financial difficulties on the other hand some properties like cars and secondary houses indicate wealth car ownership is also included in cutters original set under a separate concept housing is an important concept of social vulnerability assessment three related groups of variables are used in this study housing condition housing occupancy and housing type housing condition is associated with the physical dimension variables about house amenities are selected to indicate this aspect even though variables of this nature arent present in the original sovi they are used in the sets proposed by chen and guillardgonçalves proportion of precarious houses is added as a variable since data is available and it has a direct link with the concept according to cutter s al potential human and material losses are function of housing characteristics like value quality and density considering data structure the proportion of common house types in the area are added to replace similar variables proposed by the original sovi for house occupancy selected variables are related to the number of occupants per unit while variables about house tenure status and house value were omitted due to the lack of data most variables related to health services are not taken into consideration because of data availability issues its the case for variables about health care personnel while those linked to material resources are omitted because of the particular distribution and organization of health facilities in the algerian context in fact important health facilities are located in major cities with several municipalities annexed to them if the use of variables such as the number of health facilities and the number of beds is justified to compare provinces it is not the case in this study because some municipalities have special administrative status at the provincial or district level thus health facilities located in their territories are in fact shared facilities for several municipalities the remaining variable concerning health care insurance is calculated by using data about occupation as health care coverage in algeria is mandatory for all occupied persons occupation and employment are used in the sovi as indicators of the economic situation there is no available data about specific sectors of occupation like agriculture extraction and services therefore only general variables are selected they concern the labor force employment rate and womens participation in the labor force the variable percent of houses used for professional activity was added to the set in municipalities with large urbanized cities the transformation of houses for business indicates important economic activity both high urbanization and rurality are associated with social vulnerability the high density in urban areas makes crisis management more complicated besides urban communities are less cautious with hazard exposition because of land saturation on the other hand economic sectors and lack of infrastructure that characterize rural regions are responsible for socioeconomic disparity which results in more vulnerability rapid population growth whatever its origin puts pressure on housing infrastructure and job market leading to the aggravation of social vulnerability at the household level the family structure determines the lack or the availability of financial resources as well as familial responsibilities and dependencies affecting the ability to cope with disasters pca application the variables selection resulted in a set of 40 variables the pca is applied to the 35 municipalities of the study area with the selected variables as recommended by cutter al inputs are processed first by normalization to percentages and per capita then by standardization using a zscore method that transforms the data set to have a mean equal to 0 and a standard deviation equal to 1 following the recommendations of the sovi recipe sheet analysis is performed with varimax rotation which maximizes the correlation with a few significant variables while its minimized for the remaining ones this makes the interpretation easier despite dealing with a large number of variables the kaiser criterion is applied to extract the factors it considers as a principal component only the factors with an eigenvalue superior or equal to 1 the selected few factors have the major contribution to the total variance of the variables for the analyzed sample the extracted principal components are named using their underlying dominant drivers within each component we consider as dominant drivers the variables with a coefficient of correlation superior to 07 and inferior to 07 drivers with loadings superior to 05 and inferior to 05 may also be considered if needed to figure out the factors names a directive adjustment is applied to the factors in order to guarantee that positive values increase social vulnerability and negative ones decrease it the adjustment is performed through the examination of the underlying indicators their signs and their logical influence on the tendency of social vulnerability level in some cases the interpretation is ambiguous because variables with the same influence on vulnerability tendency have opposite signs in such situations the sovi methodology allows the use of an absolute value for the factor results sovis factors and calculation the application of the kaiser criterion revealed 6 principal components explaining 829 of the variance table 2 represents the extracted factors their dominant drivers and some secondary drivers factors are named according to their dominant drivers and if necessary secondary drivers are also used the first factor named poor housing quality and socioeconomic development explains 2745 of the total variance it is represented by 9 dominant drivers among 18 in total the main indicators of the factor are related to the poor living standards of the houses and the socioeconomic development of the community there is no ambiguity about the cardinality of the first factor a positive sign is affected to the factor since all drivers that increase vulnerability load positively like precarious housing and proportion of houses lacking basic utilities on the other hand drivers that decrease vulnerability loads negatively like labor force the second factor contributing to 2186 of the variance is poverty and education it gathers indicators representing a lack of basic house equipment and low education level positively loading drivers are vulnerabilityincreasers like the lack of house equipment and low education level while vulnerabilitydecreasing drivers have negative loads such as residents with high education levels thus the second factor receives a positive cardinality family size and labor force is the third factor with a contribution of 1335 to the variance indicators describing large households and high house occupation increase vulnerability while having positive loadings hence a positive cardinality is assigned to the factor this choice is compatible with the nature of the negative drivers describing activity and wealth because they have all the influence of decreasing vulnerability component number four named land use and demographic structure counts 4 dominant drivers and contributes to 815 of the variance all of its drivers can be linked with vulnerability rise besides the indicator qhupro which the influence on vulnerability may have divergent interpretations according to the level of urbanization however the drivers load in opposite directions and thus neither a positive nor negative sign will make sense for the direction of vulnerability progression therefore the absolute value is assigned to this factor following the sovi methodology the fifth factor related to age is responsible for 765 of the variance it receives a negative cardinality as the drivers indicating favorable age ranges for vulnerability decrease are negative while indicators for age ranges increasing vulnerability are positive the inversion of the factor cardinality with a negative sign will adjust the direction of vulnerability progression the sixth and last principal component contributes to 414 of the variance explanation it is named housing stock according to its dominant driver indicating the proportion of unoccupied houses this vulnerabilitydecreasing indicator shows a positive load hence a negative sign before the factor will adjust its influence on vulnerability level the sovi score is calculated for each municipality by the combination of the factors with their relative signs in an additive model the resulting formula is as follows sovif1f2f3f4f5f6 sovi mapping as recommended by the sovi methodology for the mapping the resulting scores are transformed into standard deviations the mapping classification counts 5 levels of social vulnerability the medium class has a sovi standard deviation between 05 and 05 values above are labeled as higher vulnerability and classed in two levels high and very high values beneath the medium level represent lower vulnerability low and very low the mapping shows that none of the 35 municipalities of the province have a very low level of vulnerability most of the provinces territory falls under the medium or the low levels the sovi map revealed three municipalities with very high vulnerability dahra breira and benihaoua with an sovi standard deviation superior to 15 a close examination of the sovi results shows that breira has the highest level of social vulnerability with a score of 31 far above the two other municipalities the contribution of the first factor poor housing quality and socioeconomic development was decisive for the high sovi score of the three municipalities by looking at the factors maps we can notice that several municipalities obtained a very high score in one of the remaining factors but it wasnt sufficient to influence the overall sovi score one municipality benibouattab obtained a very high level in two underlying factors other than the first one and only got a high level of vulnerability such cases demonstrate the decisive contribution of the first factor to the overall score in comparison to other factors this is mainly because the two factors are outweighed by the low value of the remaining factors which is not the case for the factor of poor housing quality and socioeconomic development major municipalities with important cities like chlef and tenes exhibit a good score for most of the factors particularly for the second factor concerning poverty and education the factor of age shows less diversity with only two municipalities above the medium class tenes and abou el hassan and seems to be less determinant for indicating the variability of social vulnerability fig 4 maps of the principal components of social vulnerability for the province of chlef discussion the most vulnerable municipalities labeled as very high are all located at the northern borders of the province they are characterized by the following common features the location in the coastal band a rugged mountain landscape and weak connectivity municipalities labeled with a high vulnerability share some of these characteristics like benibouattab benirached and el hadjadj which are located at the geographic ends of the province and present the same mountain character such characteristics spot geographic and economic remote regions that lack local development with no industrial and service sectors agriculture is the main resource for these areas yet even farming in the mountain areas is less profitable compared to the intensive agricultural model adopted in the lowlands of chelif valley this made the difference between some municipalities that share all characteristics apart from the agricultural model for instance the municipality of ouledbenabdelkader exhibits low vulnerability whereas benibouattab and benirached are both ranked as having a high vulnerability level despite the only distinguishing factor being the farming model as a consequence of this socioeconomic disparity poverty and weak education are higher for the concerned municipalities leading to higher vulnerability in addition they all suffer from the precariousness of their housing stock and the weak development of basic infrastructure and amenities the coastal band has a divergent pattern of vulnerability distribution with half municipalities showing high and very high vulnerability and the other half showing low vulnerability the region counts the three municipalities with the highest vulnerability scores in the province in fact despite belonging to the same geographic area coastal municipalities have different natural and economic features firstly the economy is diversified in the middle part of the coastal band with the presence of the economic activity zone and the commercial harbor secondly vulnerable municipalities at the edges of the coastal band have a larger mountainous inland area with less connectivity and more rural character low vulnerability characterizes all the municipalities located along the chelif valley as well as the main roads and railways of national importance this confirms the outcomes observed for the high vulnerability categories as the characteristics here are opposed the relation is evident between connectivity and most vulnerability indicators good infrastructure and less house precariousness better education and incomes the diversified economy of the region and its good connectivity contribute to reducing most vulnerability factors and thus the overall social vulnerability the majority of medium vulnerability areas are spread between the valley and the shore municipalities within this area have diversified economy despite the dominance of services and agriculture over industry connectivity was the determinant aspect that influenced the social vulnerability in this region as the municipalities with direct accessibility could depend on important cities in other regions on the other hand the few municipalities of the area that are labeled with high vulnerability suffer from bad connectivity despite being absent from the selected set of variables some important indicators reappear during the interpretation of the results for example specific occupations like the agriculture sector were omitted because of data availability issues however its contribution appears clearly when comparing vulnerability maps to the main activities of the concerned areas conclusion this article performed a spatial analysis of social vulnerability in the province of chlef the analysis based on an empirical placebased assessment resulted in the mapping of the spatial variability of social vulnerability for the 35 municipalities in the province the assessment replicated the sovi tool with some necessary and common adaptations to become applicable to the context of the study area the results reveal that the sovi was able to identify the underlying factors influencing the social vulnerability of the municipalities this demonstrates the convenience of the sovi as a tool for decisionmaking regarding risk management especially during early phases it helps to identify the most vulnerable units to understand the spatial variability of social vulnerability and to identify critical domains that have to be dealt with for risk management since the underlying factors are derived from empirical data the relevance of the results to the context is guaranteed the resulting vulnerability maps match with both the human and physical geography of the province the spatial distribution of social vulnerability at chlef is a direct reflection of its natural features and its territorial structure lower social vulnerability is linked to diversified economic activity and connectivity while high vulnerability is associated with remote regions undiversified activity mainly agriculturaland mountainous landscape those characteristics shaped the direct vulnerability factors such as housing quality basic infrastructure education level wealth housing stock socioeconomic development and land use which in turn influence the trend of social vulnerability level this confirms the importance of the preliminary geographical analysis of the area targeted by the vulnerability assessment the mapping of major physical and human elements of the territory is a useful tool for a knowledgeable interpretation of sovi results two major drawbacks of the study must be discussed first the data source dates back to 2008 a recent census was carried out in 2022 but its results are not yet published further studies have to be carried out with uptodate data they will allow the comparison between the two periods as well as the study of the social vulnerability evolution and the sovi sensitivity to time changes the second drawback concerns the number of spatial units included in the assessment being a statistical method the pca efficiency increases with the size of the sample the sovi methodology recommends 100 units for better results to respect this recommendation in future works the study area has to be extended to the regional level instead of the province conflicts of interest the authors declare no conflict of interest publishers note serbian geographical society stays neutral with regard to jurisdictional claims in published maps and institutional affiliations

this paper explores the empirical assessment of social vulnerability in the algerian context using the social vulnerability index sovi the sovi is applied at the municipal level in the province of chlef the assessment aims to map the geographical variability of social vulnerability for the 35 municipalities of the study area while following the original sovi methodology some adjustments were made to the variables to adapt them to the context principal component analysis pca was performed on a set of 40 selected variables resulting in six vulnerability factors after assigning a sign negative positive or absolute to each factor they were summed to calculate the overall sovi score the resulting maps highlight the most vulnerable municipalities in the province and their interpretation was aided by geographical maps depicting the natural and human characteristics of the territory

19954_0

introduction inequalities and discrimination related to cultureethnicityrace is a persistent problem worldwide neither physicians nor medical students are spared these injustices 1 2 3 the disproportionate number of culturalethnic minority health care workers and patients dying in the current covid19 pandemic in eg the us uk and sweden has heated the already ongoing debate about racism and structural discrimination in medicine following the black lives matters movement 4 5 6 researchers physicians and students have called on the medical community to take actions against structural racism within their own institutions 6 7 8 9 10 11 recurring and subtle forms of racism constitute an often overlooked obstacle to the success and prosperity of medical students from minority backgrounds 3 12 13 14 15 16 invalidations of this kind have been outlined as everyday racism andor racial microaggressions ie intentional or unintentional commonplace indignities that convey hostile or derogatory slights and insults based on perceived differences in culturalethnic background 1718 such practices sustain a privileging of white majority over racialized minority students 1315 and can have deleterious effects on minority students mental and physical health 1218 research shows that everyday racism andor racial microaggressions are difficult for victims to handle since these practices often are normalized and because they are given meaning through their repetition 1718 to date however only a few studies have discussed how racialized minority medical students cope with the stressors of racism 1315 and even fewer have explicitly examined this subject and as far as we know there are no previous swedish studies in the field furthermore to deal with stereotypes imposed on them people are forced to consider the rules norms societal discourses and power relations that characterize the context in which they find themselves 171920 therefore a study taking into consideration the historical and contemporary relations in swedish medical schools is warranted tolerance social justice and equality characterize the swedish selfimage and racism and discrimination are considered to be minimal 21 however being perceived as an immigrant which often can be equated with being seen as racializednonwhite has proven to be a basis for discrimination in terms of inferior health lower life expectancy housing standards education and employability 22 23 24 in a previous interview study we showed that while white minority students perceived the study climate as friendly and including racialized minority students faced everyday racism andor racial microaggressions 14 they regularly encountered elusive adverse treatment from supervisors peers staff and patients a dearth of support from bystanders was a common aspect of their stories these experiences pointed them out as others and made them feel less worthy as medical students in the present study the aim is to continue our work by analyzing the racialized minority medical students strategies to manage episodes of everyday racism during their education and their underlying motives and considerations this study offers a deeper understanding of racialized students situation and indicates how medical education can work to counter discrimination consistent with emergent design the analysis of the empirical material advised our choice of theory 25 we adopt a structural account of racism perceiving it as a process involving an uninterrupted often unconscious exercise of power that is based on the privilege of whiteness and the takenforgranted superiority of western culture 172627 to understand how these processes operate in everyday life at the clinic we draw on esseds theory of everyday racism and sues theory on racial microaggressions as described above 1718 culture ethnicity and race in turn are understood as social constructs where people are set apart from each other based on eg language religion and ways to dress and not as innate characteristics 28 method research design in this interview study we deployed a constructivist grounded theory approach 25 individual interviews were conducted to allow exploration of the potentially sensitive topic of social exclusion constructivist gt was selected because of its emphasis on meaning being created in interaction and people acting on the meaning they ascribe to a particular situation setting this study was conducted at umeå university in sweden in sweden the undergraduate medical curriculum encompasses 55 years and the last 6 semesters contain clinical training at hospitals and health care centers undergraduate education is followed by 1824 months of internship after which one can apply for a license to practice medicine and for a position as a resident at umeås medical school each class includes approximately 100 students the latest figures suggest that less than 10 of the students are foreignborn or have two foreignborn parents 29 the corresponding figure for all medical students in sweden is 18 30 swedish universities are legally bound to work against discrimination related to eg sex ethnicity religion or other beliefs 31 consequently an equal treatment plan outlining how equal rights are to be promoted how to inhibit discrimination and a zero tolerance policy for discrimination harassment and abusive treatment is adopted within umeå university 3233 there are no rules about including education about discrimination and racism in the medical curriculum in sweden still in the professional development course running like a thread throughout medical education in umea there are a few seminars focusing on cultural awareness and racism data collection between 2016 and 2018 interviews were carried out by the first author and by a medical student employed as a research assistant both white women interviews followed a topic guide exploring participants own medical school experiences interactions with costudents supervisors staff and patients as well as other situations where their origin became important in a positive or negative way and how participants dealt with these experiences followup questions were posed to encourage participants to provide examples and clarify details efforts were made to establish a safe atmosphere for sharing personal experiences 2535 interviews were 57 to 125 min long digitally recorded and transcribed verbatim before the interviews interviewees completed a brief demographic questionnaire analysis data collection and analysis were iterative allowing us to let emerging insights inform the consecutive interviews to saturate the emerging categories 25 we stopped interviewing when we assessed that saturation was reached ie that on a higher abstraction level no new insights emerged the analysis was inspired by the constant comparison technique of gt and by our theoretical framework we individually read and coded the transcripts each interview was also condensed into a case narrative reflecting the previous coding then the codes were compared discussed in relation to the theoretical framework and grouped into preliminary categories that included the content of participants experiences at this stage we decided to divide the analysis into two parts one focusing on various experiences of everyday racism and the present study focusing on affected students way to handle the discrimination they encountered for the present analysis ek rescrutinized the codes categories and case narratives read the 15 interviews again and interpreted the material by means of focused coding on ways to react to and manage the problematic experiences the preliminary categories created were compared and refined and a core category always on the alert managing the threats of racism was identified here a core category refers to a category that embraces all the other categories lastly ek reviewed the 15 interviews again and kh reassessed a sample of four interviews to confirm that the categories were grounded in the data epistemologically we acknowledge that the data are coconstructed between interviewer and interviewees during the entire process ek and kh therefore maintained reflexivity through critical reflections and discussion about the assumed associations between the emerging categories the theoretical framework and their own roles in the research process 36 ethics studying a marginalized group like racialized minority students always implies the risk of reifying them as a fixed category of others 37 we handled this dilemma by striving to understand the individual participants perspective posing followup questions asking for concrete examples and by searching for negative cases to pick up differences to ensure confidentiality detailed background information for participants has been withheld and details about individual people emerging in the interviews have been deleted or modified participants were given oral and written information about the study and their written consent was obtained before the interviews the regional ethics committee in umeå granted ethical approval for the study results participants generously shared and reflected upon how they navigated and negotiated adverse incidents involving supervisors staff patients and costudents a core category was established grounded in five categories describing how participants managed their situation below the core category and categories are presented and illustrated with quotations from the participants each quote is marked with the participants gender and interview number always on the alert managing the threats of racism the core category summarizes the strategies through which participants tried to manage the threats of racism recurrent experiences of constraining stereotypes and exclusion that placed them as others and threatened their success as students made participants selfaware and hypervigilant im kind of prepared all the time often they grappled with whether they could or dared take immediate action if something is really racist then i want to speak up but i have to consider the situation its not always possible however they also took many precautionary measures to prevent or mitigate the risk of provoking stereotypes depending on the context they utilized various strategies to handle the threats of racism the prevailing power relations in the educationaland clinical situations and the potential impact on their success as students were major considerations in this process while participants spent considerable time and energy navigating the risk of stereotypes and exclusion they seemed reluctant to view themselves as victims rather they wanted to be perceived as active students and professional physicianstobe speaking up and confronting all participants highlighted that speaking up and confronting were important ways to oppose racialized slights and resist peoples attempts to categorize and confine them to racial or cultural stereotypes to directly mark against injustice involved a shift of fault and responsibility to the perpetrator which was described as empowering active protests however constituted only rare exceptions many incidents were considered minor andor ambiguous making them difficult to recognize for peers and tutors and deemed not worth complaining about one student explained how the complexity of such incidents combined with racialized students lacking credibility held him back people can just protect themselves because it is nothing concrete they can defend themselves by saying no i said nothing wrong how can you accuse me of being a racist true i cant do that because they havent explicitly signed a paper where they say hereby i certify that i have racist prejudices and oppress people because of it another reason given for not speaking up was fear of negative consequences interviewees thought they stood out in the crowd and speaking up they feared would magnify this i already felt different and then i did not want to call attention by speaking up to the physician participants need to build trust with supervisors meant that their abilities to voice criticism without being discredited were circumscribed placing patients in an unfavorable situation by accusing them of racist utterances in turn interfered with their image of professional behavior maintaining a professional selfimage in relation to supervisors and patients was thus accomplished by silently accepting racism in the rare instances when interviewees had chosen not to quietly accept tacit treatment or racist stereotypes they seldom experienced any support or endorsement rather perpetrators andor bystanders dismissed and invalidated the racial insult thus in most situations they refrained from raising such issues i am a little afraid to end up in conflict with a teacher participants sometimes attempted to object to injustice by exposing prejudices through seemingly innocent questions forcing people to explain dubious statements an immigrant with stomach pain came in to the er with an ambulance whereby the resident said they always do that i played a little stupid and this quote highlights that even such factual comments opened up to scrutiny and made participants vulnerable to further aggressions knowing how frequently people reacted defensively when prejudices were called out made participants aware that protest might be damaging triggering stereotypes depicting minorities as oversensitive there was also a striving to reclaim the position as other as positive and normal and thus resist the image of the other as negative being recurrently confined to negative stereotypes some male students tried to convert them to a strength or at least something that they could use in certain situations one stated that it could be nice to play on prejudices if he did not want to be bothered he explained he just frowned and then people let him be because they thought he looked frightening this strategy however both indicates and reproduces racialized stereotypes formal reporting to make use of recognized processes within the university for reporting discrimination directly to the course management was seen as important but in reality difficult participants were on the one hand content with the measures being undertaken to facilitate students reporting negative treatment through course evaluations there is like a zero tolerance for discrimination it is a security to know that as a student you have your rights on the other hand even if these evaluations were anonymous making complaints turned out to be practically impossible since participants feared they could still be identified due to the small number of racialized students it becomes quite obvious who has reported it another female student who had experienced adverse treatment from a distinguished physician said i would have wanted to go to the course management or the course coordinator but i dont know how its just me who hasnt dared to so i think the error lies with me i am the one who should change the formal directives conveying to students that they can report discrimination seemingly make her blame herself for the continuous injustice fear of being questioned added further to participants hesitance to report discrimination to dare one must be sure that one will not be questioned a few participants were confident that the course management would take measures if they found out about discrimination others believed supervisors could still get away with inappropriate behavior because of their important role in the health care organization only one interviewee had reported poor treatment to the course management he was astonished when the teacher in question listened to and confirmed his experience and underlined how important this recognition had been for him searching for safe places trying to protect oneself from being subjected to racism and find contexts where one felt safe was important for participants they tried to escape and avoid specialties clinics and social settings where they had been or feared they would be illtreated at universities and hospitals with a larger proportion of racialized students and physicians they imagined they would be treated fairly and fit in better thus some dreamed about leaving umeå altogether experiences of mockery and scrutiny had also driven them to withdraw in educational contexts to avoid negative attention this fear that the doctor will be racist makes me feel i would rather not get in the way or dont take up as much space however to be successful such measures require that only specific individuals are carriers of racism as it turned out friends also expressed preconceived opinions some were people i was quite close to after repeated incidents where he had to face biased beliefs from classmates this participant gradually withdrew i have them at a safe distance where they cant hurt me outside of school i meet none of my classmates and thats how i want it i deny all invitations when i let people come a little too close it usually gets wrong if i put people in a position where they can hurt me then it tends to happen too so thats why i keep my distance isolation thus became a way to protect oneself from racism this strategy however added to the segregation that placed participants in a subordinate position in the first place and entailed missing out on educational possibilities it means i cant really use my full potential moreover participants strategically sought connection and affirmation to handle adverse experiences some turned to family and loved ones others underlined that it was paramount to have a network outside the family eg minority classmates or friends to receive validation it was the shared experience of being constructed as the other that formed the basis for this mutual understanding and trust interactions with racialized students were described as synonymous with security enabling participants to feel safe that one would not be questioned in my group of friends i am not judged for my language creating emotional distance this category refers to cognitive strategies aimed at creating emotional distance to discriminatory experiences to alleviate their stressful effects participants deliberately tried to reinterpret adverse experiences to protect themselves from pain i actively think that the person does not discriminate against me reinterpreting also worked to transform recurrent racist incidents into something they had the opportunity to influence as described by this male participant i never want to believe it has to do with racism so i give one million excuses instead because otherwise it will be so terrible to live so i think its a selfdefense mechanism for me that makes me survive one more day … because it is difficult when it depends on something that i have just been born to not something that i can influence because i dont know what to do what can i say sorry im black others indicated that they had learned to brace themselves and become impermeable to racial slights ive become immune i dont take it personally referring to their lack of opportunities to decide which images of them should be valid they emphasized the importance of separating selfconfidence from other peoples opinions if i myself become the source of my selfconfidence of how i handle things of how badly i feel when someone says something then i become unwavering another example of how emotional distance was established was to adopt a professional persona eg to think about what was be best for the patient be objective rational and not easily take offense as explained by this female student i take on some sort of role now im a professional obviously you can be affected get sad but i think i can let it go quite quickly i have the attitude that i am a caregiver its a bit like being a parent to someone you are the adult and then you do not take as much offence if its my best friend then i am much more sensitive the role of caregiver allowed her to uphold a positive selfimage even in the presence of downgrading comments this strategy though requires a condescending view of patients and frees them of responsibility for their actions in the end keeping painful experiences at a distance was difficult and some interviewees yielded to selfaccusation when being unable to do so i perceive myself as weak and let myself be impeded by other people i believe that many with a foreign background have experienced the same things that i have but if you are a little weak then i think you become inhibited i have become so restrained because of everything that has happened but i think if you are a little stronger and more confident and dont let anyone trample on you then theres no problem by suggesting that caring about peoples opinions is a sign of weakness in this way the focus is transferred from the perpetrators and their inappropriate behavior onto the participants themselves and their ability to handle such incidents neutralizing threatening stereotypes this strategy implied a striving to be in control to conform and to adapt to societal expectations and discourses and become accepted by refuting stereotypes when facing rude and intrusive questions about eg their background or religion from supervisors staff and patients or encountering patients skepticism of them participating in care interviewees said that they felt it necessary to be patient and informative providing comprehensive answers in order to sustain positive relations as an immigrant you must first make sure that the patient is comfortable with you consequently it seemed participants had to disregard their own needs to ameliorate the potential distress of white people one student explained how he responded to questions about his background ive tried to respond to it by continuing to say im from hometown until they ask where are your parents from then i always give in and say i am from hometown but the parents are from xcountry and then they let go of the question immediately experiences of being devalued overlooked and questioned compelled participants to put themselves forward and demonstrate their capability and knowledge it always feels like i have to prove myself a little extra because im not like everyone else they talked more during group work posed many questions to teachers and supervisors and carefully answered questions not because they wanted to excel or learned more by doing so but because they felt they had to so that they see that i am a medical student i speak swedish im just like everyone else they hoped their efforts would protect them from negative preconceptions sometimes im afraid that someone will judge me based on my appearance i dont think i would feel like that if i was a blonde because i look in a certain way i have to do twice as well so that no one will think it is that immigrant i do my best and it feels like it should protect me in some way against prejudice some participants though asserted that the prospect of being discriminated against served as a driving force for improvements it motivates me immensely i wouldnt say that i feel that i have something to prove because i dont experience that but it is still a driving force that it feels good to get other people to understand that yes but he can do it too even though this student talks about discrimination in almost positive terms as a driving force and motivator it might still be argued that he needs those in power to acknowledge him as a worthy medical student and that he is forced to work extra hard just to rise to the level of the white majority students in order not to trigger hostile stereotypes participants also described behavioral changes aimed at conforming to perceived majority culture for instance being mindful of using correct swedish and avoid making jokes one male student said i have changed behavior a lot in order not to stand out too much he underlined though that his adaptation did not constitute a real internalization of perceived majority norms like most interviewees he displayed a resistance towards assimilation combined with a change of his outer persona to mimic desirable qualities you have a facade that you show others such adaptation in turn it might be argued contributes to the normalization of cultural hierarchies discussion we explored how racialized minority medical students handled incidents of everyday racism perpetrated by supervisors staff patients and costudents participants managed the threat of constraining stereotypes and exclusion while attempting to retain a sense of self as an active and professional physiciantobe as opposed to a passive and problematic other their modes of action were constrained by the educationaland clinical power hierarchy minority students lacking credibility a dearth of support from bystanders and ideas about professional behavior the strategies included speaking up and confronting formal reporting searching for safe places creating emotional distance and neutralizing threatening stereotypes navigating implicit white norms on medical professionalism by being seen as cultural andor ethnic others our participants risked being discerned as missing qualities required of a good physiciantobe this is in line with previous studies that have shown that assessment of academic excellence and professionalism is informed not only by official criteria but also by whether or not one fits the norm of belonging to the white majority 23839 therefore it is not surprising that students strategies evolved around retaining their sense of being active and professional physicianstobe furthermore in line with previous studies participants seemed to confuse professionalism and professionalization thinking that emotional detachment was a necessary component of professionalism 40 being offended by racial slights andor speaking up was therefore viewed as lacking professionalism important parallels can be drawn between the strategies used by our participants and those formulated and described by other scholars 1719 27 41 42 all approaches carried both advantages and disadvantages acts of resistance could be liberating but participants lacked credibility and speaking up made them vulnerable to accusations of being oversensitive troublemakers 1718 furthermore they could not rely on support from bystanders hence as seen in other studies racial slights were often perceived as not worth complaining about or reporting especially in relations characterized by power differentials 131618 resisting the downgrading of cultures other than swedish culture by embracing otherness in turn meant that the interviewees identified with stereotypes created by the prevailing power order 171842 standing alone and being unable to prove or even protest against discrimination participants had to find other strategies for managing their situations searching for a safe place mitigated stress and meant having ones experiences reaffirmed however as noted by other researchers it also entails a withdrawal from contexts students have the right to seize upon and makes them more isolated and vulnerable 15 creating emotional distance a strategy commonly described in previous literature helps keep the pain away but means that the focus shifts from unfair events to the participants ability to remain unaffected by them 1842 even if participants describe themselves as immune to racial slights it remains something they have to handle furthermore studies show that being continuously subjected to racial slights is psychologically stressful resulting in eg frustration anxiety and anger 43 lastly attempting to neutralize stereotypes by eg demonstrating ones capability or conforming to the majority culture could be rational in a competitive educational environment however interviewees chances to prove their capability are probably limited because in the eyes of the majority they will likely remain representatives of the other 1942 common to many of participants strategies is that they do not question the basic assumptions behind their marginalization namely the division into essential groups based on cultureethnicity 19 rather strategies such as silence adaptation and avoidance run the risk of reinscribing belonging to the white majority as representing the norm for a medical student concurrently it means participants make themselves responsible for handling something that is not their fault while perpetrators are deprived of responsibilities for their actions but when racialized minority students experiences of and knowledge about racism are not acknowledged and they are left without any support from bystanders what are their possibilities for handling stereotypes and exclusion without reproducing their oppression this is the first study of its kind to be conducted among swedish medical students although many of the strategies the participants used have been shown in previous research our study also contributes with knowledge about the specific expressions that these strategies take in the hierarchical healthcare organization in addition our results are novel by illustrating how the strong association between professionalism and emotional detachment risks making it even more difficult to acknowledge that racism is a problem and make students even more prone to remain silent in the face of racism and what is worse racism risks being seen as something you as a professional should learn to put up with hence this study also contributes important insights into the challenges and barriers that the work on counteracting racism may entail breaking the silence surrounding racism and discrimination antiracist policies and routines for handling discrimination and harassment are important but alone they are insufficient to prevent and manage racism and discrimination in medical school racialized minority students are in a subordinate position and too easily recognized to be expected to dare speak up and report also being minority students they often lack credibility which is further undermined by spectators passivity lastly because acts of everyday racism are often normalized making complaints about them is especially hard consequently formal commitments to equality such as those held in the medical school where this study was conducted are at risk of becoming symbols of equality while inequalities remain 3233 countering racism in medical school will naturally require a longterm and comprehensive approach on a structural level it is for example important to continuously discuss and refine formal routines for reporting discrimination but other measures such as increasing the proportion of teachers tutors and supervising physicians belonging to cultural minority groups are also needed to break the silence surrounding racism and improve the situation for exposed students our results suggest that change must also occur in relationships and everyday practices at the clinics with support from management students and not least teacherssupervisors should be assigned time for attending education on structural and everyday racism andor racial microaggressions which takes into account the power relations through which racism operates 172627 otherwise there is a risk that what our participants are exposed to will not be considered andor identified as racism furthermore witnesses to racial slights should be supported to move from passive bystanders to active allies to mark and establish that these practices are intolerable a promising strategy according to recent studies 16 44 45 46 addressing racism both as a victim and as a bystander naturally entail several challenges not least the fear of retribution 16 however being an active bystander includes not only speaking up to perpetrators but also for example talking to other people who can address the incident and talking to and supporting the victim afterward 46 efforts to ameliorate these injustices should also include a discussion of what professionalism is or should be in order not to confuse professionalism with a stoic acceptance of discrimination and racism to give these issues more focused attention we propose dedicated theme days for both students and supervisors and mandatory teaching elements furthermore finding new and alternative ways of reporting discrimination may be needed as well as work on creating supportive networks methodological considerations strengths limitations future research our committed sample of selfselected participants resulted in a rich material informants however may differ from those who abstained from participating it is possible that those abstaining struggled to handle more grave experiences but did not trust the researchers enough to participate in the study or they faced no challenges and thought they had nothing to contribute the interviewees came from different backgrounds and their strategies varied indicating that enrollment was broad which offers credibility to the results our data collection was performed prior to covid19 and the attention that black lives matter got during the first years of the pandemic in sweden though black lives matter has not been discussed as a movement of much relevance for the swedish society nevertheless in the spring of 2021 an appeal from swedish physicians and medical students against racism in swedish health care was published in the media 47 later it was revealed that caregivers throughout sweden allow patients to choose to be cared for only by ethnic swedes 48 these events may have increased awareness of racism in medical education and of the importance of addressing this problem consequently had our data collection been performed now it is possible that our results would have been different that the interviewers shared the experience of being medical students with the participants may have enabled trust during the interviews however the interviewers were white which means that participants may have avoided sharing information because of doubts that their perspective would be understood future research undertaken by researchers from racialized minority groups would therefore be valuable also more research is needed on insidious forms of racism to inform strategies for effectively dismantling these inequalities lastly in the work of counteracting racism it will be important to ask for and listen to suggestions from students this was not something that the participants in this study were asked about and can be seen as a limitation the study is also limited by its reliance on data from a single medical school nevertheless similar strategies to those deployed by our participants have been seen and described in studies from other countries 1315 thus we believe that our findings apply to other swedish universities and also other western contexts still future research should investigate experiences and reactions among racialized minority students in more culturally or ethnically diverse settings conclusions racialized minority medical students managed insidious racism including threats of constraining stereotypes othering and exclusion while at the same time maintaining a selfimage of being competent medical students due to the clinical power hierarchy racialized minority students lacking credibility and lack of support from bystanders their strategies to counteract or avoid everyday racism were focused on adapting their own behavior or thinking not on speaking up or formally complaining about discrimination however constraining stereotypes and marginalization are not caused by exposed racialized students own ways of being and acting thus strategies built upon behavioral modification will not free them from racism nor will it grant them access to the desired position as active and professional physicianstobe instead strategies such as adaptation silence and avoidance risk entrenching belonging to the white majority as representing the norm for a medical student to counteract everyday racism in medical education we suggest that medical school management embrace the knowledge that racialized minority students have about structural and subtle racism within our own institutions and impart this knowledge to all students and supervisors teachers lastly witnesses to discriminatory treatment should be supported to go from silent and passive bystanders to allies that are trained to see understand support and search for the best ways to act authors contributions ek and kh were responsible for the study conception and design ek performed the data collection together with a medical student ek and kh performed the data analysis ek was responsible for the drafting of the manuscript ek and kh made critical revisions to the manuscript for important intellectual content and both authors read and approved the final manuscript competing interests the authors declare that they have no competing interests kristoffersson • support for research data including large 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background mounting evidence suggests that medical students from culturalethnic minority backgrounds face recurring and more or less subtle racist oppression ie everyday racism insights into how they handle these inequalities though are scarce especially in a swedish context in this interview study we therefore explored and analyzed the strategies used by racialized minority medical students to manage episodes of everyday racism and their underlying motives and considerations methods individual interviews were carried out with 15 medical students 8 women 7 men who selfidentified as having ethnicor cultural minority backgrounds inspired by constructivist grounded theory data were collected and analyzed simultaneouslyparticipants strove to retain their sense of self as active students and professional future physicians as opposed to passive and problematic others based on this endeavor they tried to manage the threat of constraining stereotypes and exclusion due to the power relations in medical education and clinical placement settings as well as racialized students experience of lacking both credibility and support from bystanders few dared to speak up or report negative treatment instead they sought to avoid racism by withdrawing socially and seeking safe spaces or they attempted to adopt a professional persona that was resistant to racial slights lastly they tried to demonstrate their capability or conform to the majority culture in attempts to refute stereotypesracism is not caused by the exposed individuals own ways of being or acting therefore behavioral changes on the part of minority students will not relieve them from discrimination rather strategies such as adaptation and avoidance run the risk of reinscribing the white majority as the norm for a medical student however as long as racialized minority students stand alone it is difficult for them to act in any other way to dismantle racism in medical education this study indicates that antiracist policies and routines for handling discrimination are insufficient school management should also acknowledge racially minoritized students experiences and insights about racist practices provide students and supervisors with a structural account of racism as well as organize training in possible ways to act as a bystander to support victims of racism and create a safer working environment for all

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social support and adopt new activities and roles such as interacting with staff and advocating for the care recipient these changes however do not necessarily result in the alleviation of stress and burden for caregivers former burdens may be reduced while new sources of stress may arise the present study utilizes longitudinal data in order to examine how preplacement factors influence the burden that dementia caregivers experience following nhp understanding this key transition and how preplacement factors impact postplacement caregiver adaptation is critical for social work professionals assisting families prior to during and following nhp transitions in caregiving transitions in caregiving have been conceptualized within the literature as complex and multidimensional processes meleis and colleagues in their conceptual model of health transitions have identified five properties of the health transition experience thus elucidating the complex nature in which transitions are experienced these properties include awareness engagement change and difference time span and critical points and events this complexity is reflected in the growing body of research that has examined transitions in caregiving most notably the transitions that occur during the nhp process for dementia caregivers once again these studies confirm that family caregivers do in fact stay involved in various forms of care following nhp how caregivers respond to this transition is much less clear some studies have shown that caregivers can experience declines in depression and burden following nhp this may be due to the relinquishing of certain stressful responsibilities such as constant monitoring and physical care however other investigations have shown that caregivers can experience negative outcomes following nhp this may be attributed to feelings of guilt for institutionalizing a family member or the often reported stress that is associated with interactions with staff and lack of satisfaction with institutional care questions remain as to which factors predict caregiver outcomes following the transition to institutional care prior studies of predictors of caregiver adaptation to nhp have produced mixed results several studies have suggested that behavioral problems exhibited by care recipients prior to nhp are correlated with negative emotional outcomes for caregivers after nhp other studies suggest that behavioral problems have less of an effect on caregiver outcomes following nhp familial relationship to the care recipient has also been linked to caregiver adaptation to nhp findings from these studies maintain that spouses experience more symptoms of depression and more dissatisfaction with the nh setting during the postplacement transition earlier research suggests no difference in adaptation to nhp among spouses or adult children many of these studies however do not examine trajectories of care provided within the home and how the experiences of longterm home care influence post nhp burden and stress this is important as dementia care is a longterm process for families on average families spend over five years providing athome care to functionally andor cognitively impaired relatives again the complexity of the nhp process and the multitude of factors shown to be associated with emotional distress for caregivers during this transition preclude researchers from reaching a consensus on precisely which caregivers are at greatest risk of experiencing deleterious outcomes during and after nhp there are a number of limitations that should be noted in reviewing these past attempts to elucidate the experiences of caregivers during this complex transition in care although most researchers used longitudinal methods many of these studies also relied on small sample sizes thus impacting the ability to detect changes during nhp furthermore past studies have largely relied upon static measures rather than looking at change for instance changes in caregiver resources may be a more appropriate measure in understanding stress and burden rather than a simple measure of caregiver resources at one point in time in the current study these limitations are addressed through the use of a large diverse sample and through the implementation of multiple measures over time thereby providing measures at discrete points of time as well as measures of change over the trajectory of the caregiving career these multiple measures allow for the development of a better understanding of the experiences of caregivers during this important transition in caregiving in the current study we attempt to identify and understand which factors affect the experiences of caregivers in the months leading up to and following nhp based upon the literature and an understanding of the stress process of dementia caregiving the following hypothesis was developed and tested caregivers who experience decreases in key stress variables and increases in the availability and use of resources prior to nhp will report lower caregiver burden following nhp it should be noted that caregiver depression was not included as an outcome measure a recent analysis of the same data used in the present study did not find significant clinical changes in caregiver depression following nhp for this reason the authors chose to focus specifically on caregiver burden in order to gain a better understanding of the trajectory of care we will examine these stress variables and caregiver resources at multiple points in time prior to nhp and then assess these same variables again following nhp growth curve modeling will provide an illustrative understanding of precisely which factors play significant roles in the experiences of caregivers during the nhp process methods sample the sample for the present study was drawn from the medicare alzheimers disease demonstration evaluation study madde was a largescale longitudinal study of a caregiver intervention conducted across eight diverse regions in the united states between 1989 and 1994 caregivers were defined in this study as the relative who provided the most assistance to the person with dementia throughout the course of the study as the goal of the current analysis is to examine the impact of preplacement factors on postplacement caregiver burden synthetic placement cohorts were constructed that included only those caregivers with 3 waves of preplacement data and one wave of postplacement data caregivers in the madde data set who did not have a complete set of four waves of data due to premature nhp or to attrition were excluded from the current analysis three waves of preplacement data were selected because this allowed for a more indepth empirical analysis of caregiving trajectories prior to nhp via growth curve modeling than the analysis of 1 or 2 points of data would have allowed this resulted in a final sample of 634 dementia caregivers from the original 5831 dementia caregivers who initially enrolled in madde caregivers were predominantly female older spouses of care recipients additional sample demographics are presented in table 1 measures the measures consisted of a series of quantitative scales designed to assess the following context of care caregiving stress caregiver burden and caregiver resources surveys were administered to caregivers by trained nurses and social workers three times at sixmonth intervals prior to nhp and one time during the 12 months following nhp initial interviews were conducted inperson and subsequent interviews were conducted via telephone context of carea number of contextual variables were measured at baseline such as gender caregiver relationship to care recipient age income employment status education and duration of care additional contextual variables were measured at preplacement intervals including caregivers selfreported health status and caregivers functional dependency as measured by 5 activities of daily living and 8 instrumental activities of daily living stress variablesseveral measures assessed care recipient functional behavioral and memory impairments at each preplacement study interval care recipient functional variables include dependence on 10 adls and 8 iadls care recipient cognitive status was measures using the minimental status examination administered at baseline care recipient behavior problems such as asking repetitive questions being suspicious or accusative or wanderinggetting lost were measured with a 19item measure the hours caregivers spent on providing care during a typical week was also included caregivers perceptions of unmet need providing care for adl and iadl limitations of the care recipient were summed caregiver burdencaregiver burden was measured with a 9item short form of the zarit burden interview the zbi assesses the social emotional financial and psychological distress related to family care provision the zbi was administered at all preplacement and postplacement study interviews resourcesin this study resources were defined as the various services that caregivers used to augment their caregiving capabilities these services included assistance with chores personal care services adult day services overnight hospital respite and assistance from family and friends service use was assessed using a fixed list of options at each preplacement interval and at the postplacement interval descriptive data on the measures are presented in table 2 data analysis the first objective of this analysis was to determine whether significant change occurred in the predictor variables prior to nhp since 3 waves of data were available prior to nhp a complex descriptive model was possible specifically a level 1 growth curve model was fit to describe trajectories of change in stress process variables prior to nhp a growth curve model includes two levels level 1 is an initial withinsubjects model that describes intraindividual change in a variable the withinsubjects model examines each individuals growth as a function of time to describe trajectories of change in stress process variables measured at each preplacement interval a level 1 model using lisrel was conducted lisrel provides a number of goodness of fit indicators as well as parameter estimates and mean level change values as only two parameters can be estimated with the three preplacement waves of data our level 1 models focused on initial status and rate of change parameters the main research question was addressed in the empirical analysis a level 2 growth curve model was conducted using listat this model is a betweensubjects model initial status and rate of change in stress process model variables served as the predictors in this growth curve model the dependent variable was postplacement burden stress process variables that were measured at baseline only eg mmse various context of care variables were also included in the model results for those variables measured at multiple time points prior to nhp level 1 growth curve models were fit to determine trajectories of linear change each of the level 1 models was an excellent fit to the observed data excellent fit is demonstrated in structural equationgrowth curve models where p 05 root mean square error approximation 05 nonnormed fit index 95 comparative fit index 95 and goodness of fit index 92 predictors varied as to whether they increased decreased or remained relatively stable in the preplacement measurement period specifically several variables indicated significant and considerable increases prior to institutionalization including adls iadls caregivers negative perceptions of health adult day service use and personal care use other predictor variables demonstrated significant decreases such as behavior problems caregiving hours and unmet need on average caregiver adls caregiver iadls chore service use overnight hospital use caregiver burden and secondary hours showed relative stability in the months leading up to the nh transition the growth curve model tested the hypothesis that change in key stress process variables prior to nhp would lead to greater burden after institutionalization the model explained a considerable amount of variance in postplacement burden however the model provided only a moderate fit to the observed data only one variable emerged as a significant predictor of postplacement burden baseline burden was a strong significant predictor of postplacement burden a second model was conducted that excluded preplacement burden the model is presented in figure 2 the model again provided a moderate fit to the data and accounted for a moderate amount of variance in postplacement burden several contextual variables were predictive of postplacement burden caregivers who were interviewed at a date more proximal to nhp were more likely to report postplacement burden while care recipients who were male or caucasian had caregivers indicate greater burden after institutionalization caregivers who reported greater health impairment at baseline also perceived greater burden after nhp one stressor and two resource variables appeared to predict feelings of burden after nh entry greater unmet need at baseline and increases in unmet need prior to nhp were predictive of greater burden at postplacement increases in adult day service use appeared to lead to a more difficult emotional transition for caregivers following nhp caregivers who reported reductions in hourly help from other family members or friends in the months leading up to nhp indicated greater burden after institutionalization discussion providing care to a family member with dementia is a role marked by considerable stress and burden particularly as the troubling symptoms of the dementia increase and caregivers transition care recipients out of the home care setting while researchers have considered predictors of nhp across a wide range of samples this study moves beyond a discrete analysis of predictors of nhp we examined changes in the caregiving stress process over a 12month period prior to nhp and followed these caregivers for up to 6 months after nhp to examine factors related to postplacement burden our findings indicated that significant change occurs in a number of caregiving variables prior to nhp such as the functional dependency of caregivers and the hours spent on caregiving following nhp we found that caregiver burden remained stable more importantly we were able to identify certain contextual variables and resource variables that influenced postplacement caregiver burden in this manner we believe the findings can help guide nhbased social workers and other nh staff when designing and targeting clinical interventions to assist caregiving families during the placement transition in the following section these results will be discussed in detail as will the practice implications for social work professionals who serve caregivers and care recipients before during and after nhp the first objective of this study was to investigate whether changes occurred in caregiving variables prior to nhp analysis of three waves of data in the 18month period prior to nhp revealed that there was dynamic change in certain covariates while others remained stable covariates such as care recipients functional dependency with adls and iadls caregivers negative perceptions of health and resource variables such as adult day service use and personal care use all increased significantly prior to nhp these findings help to describe dementia caregiving conditions that often precede nhp as the functional abilities of care recipients deteriorate over time their increased level of dependency can negatively impact the health and wellbeing of caregivers at the same time caregivers may increasingly seek outside sources for assistance however past research on adult day services and other such interventions has yet to definitively determine whether they are effective in reducing burden or delaying nhp as some have speculated it may be the case that such efforts to seek assistance are too little too late other caregivingrelated factors decreased over the 18month period prior to nhp including care recipient behavior problems caregiving hours and caregivers unmet need interpreting these findings is somewhat more complicated in past research behavior problems associated with dementia such as aggression or wandering have consistently been found to predict nhp and one might assume that these behavior problems might escalate prior to nhp it may be the case that behavior problems in the current sample were perceived as decreasing by caregivers as they increasingly used outside assistance such as adult day services another interpretation is that as dementia progresses behavior problems such agitation and wandering give way to more functional dependency such as increased adls while exacerbated behavior problems could pose crisis events that trigger institutionalization the sample and findings here suggest a more gradual placement process based on this functional decline eventually functional decline led to the need for 24hour skilled nursing care it should be noted that the cases analyzed in this study are more representative of relatively stable trajectories rather than crisis trajectories or shortened observed time within the community this operationalization of crisis events vs more gradual functional decline is an important issue to be addressed in future research finally several variables remained stable across the period leading to nhp including care recipient dependency with adls and iadls use of assistance with chores overnight hospital use caregiver burden and hours of caregiving assistance from family and friends again one might expect each of these factors to increase during the period leading to nhp most notably caregiver burden past studies and the findings from initial analyses of institutionalization using madde data have found caregiver burden to be a significant predictor of nhp these findings suggest that the consistency and persistency of caregiver burden may be a better predictor of nhp than simply the presence of burden measured at one point in time it is also important to note that the reasons underlying burden may change over time earlier in the caregiving process behavior problems and similar athome care demands trigger burden as the decision to place a relative becomes imminent other issues may emerge such as selection of nursing home payment issues or similar concerns which account for changes in burden leading up to and following institutionalization our second objective in this study was to test the hypothesis that changes in key caregiving variables would predict postplacement burden in our first model we found that baseline preplacement burden was the sole significant predictor of postplacement burden past research has shown that preplacement burden is strongly related to postplacement burden it is also becoming apparent that reductions in caregiver burden occur following nhp caregivers should anticipate that while certain stressors may be alleviated by nhp other stressors may arise to supplant previous burdens such as problematic interactions with nursing home staff and increased financial burdens we excluded preplacement burden in our second model to help clarify whether other factors played a role in this process three contextual variables emerged as significant predictors of higher levels of postplacement burden including the gender of the care recipient the race of the care recipient and the level of caregiver health impairment at baseline findings from a number of past studies on caregiver burden both in the home setting and following nhp have also found that burden is higher when care recipients are male and caucasian this finding is important for practitioners as it identifies a discrete group of care recipients and caregivers who may be at highest risk of burden following nhp thereby facilitating interventions our finding that postplacement burden was greater for those caregivers who had higher levels of health impairment at baseline was not unforeseen as caregivers with greater health impairment may experience more difficulty adjusting to nhp caregivers own health problems may be compounded by the changing stressors imposed during this difficult transition period two caregiving resource variables adult day service usage and hourly help with caregiving from family and friends were also found to be significant predictors of postplacement burden somewhat reflective of past research we found that increased utilization of adult day service predicted higher levels of postplacement burden as previously discussed adult day service use has not been found to delay nhp increased use of adult day services may actually be indicative of caregivers who are at the end stage of home care and are struggling to keep their care recipients in the home setting nhp may not reduce the burden experienced by these caregivers and as these findings and past findings reveal burden may be exacerbated by new stressors caregivers with diminishing assistance from family or friends may also find themselves at greatest risk of burden and stress when nhp finally occurs again there seems to be a misperception that nhp alleviates the need for assistance and support when in reality the time leading up to nhp and immediately following nhp may be a period during which caregivers need increased guidance information and perhaps case management the second model also identified two stressors variables as predictive of higher levels of postplacement burden in caregivers higher levels of unmet caregiver need at baseline and increases in unmet need in the period leading up to nhp unmet need is a condition or set of conditions in which the burden of providing care either exceeds the resources of the caregiver or creates deficits in the life of the caregiver unmet need can be comprised of several areas related to caregiving such as assistance with adls and iadls social support or financial support while past research has identified postplacement unmet need as a predictor of postplacement burden our findings indicate that the rate at which unmet need grows prior to nhp may be equally important as an indicator of postplacement burden unmet need is not static nor is the burden created by unmet need these findings confirm the dynamic nature of the caregiving process limitations there are several limitations to consider in interpreting the findings from this study first the data set for the madde study is approximately 1419 years old which makes our findings somewhat dated despite this apparent limitation there is little evidence to suggest that the experience of dementia caregivers has changed significantly over this time period particularly the burden associated with this role nonetheless the emerging development and availability of care alternatives may influence the experiences of the current cohort of dementia caregivers and care recipients while the sample in this study was relatively large it should be noted that participants were not randomly selected the sample therefore may not be representative of the overall population of dementia caregivers and care recipients which limits our ability to generalize the findings to the overall population caregivercare recipient dyads were also excluded if they were unable to complete the three waves of preplacement and the one wave of postplacement data collection while a necessary step for this analysis of caregiving trajectories we are not able to shed light on the experiences of caregivers with truncated trajectories this exclusion may have resulted in some selection bias in actuality burden may have been a contributing factor in the failure of these caregivers to complete the three waves of data collection future analyses using this data set should focus on this specific group of caregivers and care recipients finally the exclusion of the preplacement burden variable in our second model may have resulted in an overemphasis on other factors related to postplacement burden while a limitation this step provided a richer understanding of the complexity of dementia caregiving and for the illumination of factors that may have been overlooked in past models due to the strength of preplacement burden in predicting postplacement burden in dementia caregivers implications for practice for social workers who provide important clinical support to family caregivers each transition point within the caregiving career presents opportunities for interventions that may be effective in addressing caregiver stress and burden as reflected in the findings from the present study there may be warning signs prior to nhp that certain caregivers are at a higher risk of suffering increased burden following nhp it is imperative for social workers and other health care professionals to identify these atrisk caregivers and tailor interventions to address their specific challenges and needs this process should and typically does take place during interventions across the care spectrum in the home care setting these interventions may consist of care consultation provided by the alzheimers association counselingcaregiving coaching provided by area agencies on aging and multicomponent programs that include education support therapy and respite these interventions have been found to have small but significant impacts on caregiver stress burden and wellbeing researchers have found mixed results in terms of the ability of homebased interventions in delaying nhp it appears that interventions tailored to the specific needs of each caregiving situation and that use multiple approaches to addressing caregiver stress and burden may be the most effective for practitioners working with family caregivers in the community in our study we found that the variables that predict postplacement caregiver burden often increase or decrease this reinforces the notion that assessment must be an ongoing process and that interventions should be flexible to meet changing needs assessment and intervention procedures should also be sensitive to differences seen within gradual versus crisis caregiving situations in which stressors may vary considerably in each circumstance the present study further confirmed that caregiver burden can be an especially acute problem during the transitions leading to and following nhp again social workers should be particularly alert to factors that might predict burden and stress for caregivers during transition periods for instance we found that caregivers who rely increasingly on adult day services have more difficulty during the transition to nhp following nhp caregivers may also continue to experience burden that is related to a new set of factors including adjusting to the care recipient no longer living at home financial stressors and working with nh staff nursing home social workers should be cognizant of such predictors and outcomes and understand that such caregivers may require additional support and services during this time period a number of innovative programs have been developed to help caregivers during this difficult time and may be especially appropriate for atrisk caregivers one program specifically designed to assist families with adjustment to nhp has been found to be particularly effective the family involvement in care intervention consists of four components administered by trained senior nh staff upon nhp orienting the caregiver to the nh and to their role in the facility providing education to the caregiver about the nh environment negotiating a partnership between the caregiver and the staff and remaining in contact with the caregiver and renegotiating the partnership as the caregiving situation evolves an evaluation of this intervention found that it had significant effects in increasing satisfaction with care improving familystaff relationships and reducing caregivers feelings of role loss and role captivity this intervention presents a simple and costeffective method for social workers and other professionals to help caregivers adapt to and thrive in the nh setting conclusion it has long been established that transitions in life can be difficult for families and individuals researchers have confirmed that transitions from community settings to the nursing home setting are no exception to the notion of stress in transition for family caregivers in the current study it was found that this transition period is marked by both change and stability in certain caregiving variables prior to nhp and that these variables can help geriatric social workers in identifying and assisting family caregivers in need understanding the dynamic nature of caregiving during this transition period is critical for practitioners and dictates ongoing assessment and reflective adjustment to interventions in the months leading to and following nhp social work researchers should continue to focus efforts on disentangling the different predictors of caregiver stress during nhp and work with practicing social workers in a translational process to develop feasible and effective interventions sampling framework

transitioning to the nursing home setting is a complex process for family caregivers of older adults with dementia while nursing home placement nhp can alleviate certain caregiving responsibilities new stressors can also emerge in the present study the researchers examined how carerelated factors can change leading up to nhp and how these factors influence caregiver outcomes following nhp a sample of 634 family dementia caregivers n 634 were surveyed at three sixmonth intervals prior to nhp and once during the 12 month period following institutionalization growth curve modeling revealed dynamic changes in certain factors leading up to nhp eg caregivers perceived health while other factors remained stable eg caregiver burden several factors emerged as significant predictors of caregiver burden following nhp including preplacement burden and adult day service utilization for geriatric social workers these findings may be useful in assessing family caregivers and in the development and utilization of appropriate interventionsthe longterm nature of many dementiarelated illnesses has led to the characterization of family caregiving as a career with transitions that occur as diseases progress needs and capabilities change and shifts occur in care settings aneshensel et al 1995gaugler anderson zarit pearlin 2004schulz et al 2004 nursing home placement nhp represents one key shift in the caregiving career as family members relinquish certain responsibilities such as bathing and feeding continue on with other duties such as providing

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introduction three randomized controlled trials and multiple observational studies have shown that male circumcision reduces the risk of female to male hiv transmission by up to 60 1 2 3 4 circumcised men are also at decreased risk of genital ulcer disease herpes simplex virus type 2 trichomonas vaginalis and highrisk human papillomavirus 5 due to these health benefits the world health organization recommends male circumcision scaleup in countries with high hiv prevalence and low rates of male circumcision and several subsaharan african countries are rolling out largescale programs 67 while male circumcision partially reduces the risk of hiv and other stis in men the direct health benefits of male circumcision for women are less clear a metaanalysis of 19 studies including one rct and six longitudinal studies found little evidence that male circumcision directly reduces risk of hiv acquisition in women 8 as male circumcision programs expand hiv prevalence is expected to decrease in circumcised men several mathematical models of male circumcision scaleup have predicted a longterm populationlevel benefit in which hiv prevalence will also decrease in women as a result of decreased hiv prevalence among circumcised men 9 10 11 however it is estimated that the full effect of these indirect benefits could take decades to be realized 12 until the populationlevel benefits of male circumcision are realized for women there are specific situations that could put women at increased risk of hiv infection first female partners of circumcised men may be at increased risk of hiv if sex is initiated before the recommended six week postcircumcision abstinence period 13 a recent study in kenya has documented high levels of early initiation of sexual intercourse following circumcision 14 and a mathematical model predicts that moderate levels of early sexual intercourse following circumcision could lead to more new hiv infections in women in the first year than would otherwise have occurred in the absence of male circumcision scaleup 15 another threat to women in male circumcision programs is risk compensation risk compensation or behavioral disinhibition is the increase in risk behaviors as a result of a reduction in perceived risk 1617 both men and women may change their behavior based on their risk perception which could lead to increased risk of hiv for example if circumcised men have more sexual partners or reduce condom usage or if women are more willing to have unprotected sex with circumcised men because they believe they are at less risk of disease the protective effects of male circumcision could be offset 18 little risk compensation has been observed among men during the three rcts in south africa uganda and kenya 1 2 3 1920 however intensive behavioral counseling along with free and unlimited provision of condoms may have contributed to a decrease in risk behaviors among all trial participants which may not be applicable to programmatic settings little is known about the impact of male circumcision on risk behaviors of men or women in circumcision programs outside of rct settings if men or women believe that male circumcision provides more protection than it actually affords they may be more likely to engage in risk compensation which would have the most adverse effect on women a recent study by dushoff and colleagues predicts that even small amounts of risk compensation in male circumcision programs which would still likely decrease hiv incidence in men could lead to an increase in hiv incidence in women 1221 in areas where male circumcision is being scaled up it is important that women not only have a comprehensive understanding of the benefits but also the limitations of male circumcision including that circumcision does not signify an hivnegative status that hiv transmission to men and women is still possible when a man is circumcised and that women do not receive direct protection if a circumcised man is hivpositive this knowledge could help women to more accurately assess their own risk of hiv several recently published articles suggest a poor understanding of the limitations of male circumcision for example in kisumu kenya 26 of women and 19 of men agreed that condom use is less necessary now that male circumcision is available 22 additionally lundsby and colleagues found that many circumcised men in a qualitative study in zambia believe they have a slim chance of contracting hiv 23 a further study in three subsaharan african countries found that the benefits of male circumcision were exaggerated by many respondents 24 in addition to understanding how women perceive the health benefits and risks of male circumcision understanding wider social norms emerging in parallel to scaleup can be useful in monitoring any changes in womens sexual preference associated with mens circumcision status understanding these changes in social norms and perceptions can help programs to tailor communication messages that resonate with current social norms this qualitative study examines womens perceptions of male circumcision in iringa tanzania a region experiencing rapid male circumcision scaleup we assess womens understanding of male circumcision as a partially protective hiv prevention strategy for men as well as the social value women place on male circumcision methods study site this study was conducted in the iringa region of tanzania iringa is located approximately 500 kilometers southwest of the commercial capital dar es salaam at the time of the study the iringa region consisted of six districts with a total population of 15 million people 25 hiv prevalence among adults in iringa is the highest in the country at 16 which is more than 25 times the national average of 57 26 male circumcision is not commonly practiced in iringa rates of male circumcision in this region are among the lowest in the country at 30 compared to 67 nationally 26 however there do not appear to be barriers to male circumcision acceptance a national situational analysis on male circumcision in tanzania found broad acceptance for male circumcision in this study 76 of noncircumcised males said that they would be circumcised if services were available in addition 93 and 98 of noncircumcised and circumcised males respectively and 89 of females supported circumcision for their sons 27 iringa region is currently experiencing scaleup of male circumcision services circumcision is offered through government health services to men ages 1049 free of charge the program focuses on the availability of free male circumcision services by trained health care providers and the hiv preventive benefits of male circumcision 28 various channels are used to increase demand for services including radio announcements billboards and experiential media 29 the tanzanian government has set targets to circumcise 28 million men countrywide by 2015 including 264990 in the iringa region 30 participant recruitment in order to understand womens attitudes and risk perceptions towards male circumcision we conducted indepth interviews with both hivnegative and hivpositive married women whose husbands were circumcised during the previous year to triangulate across methods we also conducted focus group discussions with married and unmarried women 31 recruitment relied on selfreported hiv status and husbands circumcision status participants were purposively sampled from womens groups hiv support groups and health centers in urban and rural areas of iringa region 32 snowball sampling was also used to identify eligible interview participants study participants and leaders of relevant organizations were given business cards and asked to share them with women who might be eligible to participate when data collectors recruited women for the study they specified that they were not associated with the male circumcision program in iringa in order to reduce social desirability bias data collection and analysis we conducted idis with 18 hivnegative and 15 hivpositive married women whose husbands had been circumcised in the previous year because interviews with married women covered sensitive topics such as sexual behavior before and after their husbands circumcisions we conducted followup interviews whenever possible in order to build rapport with the study participants and gain a more indepth understanding of their experiences of the 33 interview participants 16 were interviewed once 14 were interviewed twice and three were interviewed three times this led to a total of 53 idis idis lasted between 20 and 90 minutes six fgds with 53 participants were conducted with married and unmarried women fgds consisted of between seven and 12 participants and lasted from 65 to 90 minutes participants were compensated with 3000 tanzanian shillings at the end of each idi or fgd for their time and transport this amount was chosen because it is generally enough for a meal and local transport fees but is not high enough to be considered undue inducement semistructured guides were used for both interviews and focus group discussions indepth interview guides focused on the womans understanding of the benefits and limitations of male circumcision the decisionmaking process that she and her partner went through prior to her partners circumcision her experience shortly after the circumcision and any changes in the couples relationship dynamics focus group discussion guides included questions about womens general understanding of male circumcision social norms around male circumcision information received about male circumcision and ways in which women obtain information and womens perceptions about the benefits and limitations of male circumcision questions were openended and probing was used to explore additional topics that arose throughout the interview at the end of each idi or fgd data collectors provided information to participants to clarify any misconceptions that arose throughout the conversation participants were also invited to ask any questions about the content of the interviews data collectors answered general questions to the best of their ability in addition if data collectors felt that participants had any harmful misconceptions about male circumcision or questions that were beyond the scope of what the data collector could answer participants were referred to a local health facility for further counseling andor support all idis and fgds were conducted in kiswahili and digitally recorded with the permission of the respondents data collectors took extensive notes during each interview and wrote a memo on the same day identifying main points from the session all data were transcribed in kiswahili and fully translated into english within one week weekly meetings were held in which the study team discussed findings from the interviews and the lead author read all transcripts as soon as they were available to provide feedback to the data collectors so that emerging themes could be explored in more depth memos were also written by the lead author to capture meaning from each interview and to summarize main themes from the data 33 the study team determined that data saturation was reached since no new information was being revealed 3435 a codebook was developed by the study team based on emerging themes from the data and all transcripts were then coded using atlas ti version 62 following data coding matrices were developed to compare findings between indepth interviews with married women whose husbands were recently circumcised and focus group discussions with married women and unmarried women findings were compared across matrices to determine if themes differed by marital status or data collection method consensus on final themes was reached by the study team through multiple discussions and reading of interview transcripts to confirm results ethics statement idis and fgds were conducted by four universityeducated tanzanian women who were trained in an intensive two week course on qualitative research theory and methods interviewing techniques and human subjects research ethics since no other identifying information was collected for the study asking individuals to disclose their full names by providing written consent would decrease their anonymity so oral informed consent was obtained from all participants prior to enrollment the research assistants read a consent form to all participants prior to enrollment if the participant consented the research assistant signed two copies of the form one was given to the participant and one was kept with the principal investigator this research including the decision to obtain oral informed consent was approved by the johns hopkins bloomberg school of public health institutional review board and the tanzania national institute for medical research results women in this study discussed their perceptions understanding and emerging social norms around circumcision three broad themes emerged social pressures for men to be circumcised low risk perception of sexual intercourse with circumcised men and increased desirability of circumcised men we found no major differences in understanding of the benefits and risk of male circumcision or attitudes towards circumcised men between married and unmarried women hivpositive and hivnegative women or between women in idis and fgds therefore we present results for the entire study population together social pressure for men to be circumcised participants reported a very strong social pressure for men to be circumcised uncircumcised men were described as being dirty uneducated and out of fashion one woman described uncircumcised men as follows uncircumcised men are perceived as being uneducated the community doesnt like men who know about the benefits of male circumcision but dont act on that knowledge and get circumcised unmarried woman fgd another recurrent theme was the shame associated with being uncircumcised one woman discussed how embarrassed she would be if someone found out that her husband was uncircumcised i felt bad because my husband was not circumcised i told him will you go for circumcision it might happen that you suddenly get sick and people might volunteer to come and take care of you if they find you that way uncircumcised in my heart i will feel ashamed married woman hivpositive idi women repeatedly discussed embarrassment associated with men being uncircumcised many participants explained that men were uncomfortable to bathe or urinate near other men for fear of being teased uncircumcised men feel ashamed in front of their fellow men for example when an uncircumcised man urinates in front of his friends they might see him and start to make fun of him and say eh youre not circumcised you have not removed your mzula and they laugh at him too married woman hivnegative idi similarly married women reported being very embarrassed for other women to discover that their husbands were not circumcised if women in our village know that your husband is not circumcised they will laugh at you and say what do you have your husband is not even circumcised he still has a mkonosweta sweater sleeve that woman will feel shame when her friends laugh at her married woman hivnegative idi low risk perception of hiv through sexual intercourse with circumcised men men have a greatly reduced risk of hiv a common theme discussed by participants was the belief that uncircumcised men were at very high risk of disease circumcised men were described as having reduced levels of disease which was one of their most desirable attributes i was worried that he was not circumcised because its easy for uncircumcised men to get hiv i had so many questions in my head like what if he goes outside marriage since he is not circumcised he might get infected so when he went for circumcision my heart was filled with joy married woman hivnegative idi similarly women mentioned that messages about the health benefits of male circumcision made them feel safer when their husbands were circumcised i heard from the radio and brochures that a real man is one who is circumcised because he reduces most of his risk of disease so after my husbands circumcision i know that i am safe from diseases married woman hivnegative idi many women explained that while men were at a reduced risk of disease they could still acquire hiv when circumcised yes a man can still get hiv even if he is circumcised if he has sex with a woman who is already infected with hiv he can also be infected even if he is circumcised married woman hivnegative idi however participants also reported that it is not easy to get infected or that risk of disease is eliminated in circumcised men it reduces the rate of hiv transmission in a sense that if a man is circumcised and he is not hivpositive then he cannot become infected … for example i am hiv positive if i have sex with an uncircumcised man and i refuse to use a condom i will surely transmit the disease to him but if he is circumcised he will not get hiv married woman hivpositive idi women are directly protected from hiv furthermore many participants believed that women were directly protected against hiv as long as a man is circumcised even if a man was hivpositive many noted that they heard that male circumcision reduces the risk of hiv and assumed that this applied to both men and women others described how women are protected from hiv if a man is circumcised even circumcised men who are hivpositive can have sex with women and the women will not get the infection easily married woman fgd some participants also stated that the only way women could protect themselves against disease was for their sexual partners to be circumcised personally i dont think a woman can protect herself from diseases if her husband is not circumcised its too difficult a man is the one who cleans himself just like i clean myself so i dont think there is any safe way for a woman to prevent herself from diseases if her husband is not circumcised the best way for a woman to be safe is for her husband to be circumcised married woman hivnegative idi protection against stis reduction of stis was mentioned as one of the most important benefits of male circumcision when asked about which stis were reduced almost all women mentioned syphilis and gonorrhea furthermore many women reported that the risk of all stis was either reduced or eliminated once a man is circumcised one woman responded that male circumcision reduces the risk of all the sexually transmitted infections like syphilis and gonorrhea circumcised men are more sexually desirable than uncircumcised men women prefer circumcised men as sexual partners many unmarried participants said they would refuse to have sex with an uncircumcised man uncircumcised men were perceived as being dirty and having diseases one day when i was coming back from school i saw a girl standing next to a boy they were arguing and the girl said youre not even circumcised go and be circumcised first then you can come back to me … i think the girl knew that because the boy was not circumcised he was at very high risk of having hiv and stis unmarried woman fgd in contrast participants discussed how women are much more willing to have sex with a circumcised man due to his elevated social status circumcised men feel proud in front of other people because everyone knows that circumcision is good circumcised men can find sexual partners easily but if a woman finds that a man is not circumcised she will not agree to be his lover married woman hivnegative idi some women discussed how uncircumcised men may be unable to find sexual partners because of the shame associated with not being circumcised it was suggested multiple times that uncircumcised men sometimes resort to female sex workers or in extreme cases rape because other women refuse sex with uncircumcised men according to one woman it is very difficult for uncircumcised men to find women willing to have sex with them therefore such a person uncircumcised man can go to a local bar where he knows he will find cheap women female sex workers and they will have sex in dark places where she cannot tell he is uncircumcised but circumcised men can find women easily at any time not in dark places married woman fgd a few married women threatened to leave their husbands if they did not get circumcised while others told stories of female friends who initiated sexual partnerships with circumcised men after their uncircumcised husbands refused to be circumcised there was a woman who was telling her friends every day i tell my uncircumcised husband that when we have sex he does not satisfy me but he just ignores me he does nothing i tell him to go for circumcision but he refuses so this woman looked for another man who was circumcised she still lives with her husband but she is having an affair married woman hivnegative idi circumcision increases sexual pleasure for women overwhelmingly women reported increased sexual pleasure with circumcised men compared to uncircumcised men women discussed how they did not enjoy sexual intercourse with uncircumcised men because they often felt pain and the man needed to pull back his foreskin during sexual intercourse one woman described her experience before her husband was circumcised before he was circumcised his penis was very large because of the foreskin but a circumcised mans penis is different from an uncircumcised man s penis before he was circumcised my husband needed to hold his foreskin with his hand in order for us to have sex we both had pain then the foreskin seemed to be an obstacle when we had sex married woman hivnegative idi in contrast many women reported no pain or discomfort with circumcised men and often discussed the ease with which men could have sexual intercourse once their foreskin was removed male circumcision makes a woman enjoy sex because during sexual intercourse with a circumcised man even the power of the man having sex increases before my husband was circumcised when we had sex the foreskin was going up and back frequently causing him to feel pain since he has been circumcised i enjoy sex much more and my husband does not feel pain married woman hivnegative idi male circumcision messaging the male circumcision program in iringa utilizes a variety of media channels to create demand for male circumcision by emphasizing the benefits of male circumcision 27 participants in our study were very aware of these messages and mentioned that they heard about the benefits of male circumcision from the radio billboards loudspeakers on cars and posters at health centers the way that they spoke about circumcision also indicated familiarity with the campaign messages for example the phrase dondosha mkonosweta was widely used on billboards pamphlets and signs throughout iringa in a majority of interviews women referred to circumcision as dondosha mkonosweta instead of the traditional swahili word for male circumcision tohara ya mwanaume in addition billboards and signs promoting male circumcision in iringa displayed a handsome muscular man wearing a tshirt with the phrase mwanaume zaidi 60 and many participants made reference to this during interviews referring to this campaign one married participant said my husband is now 60 more of a man since he has been circumcised all participants said they heard about the benefits of male circumcision and announcements urging men to be circumcised as one woman described it on the radio they were saying it is important for a man to be circumcised so as to reduce the risk of acquiring infections like gonorrhea syphilis and hiv that was what they were saying married woman fgd another participant said that radio advertisements help men feel safe he circumcised husband feels safer because even when he is having sex he is at peace … circumcised men feel safer because even in the radio they mentioned that circumcised men will not get hiv married woman hivpositive idi conceptual framework figure 1 describes the way in which the themes presented above are mutually reinforcing and lead to womens strong preference for circumcised men as sexual partners the most commonly discussed benefit of male circumcision by women in this study was the reduced risk of hiv and stis messages promoting male circumcision for its health benefits were widely known and the main reason that women mentioned for men to be circumcised the perception that circumcised men are healthy strong and disease free influenced social norms and increased sexual desirability of circumcised men there is strong social pressure for men to be circumcised in iringa and women commonly discussed the shame felt by uncircumcised men and female partners of uncircumcised men these social norms appear to be shaped by the messages promoting male circumcision by the belief that male circumcision greatly reduced or eliminates the risk of hiv and stis and by the increased desirability of circumcised men similarly the increased sexual desirability of circumcised men seems to be driven by a combination of the media campaigns portraying circumcised men as strong attractive and healthy as well as the perceived health benefits and strong social pressure towards circumcision each of these themes independently contributes to womens strong preferences for circumcised men as sexual partners in iringa discussion our findings indicate that women in iringa tanzania strongly prefer circumcised men because of the low risk perception of hiv with circumcised men social norms favoring circumcised men and perceived increased sexual desirability of circumcised men the combination of these emerging social norms and ideas about increased sexual pleasure with circumcised men coupled with an exaggerated belief in the health benefits suggests that male circumcision is increasingly being seen as not only a desirable trait but one that is required of men who wish to find female sexual partners in addition womens lack of understanding of limitations of male circumcision in this study may lead to increased risktaking by women who believe they are more protected against hiv than they actually are women in this study discussed many social norms around male circumcision which lead to a preference for circumcised men as sexual partners first women commonly reported shame or embarrassment associated with uncircumcised men not only do other men laugh at uncircumcised men but women also make fun of them and their female partners the social desirability of circumcision led some married women in this study to insist that their husbands get circumcised additionally many unmarried women in this study reported that they would refuse sexual intercourse with uncircumcised men these findings have several implications first demand creation programs can capitalize on the increased social acceptance of circumcised men in order to increase uptake of circumcision however too strong an emphasis on circumcision may lead to stigma in this study women suggested that some uncircumcised men may actually be so ashamed of their circumcision status or so humiliated by the perceived ridicule and rejection from their peers and potential sex partners that they resort to sex with female sex workers or even rape although it is not clear whether this type of extreme behavior was a rumor or whether it had actually happened in iringa other studies have suggested that male circumcision programs may lead to stigma eaton and kalichman predicted that male circumcision scaleup could lead to stigmatization of uncircumcised men as lack of circumcision could be perceived as a marker for hivpositive status 36 our findings suggest that many uncircumcised men are stigmatized for many social reasons which include but are not limited to hiv status and disease risk understanding emerging social norms around male circumcision can help programs to tailor messages to minimize any negative impact on uncircumcised men in addition to the increased social pressure for men to be circumcised women overwhelmingly reported increased sexual pleasure with circumcised men other previously published articles assessing womens sexual satisfaction with circumcised men have found marginally increased sexual satisfaction following circumcision 2237 married women with recently circumcised partners in our study almost unanimously stated that their sexual pleasure increased following circumcision which was mainly attributable to decreased pain and men not needing to manually hold back their foreskin during sex while women have many social reasons for preferring circumcised men our participants tended to overstate the health benefits for circumcised men and their female partners women were aware that male circumcision is only partially protective but many women thought that a circumcised mans risk of acquiring hiv is very low and that it is not easy or difficult for circumcised men to acquire diseases similar findings have been reported in zambia 38 while male circumcision does reduce the risk of femaletomale hiv acquisition some men will still acquire hiv after circumcision despite the partial protection offered by male circumcision additionally hivpositive men are routinely circumcised as long as clinical conditions do not indicate otherwise 6 it is important that women understand that a mans circumcision status does not signify a negative hiv status and that the risk of acquiring hiv while reduced still exists many women in this study felt that they received direct protection against hiv if their partners were circumcised some women assumed that the 60 reduced risk of hiv infection in men applied to women as well messages about the 60 reduced risk of hiv should be careful to articulate that the directly reduced risk of hiv applies to men but not women that circumcised men may be hivpositive and that women do not receive protection against hiv if their circumcised partners are hivpositive the belief that male circumcision reduces or eliminates the risk of all stis was very common the most frequently mentioned stis were syphilis and gonorrhea likely because these are the most familiar stis in this setting 39 a qualitative study in zambia reported a similar misconception among circumcised men 2339 however there is no biomedical evidence of any reduced risk of these infections male circumcision has been shown to reduce the risk of gud hsv2 trichomonas vaginalis and hrhpv in men and hrhpv bacterial vaginosis trichomonas vaginalis and gud in women 540 while the reduction of these stis is significant and should be promoted it is also important that women understand that circumcision does not affect the risk of all stis we found little evidence that women fully understood the limitations of male circumcision or the potential health risks specific to women because of the potential increase in risk for women associated with modest levels of risk compensation or early resumption of sexual activity following circumcision multiple articles have stressed the importance of behavior change campaigns accompanying male circumcision programs 124142 increasing the number of messages that promote decreased risk behavior and provide women with balanced information about male circumcision could help women to more accurately assess their risk of hiv or stis during sexual intercourse with circumcised men this study has several limitations first we conducted multiple indepth interviews with married women whose husbands were previously circumcised but only conducted three focus group discussions with unmarried women unmarried women who are less likely to have regular sexual partners may have different perceptions of male circumcision and indepth interviews with these women as opposed to a group setting may have yielded different results additionally in this paper we explore womens attitudes and risk perceptions towards male circumcision but do not measure the extent to which risk compensation is or is not occurring among women a further quantitative study assessing the correlation between womens understanding of male circumcision and risk behaviors could be useful finally since this study was conducted in one region of tanzania these findings may not be generalizable to other male circumcision programs throughout subsaharan africa despite these limitations this study provides unique insight into womens attitudes and risk perception of male circumcision in tanzania which may be useful to other male circumcision programs conclusion in conclusion our findings indicate that male circumcision is becoming socially normative in iringa tanzania and that women strongly prefer circumcised men male circumcision scaleup efforts in iringa have generated demand among men and cultivating strong support for male circumcision among women promotion of the social benefits of male circumcision including social acceptance of circumcised men and increased sexual pleasure among women could be effective approaches to generate even more demand for services womens strong support for male circumcision was partially derived from the many perceived health benefits to both men and women while women understand that male circumcision reduces the risk of hiv and other stis misconceptions such as direct protection against hiv and reduced risk of all stis were common the social desirability of circumcised men in combination with womens exaggerated belief in the health benefits of male circumcision may create an environment in which women are more likely to engage in unprotected sexual intercourse with circumcised men in order for women to make informed decisions about their health programs should increase genderspecific messages to women which highlight both the benefits and limitations of male circumcision

while male circumcision reduces the risk of femaletomale hiv transmission and certain sexually transmitted infections stis there is little evidence that circumcision provides women with direct protection against hiv this study used qualitative methods to assess womens perceptions of male circumcision in iringa tanzania women in this study had strong preferences for circumcised men because of the low risk perception of hiv with circumcised men social norms favoring circumcised men and perceived increased sexual desirability of circumcised men the health benefits of male circumcision were generally overstated many respondents falsely believed that women are also directly protected against hiv and that the risk of all stis is greatly reduced or eliminated in circumcised men efforts to engage women about the risks and limitations of male circumcision in addition to the benefits should be expanded so that women can accurately assess their risk of hiv or stis during sexual intercourse with circumcised men

19957_0

introduction alcohol tobacco other drug use and violent and delinquent behaviors contribute to significant morbidity and mortality among youth and influence health outcomes into adulthood a youths propensity for early initiation of substance use and delinquency may result from a complex interplay of multiple levels of influence occurring at the individual social environmental and organizational levels suggesting that successful prevention requires multilevel and multicomponent efforts one important level for prevention of highrisk behaviors is the school environment schools are a prominent socialization agent for adolescents and research has suggested that the school environment may influence highrisk behaviors however questions regarding the extent to which the school environment influences development of drug use and delinquent behavior beyond individualand neighborhoodlevel factors remain emerging evidence suggests that individualand neighborhoodlevel factors do not entirely explain variance in substance use patterns between schools and characteristics of the schools themselves may account for this variation two traditional explanations of these interschool variations are the contagion model and social disorganization theories the contagion model suggests norms reinforcing or discouraging substance use are transmitted through peer modeling and reinforcement however the contagion model would need to account for why some schools provide a good environment for contagion to spread while others do not allow this social disorganization theories have long been used to explain adolescent delinquency and posit that absence of communitylevel social control mechanisms contribute to the spread of delinquency this theory focuses on explaining criminal behaviors rather than health behaviors however ennett et al suggested it could also be applied to substance use patterns in schools a new theory developed by markham and aveyard suggests that schools promote health indirectly through school organization curriculum development and pedagogic practice rather than directly through health education programs they propose schools optimize student functioning through the provision of appropriate instructional and regulatory order and operationalize this process using a measure called valueadded education valueadded education is a contextual measure of the school whereby given the sociodemographic pupil composition the school performs better than expected on academic success and truancyattendance rates which may be indicative of school support and control they hypothesize that some schools transmit these values more effectively which may contribute to a healthand achievementpromoting school identity aveyard markham and colleagues explored the novel concept of valueadded education as a characteristic of healthpromoting schools using samples of schools within the uk they used a framework that school support and control influence student behaviors and examined whether attending schools providing valueadded education was associated with lower risk of substance use valueadded education resulted in a decreased smoking prevalence among 1116 year old students a subsequent study further revealed that valueadded education was associated with reduced risk of early alcohol initiation heavy alcohol consumption and regular illicit drug use through their work aveyard et al concluded that interschool variation in smoking prevalence is not entirely caused by differences in pupil composition but is due to differences in the onset of smoking arising because of unmeasured school factors operating on pupils decisions they identified a need for considerable research to understand how complex social organizations like schools influence pupils health and healthrelated behaviors the purpose of this study is to replicate and extend aveyard and markhams work examining the protective effects of valueadded education on tobacco use early initiation of alcohol heavy drinking and regular illicit drug use we add delinquent behaviors as other outcomes of interest as there is a strong correlation between delinquency and higher rates of alcohol and other substance use aveyard and markhams previous research on effects of valueadded education occurred in the uk primarily with white middleclass students in grades 711 we examined whether this same relationship holds true for urban low income racialethnic minority adolescents in the us replication of this work among urban racialethnic minority youth was particularly important because african american and hispanic youth disproportionately reside in metropolitan cities are the fastest growing segments of the us population and are at increased risk for drug use and delinquency thus this study tested the validity of the new explanatory approach for understanding schools as health promoting findings may guide future health promotion efforts in schools among evergrowing populations of youth who are disproportionately at risk for maladaptive behavioral outcomes methods study design and participants data were part of a longitudinal grouprandomized controlled trial of an alcohol preventive intervention for racialethnic minority urban youth project northland chicago see komro et al 2004komro et al 2008 for complete description of the projects research design participant recruitment intervention components and outcomes youth in 61 public schools in chicago participated in the trial from a list of all chicago public schools schools were selected that included grades 58 had low mobility rates and had 30 or more students per grade schools and their surrounding community areas were matched on ethnicity poverty mobility and reading and math test scores and randomized into intervention or control conditions recruited schools were similar to those throughout chicago with respect to racialethnic composition and test scores the goals of the pnc intervention were to change personal social and environmental factors that support alcohol use among young adolescents and included 3 years of peerled classroom curricula parental involvement and education peer leadership and youthplanned community service projects and community organizing and environmental neighborhood change at the end of the intervention there were no significant intervention effects on alcohol use drug use or any hypothesized mediating variables including norms supportive of use resistance selfefficacy and parental monitoring and communication the subsample for the present study comprised the 2621 students enrolled in the 61 pnc study schools who completed surveys at the beginning of 6th and end of 8th grades students were predominantly african american and hispanic had a relatively equal gender distribution male lived in twoparent households and were lowincome tables 1 and2 present a complete description of the school and sample characteristics respectively the subsample included students from both the intervention and control conditions and treatment condition was controlled for in analyses data collection student surveysrepeated crosssectional surveys with an embedded cohort of youth were administered in study schools during the autumn of 2002 spring of 2003 spring of 2004 and spring of 2005 when the students were in 6th 7th and 8th grades thus the embedded cohort had potential to complete four surveys one baseline and three followups during the intervention activities surveys were administered using standardized protocols by threeperson teams of trained universitybased research staff interviewers response rates ranged from 91 to 96 each year prior to survey administration parents and students were given the opportunity to refuse participation parent consent student assent and pnc data collection protocols were approved by the university of minnesota institutional review board for the protection of human subjects with secondary data analyses approved by the university of florida institutional review board school neighborhood characteristicsdata describing the schools and neighborhoods where the students lived were collected from three sources a selfreport survey of parents whose children were participating in the pnc trial conducted in fall 2002 publically available school records retrieved annually from cps and census 2000 data for each study community all of these data were aggregated to the school level measures school characteristicspublically available data on schools attendance and standardized test scores were used to create the measure of valueadded education data are aggregated for the entire school rather than at the individual student level measurement of academic success was derived from the proportion of students in each school meeting or exceeding the national norm for reading and math measurement of attendance was derived from the proportion of students present for school each day averaged over the academic year threeyear averages corresponding to the academic years the cohort was enrolled were used to improve reliability of these measures the valueadded measure was obtained in two steps following the original procedures used by aveyard and markham first two linear regression models were constructed where the proportions of daily attendance and students meeting or exceeding national reading and math norms were outcomes several school characteristics were specified as predictors in each model including racialethnic composition and the proportions of students who were lowincome male spoke english at home and lived in twoparent households the schools percentage mobility was also included schools do not routinely publish indicators of gender the use of english at home and the number of twoparent households so these were aggregated for each school from our pnc survey data data for all other indicators were only available at the school level threeyear averages were also used for all predictor variables to improve reliability the standardized residuals represent the difference between the observed attendance and achievement and what would have been expected based on the sociodemographic composition of the student body principal components analysis was then used to identify the number of factors adequately explaining the variance in the standardized residuals pca was conducted with the residuals from both regression models included and a varimax rotation specified pca identified a single factor with eigenvalue 1 that explained 80 of the variance in both the achievement and attendance model residuals the continuous factor from this analysis was the valueadded score schools with a principal component or valueadded score of 0 would have observed achievement and attendance rates that would not have differed from their expected achievement and attendance rates when expectations were based on the sociodemographic characteristics of the student population a valueadded score of plus or minus 1 indicated a school with performance 1 standard deviation above or below the average of zero respectively seven schools were identified with a valueadded score greater than or equal to 1 sd above average these schools were termed valueadded in reference to above average performance given the characteristics of the student population conversely five schools were identified with scores less than or equal to 1 sd below average these were termed valueattenuated as their performance was lower than expected given the schools student body profile the remaining 49 schools had scores between 099 and 099 and were termed normative the normative schools were the reference category for the drug use and delinquency outcomes analyses the valueadded score was trichotomized due to nonlinear relationships between the continuous valueadded measure and the outcomes where quadratic terms were necessary for all models to simplify and improve interpretability we used the categorical valueadded measure individuallevel outcome measuresalcohol use in 8th grade was assessed with two items from the monitoring the future study during the last 30 days on how many occasions or times have you had alcoholic beverages to drink and think back over the last 2 weeks on how many occasions or times have you had five or more alcoholic drinks in a row response options were dichotomized to reflect 0 occasions versus 1 or more occasions one item from the monitoring the future study assessed cigarette use in 8th grade during the last month have you smoked a cigarette response options were 0 no and 1 yes marijuana use in 8th grade was assessed with one item from the monitoring the future study during the last 30 days on how many occasions or times if any have you used marijuana response options were dichotomized to reflect 0 occasions versus 1 or more occasions two items assessed violent and delinquent behaviors in 8th grade during the last month how often have you stolen something from a store and during the last month how many times have you taken part in a fight where a group of your friends were against another group response options were dichotomized to reflect never and 1 or more times covariatesa perceived neighborhood problems scale was created using seven items from the parent survey below is a list of urban problems please check how much of a problem each of the following is on the block where you live … drug dealing … unsupervised youth …people drinking alcohol on the street …too many stores that sell alcohol …lack of supervised activities for youth …too many alcohol advertisements and …poor police response response options were 1 not a problem 3 a minor problem and 5 a serious problem a higher score indicated greater perceived neighborhood problems the schoollevel mean for this scale was calculated and used in the present study an area deprivation index was created using 17 census 2000 indicators educational distribution unemployment rate occupational composition median family income income disparity median home value median gross rent median monthly mortgage home ownership rate family poverty rate population below 150 of poverty threshold singleparent household rate percentage of households without a motor vehicle telephone andor complete plumbing and household crowding the creation of this scale is described in more detail elsewhere this scale displayed good internal consistency higher scores indicated greater area deprivation the schoollevel mean for this scale was calculated and used in the present study parental monitoring and communication were assessed with a fiveitem scale from the student survey how often dodoes youyour …parent or guardian ask you about what you are doing in school …parent or guardian praise you when you do a good job … eat dinner with a parent or guardian …parent or guardian have a conversation with you that lasts 10 min or more and …parent or guardian ask you where you are going or who you will be with response options were 0 never 1 hardly ever 3 sometimes 4 a lot and 5 all the time a higher score indicated more parental monitoring and communication studentlevel scores on this scale were used in the present study individualstudent academic problems were assessed with one item from the student survey during the last month how often have you done poorly on a test or important school project response options were 1 never 2 13 times and 3 4 or more times the mean for this item was 178 baseline measures of student gender raceethnicity language spoken at home number of years living in the us receipt of free or reducedprice lunch and treatment condition were selected for inclusion as covariates in the analyses raceethnicity was coded such that hispanics white and other raceethnicity youth were compared to african americans gender was coded such that girls were the referent group language spoken at home was coded such that english was the referent group number of years living in the us was coded such that all your life was the referent group receipt of free or reducedprice lunch was coded such that yes was compared to no and not sure the covariates were selected for inclusion in analyses because they represent important contributors to drug use and delinquency at the individual home and community levels and all showed significant bivariate associations with the outcome variables thus the effect of valueadded education was estimated while controlling for other important contributors and highlighted its unique contribution to highrisk behaviors all covariates were centered at zero statistical analyses multilevel logistic regression was used to examine the influence of schools valueadded status on each student drug use and delinquency outcome in 8th grade analyses were conducted with sas proc genmod a procedure in sas designed to fit statistical models where the response is not normally distributed the models were built in stages following procedures outlined by muller and fetterman first we examined and eliminated collinearity among the predictors the following individualstudentlevel items were eliminated due to collinearity with one or more variables that remained in the model language spoken at home number of years living in the us and receipt of free or reducedprice lunch eliminated schoollevel variables included perceived neighborhood strength and neighborhood and police preventive actions all of the eliminated variables showed correlations greater than 070 with one or more of the variables remaining in the model second the categorical valueadded variable was added to a base model adjusting for students baseline value of the outcome variable we included this potential confounder in the base model to illustrate the robust associations of schools valueadded education beyond individuallevel initial risk behavior next several additional schooland studentlevel covariates were added to each model to examine and control for further confounding including pnc treatment status perceived neighborhood problems around schools area deprivation parental monitoring and students raceethnicity gender and academic problems lastly we calculated odds ratios and 95 confidence intervals for each predictor and covariate across each outcome schools were specified as a nested random effect in all models to account for effects of the study design missing data youth in the pnc cohort who were present and completed surveys at the beginning of 6th and end of 8th grade were eligible for inclusion in analyses the analysis sample included 25052508 students as a result of missing values maximum likelihood estimation was used which is one of two recommended approaches for analyses with missing data there were no statistically significant differences between the analysis sample and those who only completed surveys at the beginning of 6th grade across gender and parental monitoring however the analysis sample had significantly more dual parent households 5340 p 0001 than those who only completed surveys in 6th grade additionally fewer youth in the analysis sample were lowincome 1398 p0001 or reported alcohol 1614 p 0001 and χ 2 3242 p 0001 for past month and heavy episodic use respectively cigarette 1149 p0001 and marijuana 2423 p 0001 use as well as stealing 1690 p 00001 participating in a groupagainstgroup fight 3298 p 0001 and academic problems 360 p 0001 in the past month during 6th grade compared to those lost to followup among racialethnic subgroups african american youth were more likely to be lost to followup than hispanic white and other raceethnicity youth 8851 p 00001 results table 3 presents the base and adjusted models for all drug use and delinquency outcomes considered valueadded education was associated with significantly decreased odds of recent alcohol use or060 and or 044 for past month and heavy episodic use respectively cigarette use or048 marijuana use or029 stealing or 056 and participating in a groupagainstgroup fight or069 among 8th grade students relative to normative education after controlling for students baseline risk behavior when additional schooland individuallevel confounders were considered significant protective effects for valueadded education remained for cigarette or045 and marijuana use or033 stealing or056 and participating in a groupagainstgroup fight or067 the effects on monthly or075 and heavy episodic or058 alcohol use were in the hypothesized direction and marginally significant discussion valueadded education was associated with lower incidence of recent alcohol cigarette and marijuana use and delinquent behaviors in 8th grade when considering initial risk behavior after adjustment for individualand schoollevel covariates valueadded education remained a significant beneficial influence on cigarette and marijuana use stealing and participation in a groupagainstgroup fight and showed marginally significant trends in the hypothesized direction for monthly and heavy episodic alcohol use there were no significant differences in drug use and delinquency between valueattenuated and normative schools many racialethnic minority youth reside in urban cities and are at increased risk for a number of maladaptive social and behavioral outcomes including drug use and delinquency related to their unique environments findings from this study suggest that some innercity schools may protect socially disadvantaged innercity racialethnic minority early adolescents from highrisk behaviors thus efforts to improve or achieve valueadded education among innercity schools may potentially reduce problem behaviors the magnitude of effects suggests that drug use and delinquency may be reduced by 25 on average with schoollevel interventions improving student academic achievement and attendance this is in contrast to individuallevel interventions that show 8 to 10 reductions and are expensive in terms of cost and time markham and aveyard suggest that school organization curriculum development and pedagogic practice may contribute to valueadded schools outperforming schools with similar sociodemographic compositions for example valueadded schools may transmit instructional and regulatory order more effectively which may contribute to a healthand achievementpromoting school identity however the specific procesees remain unclear studies suggest that who provides the support and how control is defined and enforced may be important contributors to attendance and achievement more research is needed to elucidate the specific processes that contribute to enhanced schoollevel support and control to inform efforts promoting child and adolescent wellbeing in highrisk areas it is interesting to note that the effects of valueadded education were reduced when including other important individual homeand communitylevel variables in particular one covariate individuallevel academic problems was a significant risk factor for all of the highrisk behaviors we examined yet the protective effects of schools valueadded education persisted it has been well established that individual academic achievement is protective against a number of deleterious behaviors among youth however findings here suggest that schoollevel academic achievement and attendance remain important in protecting against drug use and delinquency even beyond that of the individual this is consistent with roses work describing populationbased approaches to public health positing that contributors to many diseases and risky behaviors may differ both within and across populations and suggests that prevention should occur at both the individual and school level thus educators efforts to ameliorate individual risk should persist and occur in concert with efforts to improve schools academic achievement and attendance the present study was a replication of work conducted in the uk by aveyard markham and colleagues among primarily white middleclass 11 to 16 year old youth our findings support the validity of their explanatory approach to understanding the health promoting capacities of schools showing that valueadded education may significantly reduce the risk of drug use and delinquency among youth beyond a number of important individualand schoollevel factors however this study differed from those previous in three important ways first we investigated delinquency in addition to substance use second our sample of schools and youth were from innercity chicago and were characterized largely by great sociodemographic disadvantage high rates of problem behavior and low educational attainment that we saw significant protective effects of valueadded education among such a highrisk population is noteworthy third our data allowed us to consider additional contributors to educational achievement and attendance in the creation of the valueadded score and other important confounders to the influence of valueadded education on drug use and delinquency specifically we additionally considered language spoken at home family composition and the mobility of schools pupil populations in the creation of the valueadded score and perceived neighborhood problems and parental monitoring and communication in estimating the effects of valueadded education consideration of these additional variables lent to a more comprehensive determination of valueadded education and conservative estimates of its protective effects this study has three primary limitations first it could be argued that the independent effects of valueadded education are the result of insufficient control of confounding neighborhood schoolor individuallevel risk factors future studies may consider additional measures of neighborhood deprivation and disorder andor school and family environment and attachment our data precluded inclusion of additional measures however we were able to control for more potential confounders at each level of influence than considered previously and the protective effect of valueadded education persisted second this sample was derived from an alcohol prevention study and there may be some bias in observed effects related to treatment group assignment this bias is likely to be minimal as we appropriately controlled for treatment group assignment in all analyses and no significant effects of the pnc intervention have been observed lastly outcomes are selfreported singleitem measures which may limit their reliability limitations notwithstanding findings from this study support aveyard markham and colleagues concept of valueadded education and suggest that innercity schools may break the strong link between social disadvantage and drug use and delinquency among adolescents while the present study is primarily generalizeable to other samples of urban racialethnic minority lowincome early adolescents findings are consistent with those observed in primarily white middleclass students in the uk thus findings have been robust to considerable variations in context and highlight schoollevel academic achievement and attendance as important targets for the promotion of student wellbeing future research should identify specific processes related to valueadded education to further inform preventive efforts considered together with the high financial and temporal costs associated with individuallevel interventions efforts to improve the school environment may be warranted

we examined whether schools achieving better than expected educational outcomes for their students influence the risk of drug use and delinquency among urban racialethnic minority youth adolescents n2621 who were primarily african american and hispanic and enrolled in chicago public schools n61 completed surveys in 6th aged 12 and 8th aged 14 grades valueadded education was derived from standardized residuals of regression equations predicting schoollevel academic achievement and attendance from students sociodemographic profiles and defined as having higher academic achievement and attendance than that expected given the sociodemographic profile of the schools student composition multilevel logistic regression estimated the effects of valueadded education on students drug use and delinquency after considering initial risk behavior valueadded education was associated with lower incidence of alcohol cigarette and marijuana use stealing and participating in a groupagainstgroup fight significant beneficial effects of valueadded education remained for cigarette and marijuana use stealing and participating in a groupagainstgroup fight after adjustment for individualand schoollevel covariates alcohol use past month and heavy episodic showed marginally significant trends in the hypothesized direction after these adjustments innercity schools may break the links between social disadvantage drug use and delinquency identifying the processes related to valueadded education in order to improve school environments is warranted given the high costs associated with individuallevel interventions

19958_0

introduction research on the unsafe behavior of miners at home and abroad has taken place for more than 70 years however studies in recent years have shown that more than 9409 of mine accidents were attributed to human factors of which intentional violation mismanagement and defective design accounted for 3543 5512 354 of cases respectively the reason why the unsafe behavior has not been effectively controlled is that it has the characteristics of transmission accumulation extensiveness uncontrollability and repeatability therefore how to control the miners unsafe behavior propagation becomes even more important there are widespread transmission phenomena in real life such as the spread of disease among people the propagation of computer viruses on the internet the spread of information and public opinion on various social networks etc and propagation on complex networks has become a research hotspot of scholars in many fields recent studies have shown that besides diseases information public opinion and so on can be spread on various networks and human behavior can also propagate on social networks behavior propagation refers to the trend and process of individual behavior triggering the same behavior of neighbors centola pointed out that peoples behavior is similar to information and in most cases can be spread in the crowd through social contact when gordon put forward his theory of epidemiology he pointed out that there is a certain similarity between disease and accident and the occurrence of accidents also has certain infectivity and susceptibility subiaul elaborated the spread of behavior from the perspective of demonstration imitation pointing out that imitation is the process by which an individual learns how to produce a similar behavior on the basis of observing the demonstrator different scholars have carried out indepth research on behavior propagation some studies pointed out that individualization affects the occurrence of behavior propagation and some studies indicated that social normative pressure limits the occurrence probability of behavior transmission and many other scholars confirmed that behavior propagation is the result of complex effects of multiple influencing factors in past research people have paid more attention to the propagation of diseases information and public opinion and established various network propagation models based on the average field method however little research has been done on the behavior propagation on social networks with most of them being qualitative research and few quantitative ones the behavior transmission process in social life is different from epidemic transmission in the spread of disease individual contact between network nodes can complete virus transmission under certain probability while social behavior spread is relatively complicated it is through individual decisionmaking whether to accept and join the spread of the process in which the uncertainty of individual decisionmaking determines the complexity of social behavior propagation therefore in a largescale social network it is of great significance to study the factors that affect individual decisionmaking in order to control behavioral transmission at present the research on unsafe behavior of miners mainly focuses on exploring the influencing factors of individual unsafe behavior and its occurrence mechanism from external factors analysis researchers have demonstrated that safety atmosphere leader behavior organizational policy environment and safety management have important implications for employee safety behavior through empirical research from the analysis of individual internal factors safety knowledge mastery psychological factors safety skills mastery and work pressure have a certain correlation with employee unsafe behavior researchers used evolutionary games and other methods to describe the mechanism by which coal mine employees choose unsafe behavior wang xh et al analyzed the propagation mechanism of ubp among miners based on propagation dynamics theory and constructed the sirs propagation model of miners ubp in fact in the working environment of coal miners in china most teams are small groups there is a lot of physical contacts between miners communicating and transmitting various information and affecting each others behavior therefore once the unsafe behavior of coal mine employees is formed it is easily imitated and learned by other employees and spread under appropriate conditions so that unsafe behaviors are accumulated and superimposed to eventually induce accidents studying the spread of unsafe behavior of miners and predicting managing and controlling them have important theoretical and practical significance for reducing unsafe behavior of miners unlike the traditional research on the influencing factors and occurrence mechanism of unsafe behavior the spread of unsafe behavior studied in this paper is a process of copying and emulating unsafe behavior among multiple subjects the purpose is to study which factors will lead to the spread of unsafe behavior among multiple miners rather than simply exploring which influencing factors can cause individual miners to take unsafe behavior therefore in order to confirm that the unsafe behavior of the miner has occurred it is caused by the imitation and reproduction of the unsafe behavior of others this study only considers situations in which miners make the same or similar unsafe behavior after observing the unsafe behavior of others this paper identifies the influencing factors of miners unsafe behavior contagion and puts forward relevant hypotheses through relevant literature research and survey results and then uses sem to quantitatively analyze it which provides a theoretical basis for controlling the spread of unsafe behavior of miners literature review and hypotheses safety atmosphere and ubp zohar suggested that safety atmosphere is the common cognition of all employees in an enterprise to the dangerous working environment mearns and flin argued that safety atmosphere is an employees perception belief and attitude toward risk and safety at present in the fields of construction subway construction coal mines etc scholars have paid attention to the impact of safety atmosphere to unsafe behavior but few researchers have focused on the influence of safe atmosphere on ubp the study found that unsafe behavioral transmission is divided two ways demonstration imitation and infection conformity according to the theory of propagation the main elements of infection conformity are the safe atmosphere and the psychological state of the behavior recipient at the same time relevant research found that the safety atmosphere of the construction team has a significant effect on the propagation of human unsafe behavior in modern social psychology selective imitation refers to imitating people selectively after thinking therefore when employees are exposed to unsafe behaviors they will not immediately imitate but choose whether to spread them through individual decisionmaking employees will improve their safety awareness and attitude in a good safety atmosphere thereby constraining their own behavior and preventing themselves from imitating and learning from others unsafe behavior thus hindering the spread of unsafe behavior therefore we proposed the following hypothesis 1 safety atmosphere is negatively related to ubp safety knowledge and ubp safety knowledge is the knowledge and skill for safe operation that operators must possess including the ability to identify potential safety hazards and make timely decisions in the usual sense safety knowledge includes safe facts and information theory and understanding in practice as well as safety experience background and awareness gained from education safety knowledge is considered to be an important variable affecting employee safety behavior which has been studied by many scholars but few scholars have focused on the impact of safety knowledge on ubp human behavior can be spread through demonstration imitation modern social psychology divides imitation into adaptive simulation and selective imitation among which selective imitation refers to imitating people selectively after thinking bala and goyal argued that when the rewards of different behaviors are unknown people will use their past experience and the experience of the people around them to guide decisions and choose one of them that is when a person is unable to determine the reward of imitating others behavior his own experience and knowledge will largely influence his decision rundmo suggested that employees ability to identify risks will act on the choice of unsafe behavior in discussing the relevance of safety practices and safety behaviors vinodkumar and bhasi found that employees safety knowledge and safety motivations dominate the selection of individual unsafe behaviors this indicates that in the face of the unsafe behavior of others his own safety knowledge will affect his value judgment on these unsafe behaviors and thus he will choose to imitate or not follow these behaviors han et al and zhou found through empirical research on the factors affecting the transmission of unsafe behavior among construction workers that individual safety knowledge can hinder the spread of unsafe behavior therefore when the employees safety knowledge is higher the employees ability to identify dangerous behavior and handle hidden dangers is stronger thus ignoring or even stopping the unsafe behavior of other individual members of the group based on this assumption hypothesis 2 safety knowledge is negatively related to ubp mediating role of safety knowledge synthesizing the research results of safety atmosphere at home and abroad it is generally used to evaluate safety atmosphere from the following dimensions safety management safety training safety system safety regulations and risk perception professional knowledge and skill as well as the ability to identify potential safety hazards and make timely decisions are important factors to measure the level of employees safety knowledge vinodkumar and bhasi concluded that safety training can predict safety knowledge and safety motivation through empirical research flin et al found that employees work abilities are related to the safety atmosphere when measuring safety atmosphere some scholars have specifically studied the relationship between safety atmosphere and safety behavior and found that safety atmosphere can indirectly affect safety behavior through safety knowledge at present there are few achievements in directly studying the relationship between safety atmosphere and safety knowledge but some studies have proved that the preinfluence factors of safety atmosphere such as safety management safety training risk perception and so on will have a positive impact on individual safety knowledge therefore a good safety atmosphere will improve the safety knowledge level of employees the higher the level of safety knowledge the less likely it is that the unsafe behavior of others will be imitated so the safety atmosphere can indirectly hinder the spread of unsafe behavior through safety knowledge accordingly we hypothesize the following hypothesis 3 safety atmosphere is positively related to safety knowledge hypothesis 4 safety knowledge mediates the relation between safety atmosphere and employees ubp influence degree of key figures and ubp de tarde the pioneer of the imitation theory pointed out in his book law of imitation that for those of higher status the people nearest are the most likely to imitate and that the lower groups tend to imitate the upper groups sociologist lazarsfeld argues that there are public opinion leaders between the mass media and the public that they are the main source of public access to information and acceptance and that they spread the mass medias message to the public as well as publish subjective judgment li z et al found that the spread of online public opinion is influenced by several influential opinion leaders and people are more likely to accept information from opinion leaders than to explore the source of information themselves from the coreedge theory the more experienced members such as the team leader technical backbone and master are more likely to become opinion leaders and act as key demonstrators of unsafe behavior and members with relatively low safety knowledge can easily copy their unsafe behavior directly generally speaking managers cannot directly determine the miners behavior but only influence or control the miners behavior choice through their own behavior yang et al found that the authority and influence of key figures greatly promotes employees to imitate and learn their corresponding unsafe behavior thereby promoting the spread of unsafe behavior in the study of construction workers behavioral propagation therefore when key people produce unsafe behavior other employees have the possibility to follow their unsafe behaviors thus allowing unsafe behavior to spread conversely when key personnel conduct safety education for coal mine employees employees will trust their opinions because of the authority of key people and give up the choice to imitate and copy the unsafe behavior of other individual members of the group thus inhibiting the spread of unsafe behavior so the influence degree could be positive or negative this paper only discusses the significant correlation between the influence degree of key people and ubp when the unsafe behavior of key people has occurred thus we propose the following hypothesis 5 influence degree of key figures is positively related to ubp influence degree of key figures as a mediator in order to better understand the influences of key people on the spread of unsafe behaviors this paper conducted a field interview with a coal mining enterprise in shandong province interview results showed that there are many formal or informal teacherapprentice connections among coal miners due to the lack of professional skills training institutions workers safety knowledge level is low and they have to rely on imitating or directly copying key persons such as the team leader technical backbone and master to acquire skills the more influential key figures are more susceptible to worker imitation numerous studies have shown that safety knowledge has a positive impact on safety behavior when the safety knowledge of employees is high the employees awareness of work risk and the ability to deal with hidden dangers is stronger employees will further judge whether the behavior of key people is safe rather than blindly imitate or directly copy their behavior therefore the higher the safety knowledge of employees the more safety behavior employees will consciously take at this time the influence of key people such as the team leader technical backbone and master is weakened accordingly we hypothesize the following hypothesis 6 safety knowledge is negatively related to influence degree of key figures hypothesis 7 the relation between safety knowledge and ubp is mediated by influence degree of key figures the conceptual model we propose in the present study is depicted in figure 1 materials and methods participants and procedures procedures from march to april 2018 we conducted a large amount of data collection with the opportunity of national coal mine safety standardization investigation work we conducted an additional investigation on a total of 500 rankandfile miners in 20 coal mines in the process of investigation each coal mine had a liaison person in charge and with the assistance of the responsible persons 25 rankandfile miners were randomly selected from each coal mine to participate in our investigation in order to explain the purpose and precautions of the survey to the respondents and to make the participants willing to be truthful our research team first conducted a brief investigation description with the participants in each coal mine the interview included the purpose of the survey and showed that the survey did not involve any real names did not affect the individual and described some of the considerations in the survey and we also prepared a beautiful little gift for each participant who completed the survey after the interview the survey was conducted in the form of a questionnaire in order to not delay the participants time and ensure the validity of the questionnaire the participants needed to complete the paper questionnaire within 30 min the questionnaire was distributed and collected by the research team the survey was part of a largescale research project on the behavior of coal miners and relied on the opportunity of national safety standardization investigation to enable the investigation to be completed efficiently and smoothly scale design in china the coal mining industry and the construction industry are highrisk industries and the working environment of workers is based on small groups therefore the observation indicators in the questionnaire of this study mainly refer to the questionnaires of the chinese scholars zhou and yang et al on the factors affecting the transmission of unsafe behavior of construction workers which have achieved good reliability and validity in the chinese context combining the actual working situation of coal mine enterprises and the management status figure 1 hypothetical model of unsafe behavior of employees and referring to many related questionnaires about the influencing factors of unsafe behavior of coal miners the scale was adjusted and improved to form a preliminary questionnaire on the influencing factors of ubp of coal mine employees the questionnaire was designed using the likert fivepoint scale method from 1 to 5 the content validity of the questionnaire was tested by expert assessment method and onsite pretest it was divided into two rounds of expert consultation in the first round of expert consultation we invited 10 experts including 2 rankandfile miners 2 team leaders 2 technical backbones 1 deputy mine manager 1 professor engaged in miner behavior research 1 professor engaged in coal mine safety management research and 1 masters degree student familiar with the scale construction process the 10 experts returned to the revised opinion 2 weeks after receiving the questionnaire and we modified the questionnaire items according to the comments the main contents of the revised questionnaire include background information and 12 items which are in a descriptive language that is easy to understand three specific items measure safety atmosphere three specific items measure safety knowledge three specific items measure influence degree of key figures and three specific items measure ubp a second round of expert consultations followed this time 10 experts scored the items of the questionnaire through content validity index the icvi of all items was greater than 078 and the k was greater than 074 meanwhile the scvi of the scale was 094 and greater than 09 therefore the questionnaire had good content validity finally the questionnaire modified by the expert consultation was pretested in one of the research units through the analysis of the pretest questionnaire data supplemented by literature research and onsite investigation the final questionnaire was formed the specific topics of the questionnaire are detailed in table 1 data analysis strategy the reliability and validity of the scale data was analyzed using spss 230 the cronbach reliability coefficient was used to measure the reliability of each influential item of the sample and the kmo and bartlett spherical tests were used to measure whether the sample was suitable for factor analysis the hypothesis model was tested using the maximum likelihood structural equation model with amos 220 according title number questionnaire items index sa1 the more often workers around you volunteer to attend safety training and other lectures the less you will indulge yourself to create unsafe behaviors thus following the safe behavior of most members safety atmosphere sa2 the more strictly the workers around you work in accordance with the operating rules the less you will indulge yourself to create unsafe behaviors thus following the safe behavior of most members sa3 the lower the accident rate and unsafe behavior rate in your mine the less you will indulge yourself into unsafe behavior and follow the safe behavior of most members sk1 the higher your skill level the less likely you are to copy other peoples unsafe behavior safety knowledge sk2 the more you value security the less you will copy the unsafe behavior of others sk3 the richer your homework experience the less likely you will copy other peoples unsafe behavior ikf1 when the team leader has already produced unsafe behavior the more authoritative the team leader is the easier it is for you to copy his behavior and produce the same or similar unsafe behavior influence degree of key figures ikf2 when a technical backbone has already produced unsafe behavior the better its professional skills the easier it is for you to replicate his behavior and produce the same or similar unsafe behavior ikf3 when a safety pacesetter has already produced unsafe behavior the better his safe operation habits the easier it is for you to copy his behavior and produce the same or similar unsafe behavior ubp1 you will copy the same unsafe behavior based on observing other peoples unsafe behavior unsafe behavior propagation ubp2 you will gradually indulge yourself and choose to follow other peoples unsafe behaviors because of a bad safety atmosphere for a long time ubp3 at work you are very susceptible to group pressure resulting in conformity mentality thus emulating their unsafe behavior to the recommendation of anderson and gerbing the twostep method was utilized to test the mediation effects the first stage was measurement model testing at this stage we used confirmatory factor analysis to test the discriminatory validity of variables the fit indices of the hypothesis factor model were compared with the alternative factor models to select the optimal model based on the fitness in the second phase we compared the fit indices of the proposed model with those of alternative models to determine which model was the best after the first stage verification in order to study the adequacy of the estimated model this paper selected χ2df root mean square error of approximation goodnessoffit index comparative fit index and normed fit index to test the fit of the model it is acceptable for χ 2 df to be between one and five the cfi nfi and gfi should be over 090 and the value of rmsea should be less than 008 results common method variance common method variance refers to the expansion of correlations between variables when collecting data using selfreported questionnaires this may lead to false support for hypotheses to test whether cmv was a problem we employed harmans singlefactor test we loaded all the items of each variable into a factor analysis the result showed that the first factor explained 2096 of the variance which is much less than 50 indicating that cmv was not a problem in this study reliability and validity analysis reliability analysis to ensure the rigor of the study the reliability of the questionnaire used in the survey was tested the specific reliability analysis results are shown in table 2 which shows that the cronbachs alpha of each variable is greater than 07 according to the reliability test criteria the latent variables of the related topics have high consistency and the reliability of the questionnaire is acceptable validity analysis to ensure the rigor of the study the validity of the questionnaire used in the survey was tested the specific validity analysis results are shown in table 3 the chisquare value of bartletts sphericity test in the scale is 2416487 so the bartlett test is significant the kmo value is 0806 greater than 07 indicating that there is a certain correlation between variables which is suitable for factor analysis in addition using the principal component method to extract the factor the results show that four common factors with eigenvalue greater than 1 are extracted factor rotation adopted the maximum variance method the cumulative variance interpretation rate of the four factors reaches 61466 more than 50 and all factor loads are above 05 the rotated factor structure and the distribution of items are also in line with the theoretical expectations of this study indicating that the scale has a good structural validity measurement model testing in order to test the discriminant validity between key variables before examining the hypotheses this study first used amos 220 to perform confirmatory factor analysis on key variables in order to minimize the magnification of potential variable measurement error researchers believe that project packages should be created as indicators of variables without subscales therefore four latent factors and twelve observed items were contained in the study the advantages of aggregatelevel data are obvious compared to projectlevel data the measurement model was tested by comparing the fit indices between the singlefactor model 2factor model 3factor model and 4factor model the results showed that the 4factor model had a better fit than the 1factor 2factor and 3factor models so it has a good discriminant validity and can be used for the next sem analysis structure model testing this study used sem to test the mediation effects of safety knowledge and influence degree of key figures we built several alternative models to test the mediation effects first we constructed model 1 to test the main effects between the various influencing factors and the ubp in this model each influencing factor is directly related to ubp the result showed that model 1 did not fit well with the data second we added a direct path from safety atmosphere to safety knowledge based on model 1 thus establishing model 2 the results revealed that model 2 also has unsatisfactory data fitting comparing the path coefficients of model 1 and model 2 after adding the mediation variable of safety knowledge we found that the path coefficient of safety atmosphere to ubp became smaller indicating that safety knowledge plays a part of the intermediary role between safety atmosphere and ubp furthermore by comparing model 2 with model 1 we found that the chisquare difference reached significance χ 2 1002 p 005 indicating that model 2 is better than model 1 to find the most satisfactory model we added a direct path from safety knowledge to influence degree of key figures based on model 2 and built model 3 the results demonstrated that model 3 fit well with the data in addition each latent factor was well represented by its indicators because factor loadings on these ranged from 027 to 088 by comparing model 3 with model 2 we found that the chisquare difference χ 2 30374 p 0001 reached significance which indicated that model 3 is superior to model 2 therefore model 3 was selected as this studys final structural model according to the recommendation of preacher and hayes we used the bootstrapping method to test the mediation effects displayed in model 3 bootstrapping is an ideal way to examine indirect effects as it avoids nonnormal sampling distribution if the 95 confidence interval does not contain zero then the indirect effects reach a significant level the results showed that our hypotheses are all verified first the total effect from safety atmosphere to ubp was notable supporting h1 second the total effect of safety knowledge on ubp was also significant supporting h2 third the safety atmosphere had a positive effect on safety knowledge and thus h3 was supported fourth the indirect effect of safety atmosphere on ubp via safety knowledge was significant supporting h4 fifth influence degree of key figures had a positive effect on ubp and h5 was confirmed sixth the path coefficient between safety knowledge and influence degree of key figures was notable confirming h6 seventh the indirect effect from safety knowledge to ubp via influence degree of key figures was significant supporting h7 finally we also proved that the link between safety atmosphere and ubp was sequentially mediated by safety knowledge and influence degree of key figures discussion miners unsafe behavior will directly or indirectly cause losses to coal mine organizations there are many studies on the causes and consequences of unsafe behavior of miners but there are few studies on the spread of unsafe behavior among miners in this study through the analysis and comparison of hypothesis model and substitution model we found that safety atmosphere and safety knowledge are negatively correlated with ubp and the relationship between safety atmosphere and ubp is partly mediated by safety knowledge the influence degree of key figures is positively correlated with ubp and the relationship between safety knowledge and ubp is partly mediated by the influence degree of key figures theoretical implications our research has some theoretical significance firstly we used the relevant theories of propagation for reference and explored the role of behavioral propagation in the process of miners unsafe behavior through empirical research previous studies on controlling miners unsafe behavior often focused on reducing the occurrence of unsafe behavior by improving monitoring methods and seldom studied the mechanism of multiple factors influencing miners unsafe behavior from the perspective of the spread of unsafe behavior therefore this study goes beyond the limitations of previous studies helps to deepen the understanding of the role of behavioral propagation in the process of miners unsafe behaviors and provides a basis for curbing the occurrence of miners unsafe behaviors from the perspective of behavioral propagation in addition this study comprehensively considers the influence of internal and external factors on the spread of unsafe behaviors of miners which provides ideas for further research on the propagation of unsafe behaviors of miners secondly this paper tests the role of safety atmosphere safety knowledge and the influence degree of key figures in the propagation of miners unsafe behavior through empirical research we find that safety atmosphere not only directly affects safety knowledge and ubp but also affects ubp through the mediation effect of safety knowledge and the influence degree of key figures at the same time safety knowledge not only directly affects the influence degree of key figures and ubp but also affects ubp through the mediation effect of the influence degree of key figures this indicates that the internal factors of the miners and the external factors of their environment will affect the spread of their unsafe behaviors in the process of the propagation of unsafe behavior of miners the factors are not independent individuals this helps us understand the mode of action among the factors affecting the spread of unsafe behaviors among miners and provides ideas for the study of reducing unsafe behaviors by inhibiting the path of spreading unsafe behaviors practical implications the research results have practical significance for controlling the unsafe behavior of miners from the perspective of behavioral propagation first considering that the safety atmosphere can not only directly affect the spread of unsafe behavior but also have an impact on safety knowledge and the influence of key figures it is necessary to pay attention to the influence of safety atmosphere in the process of the propagation of unsafe behavior of miners to this end the organization should start from the perspective of changing leadership style shaping organizational culture and improving the responsibility system to create a good safety atmosphere for miners in practical situations it is unrealistic to adjust leadership style to meet the need of shaping a safe atmosphere at any time in this case organizations should focus on shaping organizational culture and improving the responsibility system managers should actively create an organizational environment full of trust and take their actions as an example to mobilize employees to shape an organizational culture that attaches importance to safety in addition the organization should establish and improve the responsibility system of the coal mine clarify the responsibilities of each employee in order to eliminate the responsibility shifting among the members of the organization and promote the miners to spontaneously create a good safety atmosphere in the coal mine second because safety knowledge is negatively correlated with the influence of key people and ubp miners safety knowledge should play a positive role in the process of suppressing the spread of unsafe behavior organizations can improve the overall safety knowledge level of miners in various ways such as shaping a good organizational culture mentioned above which can provide internal motivation for miners to actively improve safety knowledge level in addition the organization should strengthen the training and assessment of miners safety knowledge and the training and assessment of safety knowledge should not be superficial the organization can build a model base of miners quality according to its own ability clarify the safety knowledge needed by miners in various positions and record the safety knowledge level of each miner and the results of previous safety knowledge assessment and then dynamically determine who needs to be trained according to the information of the model base and formulate a training and assessment plan for each miner dynamically finally in order to reduce the promotive effect of the influence of key figures on the spread of unsafe behavior of miners the organization should provide enough correct safety behavior hints for miners to weaken the influence of key people on unsafe behavior of general miners organizations can place safety behavior tips in operation areas high risk areas and personnelintensive areas to provide correct operation guidance for miners at any time so as to reduce the dependence of inexperienced miners on the unsafe experience of key persons such as team leaders thereby eliminating the adverse effects of key persons limitations and future research inevitably this research has some limitations first our study uses crosssectional design therefore it would be premature to draw exact conclusions about causality for example in our study we hypothesized that miners with adequate safety knowledge are less vulnerable to the impact of key people on their unsafe behavior however the causality may also be that due to the influence of key people miners use the irregular experience from key people to replace the safety knowledge that should be acquired through safety training resulting in a low level of safety knowledge therefore in order to further confirm the causal relationship between factors future research should adopt longitudinal and experimental research methods second we use personal questionnaires to evaluate variables because of the social desirability response bias respondents may conceal their true thoughts to some extent this may lead to some deficiencies in the results of the questionnaire survey therefore we should introduce other measurement methods to our future research such as colleague assessment leadership assessment and behavior observation and so on to enhance the effectiveness of the survey results last since the data in this study were derived from a questionnaire survey of miners in several large coal mines in several provinces of china and there is no survey of small and mediumsized coal mines the miners surveyed may not truly represent all the coal miners in china in addition different industries may have different hr practices and organizational cultures and the same research may lead to different conclusions in different industries in order to make our research universal future researchers should test our models in more industries to extend the research conclusions data availability statement the datasets generated for this study are available on request to the corresponding author ethics statement this study was carried out in accordance with the recommendations of ethics committee of china university of mining and technology with written informed consent from all subjects all subjects gave written informed consent in accordance with the declaration of helsinki the protocol was approved by the ethics committee of china university of mining and technology 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

this study aims to explore the causes of unsafe behavior propagation ubp and then control the spread and prevalence of unsafe behavior in miners social networks based on social learning theory this study built a hypothetical model of correlation between safety atmosphere safety knowledge influence degree of key figures and ubp we administered an empirical study of an effective questionnaire from 433 miners in coal mines via structural equation modeling the results showed that safety knowledge played a mediating role in the process of ubp influenced by safety atmosphere and the influence degree of key figures also mediated the relationship between safety knowledge and ubp furthermore the relation between safety atmosphere and ubp was sequentially mediated by safety knowledge and influence degree of key figures our research results provided new theoretical and methodological support for intervening in miners unsafe behavior

19959_0

introduction social exclusion became the subject of debate in france during the 1960s where academics activists politicians and journalists started to refer to those people in poverty and not covered by the social security system as the excluded subsequently the concept was used to capture those people presenting a weakening or rupture of bonds in relation to mainstream society referring to multiple deprivations and inequities experienced by them but it was in the 1990s when the concept was located as a core element in european union social policy the european commission adopted the term social exclusion to replace the notion of poverty in the 1990s use of the term subsequently spread throughout many supranational organisations to other parts of the globe including developing countries despite the decline of the concept of social exclusion in european social policy in recent years in chile it has had a prominent role in debates about the development of social policies since the return of democratic regimes in the 1990s overcoming not only poverty but social exclusion and promoting social integration have been some of the most relevant ideas underlying social policy in a context where social bonds had been broken by the political and economic consequences of the pinochet dictatorship indeed the concept of social exclusion has proliferated in most of the documents guiding the implementation of social policy since the 1990s onwards as the academic literature suggests social exclusion is an elastic and polysemic notion which may serve different ideological purposes that originate from a variety of discourses drawing upon the findings of a qualitative study this article examines the discourses on social exclusion and underlying assumptions held by social workers working in nongovernmental organisations with responsibility for implementing social policy in chile and analyses the way in which these approaches are translated into interventions from the critical policy studies approach adopted here the relevance of studying discourses underpinning social policies lies in the belief that problematising the way we understand social problems can give place to new approaches in practice which may contribute to the promotion of social justice by confronting our own understandings we may become aware of inconsistencies and contradictions between our own belief systems and actions which can contribute to improving the implementation of social policies that affect those most excluded from society the article is organised into five further sections the theoretical framework on social exclusion neoliberalism and resistance that guided the research is discussed in the next section followed by an overview of chilean social policy and social workers role in such a context the methods of the study are then outlined before its main findings are presented and discussed to conclude the article reflects on the findings and the challenges they pose to chilean social policy and social work training social exclusion as discourse neoliberalism and resistance a vast literature on social exclusion has been produced since the global proliferation of the concept since 1990s on a descriptive level the multidimensional complex dynamic and relative nature of social exclusion are some of its most commonly agreed characteristics but these also make it difficult to define embracing any notion of social exclusion entails the adoption of a theoretical and ideological position in this vein room distinguished two broad analytical traditions of social exclusion which took place in europe during the last century a continental more specifically french tradition which emphasises the detachment of individuals and collectives from a moral order and an anglosaxon more specifically british tradition which focuses on the disparities in the distribution of life chances that generate poverty social exclusion has been observed as a flexible term which can be employed to support different and even contradictory political purposes in this regard silver asserted that the discourse of exclusion may serve as a window through which to view political cultures … the different meanings of social exclusion and the uses to which the term is put is embedded in conflicting social science paradigms and political ideologies silver identified three paradigms to understand social exclusion the solidarity paradigm views social exclusion as the result of the weakening or breakage of solidarity bonds emphasising the ways in which cultural or moral boundaries between groups socially construct dualistic categories for ordering the world this approach related to french republicanism proposes that social exclusion needs to be tackled by the state promoting moral integration through insertion this can imply assimilation of the individuals into the dominant culture to keep the social order or the promotion of intercultural exchanges the specialisation approach the second paradigm identified by silver sees social exclusion as a consequence of social differentiation and the economic division of labour this perspective which is underpinned by angloamerican liberalism considers that the social order consists of networks of voluntary exchanges between autonomous and competing individuals in a free market environment in contrast the third paradigm called monopoly focuses on the structural causes of social exclusion rather than on the individuals behaviour from this approach social exclusion is produced from the formation of group monopoly and serves the interests of the included social order from this view is seen as coercive imposed through a set of hierarchical power relations analysing labour party policies in the united kingdom in the 1990s levitas proposed another typology to understand the diverse and contested nature of social exclusion redistributionist discourse moral underclass discourse and social integrationist discourse red developed in british critical social policy is similar to the silvers monopoly paradigm from such a structural approach poverty is understood as the prime cause of social exclusion its concern with poverty is embedded in a critique of inequality addressing the exclusionary processes in all areas of society which result in imbalances of power and resources that divide it combating exclusion implies redistributing wealth and power on the contrary mud is based on a neoliberal rationality it focuses on individuals as responsible for their own exclusion rather than the social structure that produces exclusionary processes people are excluded because they do not fit with the morally accepted social order benefits for the poorest the socalled underclassare problematised as promoting a culture of dependency on the other hand sid also highlights individuals responsibilities in the overcoming social exclusion as it understands exclusion occurring through the lack of participation in paid work from a critical social policy approach as the adopted in this research social exclusion is underpinned by power imbalances and inequality resulting from the adoption of the neoliberal model in a similar vein as explained in silvers monopoly paradigm and levitass red neoliberalism is a variant of liberal thought which exacerbates economic liberalisation through market freedom deregulation privatisation and competition which has been installed as a new hegemonic discourse on a global scale the hegemonic nature of neoliberalism lies in its capacity to penetrate not only the economic but also the cultural and social domains of life by colonising the commonsense way people interpret live in and understand the world operating as an ethic in itself such a neoliberal hegemony following gramsci is underpinned by structural mechanisms that enable domination and configuration of the political intellectual and moral life of some groups of the population the hegemonic nature of neoliberalism from this perspective needs to be understood not as the simple and lineal domination of privileged sectors of society over passive masses but as the construction of crossclass alliances and consensus which need the active involvement of hegemonised groups this perspective enables us to develop a focus on neoliberalism which goes beyond pessimistic approaches that see its hegemony as an inevitable in fact gramsci highlights the possibility of constructing counterhegemony an alternative which is underpinned by the belief that agency and collective political action can affect structural mechanisms that produce oppression in other words resistance to neoliberalism is entirely possible resistance in the context of policy implementation refers to the collective and deliberate acts to make sociopolitical changes which are undertaken in opposition to a belief an ideology or a practice which is oppressive unjust or leads to the reinforcement of inequality it is always a form of challenging hegemonic power hence the strategic knowledge of power is necessary for effective resistance exerting resistance means to critically examine global neoliberal hegemonic norms which emphasise individualism and consumerism in policy implementation the counterhegemonic vision as deepak asserts is of inclusion solidarity and the promotion of collective projects mechanisms of resistance from the practice of social work professionals implementing social policy are diverse and do not necessarily involve immediate and radical social transformation they may involve minor transgressions of rules andor advocacy for change or may address more structural targets by diffusing ideas in the public space as well as influencing changes in policy and legislation as presented in the following section this approach to resistance as a viable alternative in policy implementation is particularly relevant for chilean social workers as the profession was abruptly affected by the imposition of the neoliberal model during the pinochet dictatorship in the 1980s and as the consequences of neoliberalism unfolded over the next four decades policy context and social work practice in chile chile has been considered the laboratory of neoliberalism around the world under the cloak of pinochets dictatorship the socalled chicago boys a group of 30 chilean economists trained at the university of chicago by milton friedmanled the imposition of the most extreme version of the neoliberal doctrine in the early 1980s in such a context a rapid process of privatisation and deregulation of the market along with a reduction of the states role in social policy were imposed the dismantling of social services which had been developed by the previous governments of salvador allende and eduardo frei montalva followed the drastic reduction of social expenditure and the targeting of social programmes to extreme poverty sectors only these and other measures that configured the core of the neoliberal turn in chile were adopted in a context of suppression of all political rights and the repression of all types of collective action in such a context many schools of social work in the higher education sector were closed because they were considered a source of radical ideas and subversion the critical approach underpinning social work curricula developed by social workers in previous decades mainly influenced by structuralmarxist literature was rapidly repressed even social work books and dissertations were burned as a means of censorship many social workers social work students and academics disappeared or were tortured and killed due to their opposition to the pinochet regime during the 1980s the reestablishment of democratic regimes in 1990 is identified as a new stage in the development of social policy and social work in chile political rights were gradually restored and the reconstruction of trust and civic engagement become an urgent task for the new government to differentiate from the poverty approach employed during the dictatorship era the democratic coalition adopted the notion of social exclusionsimilar to the french tradition which enabled the development of a focus on the rupture of bonds that tie the individual with society by the mid1990s the term social exclusion had emerged as an important concept which enabled the understanding of poverty as social exclusion which adds the social cultural and political to the income dimension this new approach resulted in the creation of new social programmes which would be implemented by social workers and targeted to vulnerable sectors experiencing poverty and social exclusion despite the attempts of postdictatorial governments to recover the states role and repair the ruptures in social bonds produced by the dictatorship the neoliberal ethos has remained as the cornerstone of the chilean model of development the outsourcing of social policy interventions by which the private sector became involved in the delivery of social policy is an example of that along with the intensification of the privatisation of higher education in the case of the social work profession this resulted in the abrupt increase in private higher education institutions delivering social work programmes throughout the country the tripling of the number of social workers in the labour market and the considerable decrease in social workers salaries it needs to be recognised that as ngos have become increasingly dependent on the state for funding over the last decades social workers employed in these organisations started to experience labour instability and precariousness as social interventions have a relatively short span and state funding covers only the award period social workers are contracted on a fixed term basis with no access to social security and may have periods without a salary currently the social policy approach on poverty and social exclusion has adopted remains similar although the incorporation of the notions of risk and protection have gained relevance since the creation of the social protection system in 2000 following the world banks approach the success of social policy interventions is measured according to a set of outcomes defined for each family with individual family members being targeted despite these orientations these guidelines merely indicate the goals to be achieved in the intervention process they do not dictate how the intervention should be conducted which suggests that there may be some room for manoeuvre by social workers to exert discretion during the implementation process nowadays the social protection system organises the structure of social services provision in chile it is formed by four subsystems coordinated at the national level integrated protection for children support and care for dependant adults and children family programmes and community health programmes all these interventions aim to address social exclusion by promoting the social integration of diverse groups of the population which also experience income poverty following the approach initiated in the 1990s the subsystems and their associated programmes are implemented by ngos in local areas from which many social workers are employed to design and implement individual and family intervention plans in the frontline the study the article draws on a study investigating how social workers implementing interventions designed to address social exclusion understood such a notion and approached their practices in total 26 semistructured interviews were carried out with senior social workers employed by two large national ngos whose programmes aim to address poverty and social exclusion the home of christ and the foundation for overcoming poverty the investigation focused on social workers occupying senior positions as it was assumed that the room for manoeuvre they enjoy as senior professionals would enable them to incorporate their own ideas values and approaches within the intervention process the study included 19 female and 7 male social workers most of them graduates from 1990 and 2000 three of them implemented interventions in the north zone of chile 11 in the centre and 12 in the south following data saturation thematic analysis was conducted with a focus on not only the semantic content of data but also its latent meaning in addition documentary analysis of the two organisations written material was carried out in two phases before and after conducting interviews this facilitated an examination of how interventions had been planned and understood by social workers and their organisations it included the analysis of publicly available materials such as projects reports theoretical frameworks guidelines for practice and evaluation instruments documentary analysis prior to conducting the fieldwork enabled the contextualisation of interviews and the formulation of more pertinent questions the analysis operated as a strategy for comparing social workers views with their organisations statements this enabled the observation of differences similarities and possible gaps between social workers and their organisational contexts in addition documents were also treated as data in their own right after conducting interviews specific documents suggested by the interviewees were also analysed to reach a deeper understanding of their interventions by complementing interviews and documentary analysis data were triangulated ethical permission for the study was granted by the authors organisation results and discussion a rhetoric emphasising structural processes was employed by social work professionals when reflecting on their understanding of social exclusion they recognised the political economic and social power imbalances that are central to the neoliberal model simultaneously however most social workers drew upon an individualbased discourse in which the solutions to social exclusion were seen as the responsibility of the individuals living disadvantaged lives on the other hand a small handful of participants presented a more coherent analysis of social exclusion in terms of both cause and response specifically through the deliberate employment of their professional discretion to undertake alternative practices to address power asymmetry at a local scale despite the differences observed between the individualbased and this more coherent structural discourse all social workers agreed that connecting socially excluded individuals with the available social programmes was the main intervention strategy used to address social exclusion the individualbased discourses and the problems of eclecticism despite most social workers recognising the involuntary nature of social exclusion and criticising neoliberalism as the ultimate cause of disadvantage a conservative view of poor peoples moral and economic behaviour was overwhelming emphasised a general pattern emerged in which participants would initially draw from structural approaches on social exclusion but their answers then became blurred and frequently eclipsed by a belief that the responsibility for poverty and exclusion lay with the poor themselves the transition between a view closer to levitass red and an approach like mud can be clearly observed in the statement of one interviewee the cause of exclusion is lack of opportunities social injustice and inequality i believe that crime is a symptom of exclusion not to justify criminals or drug addicts but if you look at their stories you realise that their families are disruptive violent with no values mum is in jail dad is a drug addict so there is no authority children grow up in that environment learning everything on the street the family does not give the values they should provide so they learn a bad way of relating with others which ultimately ends up excluding them from society among those who emphasised moral imperatives blaming poor people manifested in arguments that focused on a lack of moral guidance andor as selfexclusion exclusion for me is realising how opportunities are passing outside your house and not being able to participate and this is produced by our neoliberal model … but there are some problems with the poor as well they live in spiritual poverty they are indifferent they do not want to participate they do not want to help their neighbours…this also leads to their own exclusion in a similar fashion whilst still departing from a structural critique of neoliberal model as the ultimate cause of social exclusion some interviewees expressed the view that the inability to consume material goods would lead to people feeling socially excluded exclusion is generated by the neoliberal model which indicates that we have to consume goods to take part in it the excluded is the one who feels poor who feels out of certain circles who feels that they do not have resources to go to the shopping centre and buy something or who feels that the house heshe owns is not what heshe expects and is not enough to live well with hisher children i believe that is the one who feels excluded … to me exclusion does not exist it has a lot to do with a perception for these social workers the ultimate form of inclusion is through the consumption of goods and services this explains why some proposed providing vouchers to poor people to enable them to purchase services such as health care education and housing yet at the same time criticised market rationality as the main cause of social exclusion their accounts stopped short of reflecting on the weakness of the states role in providing such services as universal social rights and illustrated how a market discipline is subtly imposed through discourse underlying these views the structural conditions that generate exclusion were dismissed and an approach closer to the silvers specialisation paradigm emerged instead these findings show how eclectic and even inconsistent approaches coexist within the views of some social workers discourses grounded in a critique of the neoliberal model whilst at the same time focusing on the individual were common among the interviewees which suggests the need to critically examine the internal rationality of their accounts eclecticism is not new in social professions and neither does the problem lie in the combination of diverse perspectives indeed employing different approaches can be useful in some cases to address complex social phenomena the problem with eclecticism emerges when perspectives are combined without a critical examination of their underlying assumptions and logical consequences in practice and when eclecticism allows the ascendency of oppressive perspectives to be hidden under apparently progressive and radical approaches as found in this study eclecticism thompson asserts can be the result of the avoidance of addressing the links between theory and practice some social workers reported that there were no opportunities to have meetings with other professionals to discuss the orientation of interventions they acknowledged during the interview that this was the first time they had reflected on their practices which suggests that their eclecticism was unplanned and a spontaneous way of organising ideas about interventions the lack of group discussion may affect the capacity of the interviewees not only to reflect on the consistency of perspectives adopted and implemented in practice but also to imagine possibilities for the transformation of the social economic and political hegemonic order structural perspectives and the limits of intervention for some social workers social exclusion was conceived as the lack of universal social rights representing a discourse that coheres with the french tradition of social exclusion as identified in silvers monopoly paradigm and the british tradition as highlighted in levitass red they identified the denial of rights resulting from the implementation of the neoliberal model since the dictatorship period central to their ideas of social exclusion was the issue of power specifically they identified that practices of authoritarianism and clientelism resulted in rights being used as a means to exchange political favours in rural and isolated areas in such context social exclusion serves the interest of the political and economic elites and is characterised not only by a lack of income and inequality but also and especially a lack of voice and power the role of social workers in these instances revolved around envisaging alternatives to counteract the damaging impact of neoliberalism they saw themselves as introducing small but effective changes at a local scale despite the strength and consistency of this structural approach in discursive terms the interviewees identified numerous difficulties related to the implementation of alternative practices only a few social workers carried out initiatives in which the structural approach of social exclusion was put into practice although exceptional these practices contributed in their view to challenging patronising relationships occurring in local areas through the promotion of citizen control i believe the programme contributes to strengthening citizen control practices at the local level of course not in every intervention in every community but in some cases there are processes that are worth highlighting in a community for instance mayor candidates commit to many things during their campaign we have been supporting community organisations in demanding accountability how much of what they promised has been done thats something that didnt happen before in these communities such initiatives promoting citizen control represent a way of challenging dominant social policy perspectives specifically power is understood as an attribute to be disputed and resisted through the promotion of citizen control that is the control that citizens can exert to govern a programme or an institution people experiencing poverty and social exclusion can from this discursive perspective not only participate in the policy implementation process but also demand that mayors and other public servants are accountable for policy decisions and outcomes in their territories considering that the guidelines provided by the chilean state and the ngos do not include the promotion of citizen control as a strategy to address social exclusion these findings show that professional discretion can be used as a way of counteracting neoliberal rationality underlying social policy however the participants also acknowledged the limitations of their ability to challenge power through the promotion of citizen control community reluctance to get involved in the decisionmaking process the lack of political will of authorities exerting power at the local scale especially mayors to democratise the decisionmaking process and the lack of skilled frontline professionals were some of the obstacles of translating the approach into practice the interviewees also highlighted that the very nature of social policy hinders the possibility to challenge power relationships as it promotes individualism and competition between service users that is clear in antipoverty policies which offer funds for social organisations located in targeted communities as the application for those funds is individualbased the very policy promotes competition and distrust between neighbours this limits the possibility of creating collective projects and therefore challenging power on a structural level despite believing that the redistribution of power was a key strategy to tackle social exclusion the study participants all recognised that apart from a few exceptions their interventions were limited mainly to linking service users with available social services and programmes which are part of the current social protection system social exclusion and the focus on disconnection to social services although the idea of social exclusion was approached by the social workers drawing upon these two broad and competing perspectives they all agreed that their main strategy to address social exclusion in practice was connecting socially excluded people with the available social services or programmes participants in referring to these socalled networks or structure of opportunities described their role as mediator between service users and the structure of social services a discourse that fits closer with the french tradition on social exclusion people are excluded because they do not know the benefits they can have most of our services users do not even have a national identity card they do not know where the health service is located how to apply for a subsidy or get a place in a school for their children … our work consists of connecting those people with the networks … we are like the bridge the relevance attributed by social workers to the idea of connecting users with goods and services is not surprising given the limited welfare structure and the lack of universal social rights in chile after the implementation of the social protection system in 2000 which created a vast array of new social programmes the idea of connection between users and social services and programmes became even more relevant many potential users especially those who live in isolated communities are unaware that they are entitled to access these services in addition the relatively fast proliferation of programmes has represented a major challenge in terms of coordinating diverse public services this may explain the relevance that coordinating actions with other social services have for all the interviewees independently of their approach to social exclusion the idea of social exclusion underpinning chilean social policy has been closer to the solidarity paradigm identified by silver in the french context in all the documents analysed social exclusion is defined as the rupture of bonds which connect the individual with the society however our findings suggest an inconsistency between this concept of social exclusion embedded in government policy and the social workers accounts of their practice social exclusion as described in the solidarity paradigm needs to be addressed by recomposing diverse type of social bonds between individuals and community between different communities between communities and the state and the larger society such an understanding of connection may lead to interventions that challenge structural mechanisms that reinforce social exclusion in contrast all the interviewees pointed out that their interventions consisted of connecting individual users only with the available social programmes disregarding other types of connection some of them reflected on the complex nature of addressing social exclusion from such a structural perspective pointing out that their actions were constrained by the need to meet performance targets set by the state the world banks approach underlying the social protection system which promotes the link between individual users and social services has clearly influenced the way the social workers approached their interventions and how they prioritised actions in practice lack of access to goods and services is widely accepted in the literature as a key dimension of both poverty and social exclusion yet the states approach on social exclusion as reflected in the practices of social workers assumes that there are goods and services available for all and that the problem lies with the users lack of knowledge on how to best take advantage of the structure of opportunities despite most of the social workers recognising the failure of the neoliberal model to provide a universal coverage of social rights when explaining their interventions they did not question the availability or quality of such goods and services the focus of interventions is the individual to be connected rather than the structure as the structure of opportunities is not questioned at all this makes clear that the dominant approach of the participants interventions is the individual despite the dominance of a structural rhetoric when reflecting on the idea of social exclusion neoliberalism and resistance in chilean social policy the findings in this study identified how the supreme worth of the individual the cornerstone of neoliberal rationality underlying chilean social policy has been adopted by social workers in their daily practices most of the participants views and practices can be interpreted as concrete expressions of such a phenomenon the eclecticism which masks individualising perspectives and the noticeable focus on individual disconnection from the structure of social services are some examples of that although most of the participants stated that the neoliberal model caused social exclusion a neoliberal rationality pervaded accounts of their work as the interviews progressed this served to illustrate how neoliberal rationality is assumed and reproduced as common sense appearing in a subtle manner in peoples daily experiences either blaming service users or imposing market discipline in chile the neoliberal model was imposed through violence and repression during the dictatorship period this posits a complex scenario in which the possibilities of imagining alternative projects for society are reduced because of fear depoliticisation andor distrust in collective action this lethargy an inheritance from the dictatorshipappears to be still blocking the possibilities of discussing and implementing social policy from a critical approach which demands social workers to be aware of possible gaps between rhetoric and practice the participants structural discourses on social exclusion became diluted as the interviews progressed turning into individualbased perspectives and sometimes into approaches that stigmatised the poor similarly their structural accounts became eclipsed as they proceeded to describe their interventions in addition the world banks approach has not only reinforced individualbased explanations of social exclusion but also has put a strong emphasis on the achievement of outcomes which diverts social workers attention away from structural reflections on their work chilean ngos which occupied a core role in criticising the development and implementation of neoliberal policies from the dictatorship period since the 1990s have become largely coopted by the same neoliberal model as a result of their financial dependence on the states funds the gap between rhetoric and practice has been reinforced by the precarious labour conditions of social workers implementing social programmes as the relatively short duration of the intervention process and professional turnover experienced by the teams inhibit the possibilities of reflecting and learning from the experiences gained throughout the implementation of social policy this is a very relevant topic considering the key role of frontline professionals in translating social policy to service users our interviewee findings suggest that chilean social policy has changed in its approach in recent years although addressing social exclusion is still part of its guidelines the approach has moved from a focus on recomposing social bonds in a broad sense to a focus on the capacity of individuals in generating bonds with the available structure of social services documents produced by both organisations since the implementation of the social protection system show how guidelines orienting social workers interventions follow strictly the chilean states approach that is the world banks approach such an approach favours individualism privatisation and reduction of the states role as it assumes that individuals are free to operate as they choose hence the neoliberal approach of social policy promoted by the supranational agencies funded by the chilean state and implemented by ngos in chile is based on the idea of individual responsibility which is reflected in the discourses adopted by most of the social workers participating in this study with such an understanding of social exclusion the neoliberal idea of liberty appears as a promise under the slogan of having control over ones own life an expression found in both the organisations guidelines that is freedom to choose rather than freedom or liberty as nondomination and based on positive rights however and although applying to a minority of participants this research has shown that despite these organisational structures it is possible for social workers to adopt a structural approach on social exclusion in their interventions a discretional space although constrained provides opportunities to adopt a more critical perspective in practice by revisiting the issue of redistribution of resources and power the use of such a room for manoeuvre by some participants has been interpreted in this article as an act of resistance contesting the very configuration of chilean society that is a society characterised by an authoritarian culture through the promotion of citizens control among the socially excluded population is interpreted as a counterhegemonic practice our analysis affirms that the idea of resistance which is underlying the strategy of disputing power as mentioned by some social workers is more a subtle than a radical version of resistance the idea of disputing power is located at a local scale only which means that these social workers proposed modifications to patterns of democracy within local territories by raising awareness among mayors on the relevance of democratic governance there is no suggestion on the part of the interviewees of the generation of links between the targeted communities with other communities or with regional national or global social movements which can be a way of activating community power on a wider scale in addition their action is focused on negotiation and consensus rather than on highlighting conflict and power asymmetry however that these social workers did not attempt to radically transform the hegemonic state does not mean that within the chilean context these initiatives do not have particular significance although nearly three decades have passed since the end of the dictatorship issues related to the redistribution of power in society remain almost untouched practices of clientelism and patronage are still common in policy implementation and service users are generally not engaged in community activism and political mobilisation in such a context the efforts made by social workers to promote citizen control can be understood as an attempt to politicise their practices and counteract power imbalances in policy implementation which is interpreted here as a small but significant contribution to rethinking strategies to address social exclusion from a structural view conclusions drawing upon the overall study findings discussed above the article has identified how neoliberal rationality has impacted on the way in which ngo social workers understand and address social exclusion in chile whilst at the same time it has brought to light strategies employed by some of them as a means of defying such a rationality understanding the process of implementation of social policy from a critical tradition entails two main assumptions first that it is the acknowledgment of oppression imposed by hegemonic powers which enables us to exert resistance to them and second that a solid understanding of how hegemonic powers work is crucial to imagine and undertake alternative professional projects this approach is particularly relevant in latin american countries chile included as social exclusion takes place in a postdictatorial era in which democratic regimes are not fully consolidated yet characterised by significant inequality gaps weak welfare systems and limited coverage of social rights practices of resistance in the implementation of social policies can potentially contribute to the redistribution of power which is not only relevant but also urgent in the consideration of policies tackling social exclusion in the chilean context considering the study findings some challenges for improving the implementation of chilean social policy from a critical approach are identified training courses for social workers and other professionals involved in the implementation of social policy need to be examined schools of social work have a critical role in discussing theoretical approaches underpinning social policy analysing gaps between rhetoric and practice and promoting as levitas asserts the imagination of alternative projects of society among current and future social workers and policymakers related to this we identify that the reactivation of social workers professional bodies is also a vital task we suggest that professional bodies exert a more prominent role in affecting social policy from a bottomup approach disseminating frontline social workers counterhegemonic initiatives promoting public engagement in the construction of social policies and encouraging collective practices of resistance against neoliberal discourses operating at a local national and global scale professional and academic social work bodies need to work together to problematise and make visible the precarious labour conditions of social workers and other professionals implementing social policies in chile if we expect that social workers promote practices of resistance in their interventions with service users we need to reinforce a critical perspective in social work education to expand social workers imaginations and possibilities to resist the neoliberal rationality underlying the provision of social services in chile all these efforts can be more effective counteracting the neoliberal rationale of social policy from a reflective and transformative perspective

the views of social workers in chile are rarely heard and considered in the policy debates this article addresses this lacuna by examining discourses of social exclusion and underlying assumptions held by social workers with responsibility for implementing social policy interventions in chile it draws upon the findings of a study involving interviews with senior social workers from two large nongovernmental organisations ngos tackling social exclusion we found that individualbased narratives and neoliberal rationality are dominant in the implementation of chilean social policy at the same time antihegemonic strategies pursued by some social workers were also identified such an approach is highly relevant in the chilean context in which power imbalances remain almost untouched since the return of democratic regimes in the 1990s the study findings pose diverse challenges to chilean social policy and social work professional training the necessity of promoting transformative imaginations that favour collective practices of resistance is identified to counteract through a critical discourse the neoliberal rationale its rhetoric and practices affecting excluded peoples lives

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1 3 outcomes ranging from infections injuries and chronic respiratory disease to developmental harms anxiety and depression 2 layering in instability and the threat of eviction brings further vulnerabilities as these factors are also linked to poor health outcomes including cardiovascular disease psychological distress and suicide 34 unfortunately exposures to both poor conditions and evictions are highly prevalent particularly for people living in public housing 56 however the relationship between these factors has received minimal quantitative study the implied warranty of habitability doctrine and regulations governing public housing should in theory afford legal protections against evictions in the presence of unhealthy housing conditions but the scant evidence available on this topic suggests these rights are rarely realized 7 this is a particular concern given the potential for landlords to use evictions to retaliate against tenants who file housing quality complaints we therefore sought to examine the relationship between formal housing safety inspections addresses and address types and the number of units per development finally we geocoded building addresses to identify census tracts and merge in data from the center for disease control and preventions social vulnerability index 10 svi uses 15 variables related to socioeconomic status household composition and disability minority status and language use and housing type and transportation to construct scores by either county or census tract 10 it creates percentile rankings at either the us or individual state levelswe focused on new york statewhere values closer to 1 indicate greater vulnerability rather than using the composite ranking however we included the individual variables to allow for richer inspection of the individual factors doing so did not alter findings measures because unitlevel data was not available we used buildinglevel residential addresses as our unit of analysis our dependent variable was a binary indicator of the presence of at least one forced marshalfacilitated eviction during the study period the independent variables of interest were two binary indicatorsthe presence of at least one rodent inspection and the presence of at least one indoor environmental inspection during the study periodas well as an interaction of these indicators inspections are primarily triggered by tenant complaints making them a measure of tenantraised concerns about housing safety conditions as covariates we included a binary indicator of whether the development of which a building was a part was federally funded the number of units at the development and 14 of the 15 svi variables statistical analyses we used a hierarchical logistic regression model to estimate associations between whether an eviction occurred and whether or not rodent andor environmental complaints were filed at the building level adjusting for the covariates described above we used loglikelihood ratio tests to assess whether accounting for the nesting of addresses within developments andor developments within census tracts was necessary we found that accounting for nesting at these two levels significantly improved model fit and therefore included random intercepts for development and census tract for developments that were split geographically across more than one census tract we treated each subset of buildings within one census tract as a triggered by tenant complaints and evictions leveraging publically available data covering buildings managed by the new york city housing authority a public development corporation that provides public housing to over 173000 families and 392000 residents in new york city 8 unforeseen causal pathways for the evictions unrelated to our study question regardless future studies with longitudinal data particularly if linked to health and healthcare outcome data would significantly enhance our understanding of the phenomena examined here methods conclusions substandard housing and evictions are independent public health concerns making possible links between themparticularly if attempts to address one may precipitate the othera serious concern policies that can instead link improvements in both areas such as having inspection failure data automatically sent to court systems that adjudicate evictions should be considered not only for their potential to yield better enforcement of existing tenant protections but also for their importance to community health unique development for the purposes of nesting all analyses were conducted using stata results of the 3746 buildings in our sample 94 were in federally funded developments with an average of 991 units per development the average svi percentile for the buildings in this study was 090 indicating that on average these buildings were located in areas with greater social vulnerability than 90 of other census tracts in new york state during the study period 19 of buildings had at least one inspection and 28 had at least one eviction in fully adjusted models inspections for both rodents and indoor environmental problems were significantly associated with evictions at the p 0001 level but their interaction was not statistically significant the adjusted predicted probability of an eviction occurring in a building increased from 34 to 43 in the presence of a rodent inspection and from 34 to 46 in the presence of an indoor environmental inspection discussion we found that inspections related to unsafe housing conditions in nycha public housing were associated with marshalfacilitated evictions at the building level analyses of housing and urban development data during this period estimated that 56 of public multifamily housing had urgent health and safety problems 5 nearly three times the 19 of nycha buildings we found to have a formal tenantinitiated inspection during this time this discrepancy between poor conditions and requested inspections to trigger repairs is consistent with prior research showing that lowincome renters often lack the resources or access to information to address housing quality issues themselves 11 beyond resources and information however our present finding that inspections are associated with evictions raises the possibility that at least part of this discrepancy may be driven by a rational view that an inspection may be more likely to lead to an eviction than to repairs 7 the lack of comprehensive longitudinal data at the individual level was a limitation of these analyses despite using some of the most comprehensive data on legally sanctioned evictions available 12 although we can conclude that the evictions measured were not due to renovationcaused relocations it is not possible to rule out other data data on evictions inspections nycha developments and arealevel factors were merged we utilized nyc open data 9 for information on evictions and housing safety inspections between january 2017 and march 2020 nyc open data contains information on all marshalfacilitated evictions as well as information on inspections regarding housing safety code violations eviction and inspection data were merged based on street addresses at the building level within these data 299 developments consisting of 3746 unique residential buildinglevel nycha addresses were identified using publicly available nycha directory information that included development names and types data availability all data analyzed during the current study are publicly available as noted in the manuscript text code availability stata was used to conduct all analyses authors contributions all authors contributed to the conceptualization and design of the study data analysis interpretation of findings and manuscript drafting and revisions all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work ethical approval not applicable consent to participate not applicable consent for publication not applicable

poor housing conditions and evictions are both associated with poor physical and mental health outcomes such as increased risks for cardiovascular disease depression and injuries however the relationship between these two negative housing outcomes has received little quantitative study including in public housing where exposure to these factors and to negative health outcomes are elevated we therefore sought to examine the relationship between evictions and formal housing safety inspections triggered by tenant complains about poor conditions we estimated a hierarchical logistic regression model assessing associations between housing quality inspections and evictions using data from january 2017 and march 2020 on 3746 residential buildings within 299 new york city housing authority nycha developments adjusting for development size funding type and arealevel social vulnerability indicators the average social vulnerability index percentile for the buildings included in this study was 090 sd 012 indicating that these buildings were in areas with greater social vulnerability than 90 of other census tracts in the state adjusted predicted probabilities of an eviction increased from 34 to 43 in the presence of a rodent inspection and from 34 to 46 in the presence of an indoor environmental inspection p 0001 for both indicating that inspections for unsafe housing conditions were associated with evictions at the building level substandard housing quality and evictions are important public health concerns policies to enhance protections for tenants against both of these social ills simultaneously may be needed to improve community health outcomes

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implications for policy makers • products and systems of the food alcohol and gambling industries have significant impacts on public health and wellbeing with similarities to those of the tobacco industry • powerful industries such as the food alcohol and gambling industries have unequalled access to policymakers and policymaking processes such access is not transparent and represents a threat to both good governance and ph • the current dominance of neoliberal ideological discourses is detrimental to ph and wellbeing the pandemic of noncommunicable diseases cannot be addressed through business as usual processes • there are opportunities for policymakers to play an active role in promoting ph at the policy level there is a need to carefully reorient policy toward protecting health and wellbeing and to eliminate the opaque influence of the food gambling and alcohol industries implications for the public the commercial determinants of health are often observable via the products and activities of specific actors and industries the food alcohol and gambling industries manufacture and promote products that harm public health to varying degrees and engage in normalising activities for their products including at the policy and regulatory levels in public policy processes this research identifies the substantial power and influence of these industries as identified by key experts there are a number of sources to this power however control over framing issues and what is and is not discussed normalised and therefore regulated is arguably the most dominant form of power the finding of this study can inform public understandings of power and other cdoh in relation to the australian food alcohol and gambling industries this can be used to advocate for prioritising ph and wellbeing over commercial interests and rendering political processes more transparent key messages frame email invitations were sent followed by up to two weekly reminders where individual email addresses were unavailable enquires were submitted via organisational addresses or online contact portals if these were unavailable invitees were phoned explanatory statements were sent approximately one week or as early as possible before each scheduled interview before each interview the interviewer confirmed participants had received the explanatory statement and addressed any questions informed consent was confirmed verbally before recording commenced participation was voluntary with no remuneration offered the first author conducted interviews between january and march 2021 via phone or zoom teleconferencing interviews took 3060 minutes were audio recorded blinded and transcribed by a professional transcription service the interviewer also took detailed notes participants were asked their perceptions of the australian food alcohol and gambling industries including similarities and differences power and influence industry relationships with government advisory lobbying union consultation and other roles regulatory and other mechanisms reinforcing influence or power and opportunities needs and priorities for interventions to reduce harms and enhance benefits hard power was conceptualised as coercive power while soft power was conceptualised as persuasive power 32 the interview guide was informed by a recent cdoh systematic review 33 data were analysed thematically the first author coded transcripts thematically utilising nvivo software the coding frame was developed reflexively in multiple stages in consultation with all authors this was initially based on the interview guide then revised based on participants responses following this themes emphasising neoliberal discourses became prominent including choicecentric themes emphasising individual agency voluntarism and choice advocacy for limited state intervention and perceptions that state intervention limits individual agency 26 alignment of these themes with prominent orthodox neoliberal discourses is highlighted throughout results sixtyfour people were invited to participate forty responded with 28 expressing interest however four could not interview within the recruitment period one felt they lacked required expertise and one responded after recruitment concluded two industry representatives who scheduled interviews withdrew before completing these due to perceived conflicts of interest with their work twelve individuals declined invitations with four referring colleagues reasons for declining included disinterest and work commitments four regulatory bodies and a food industry body said nobody was available andor that all relevant information is already on public record one gambling industry body emphasised no representatives would participate complaining to our faculty about perceived researcher bias from alleged antigambling sentiments twenty interviews were conducted via zoom or phone participants represented jurisdictions across australia with experience and expertise in the food alcohol and gambling industries all keyinformant groups were represented most had experience and expertise across multiple areas the four overarching themes are discussed below industry similarities and differentiation participants identified regulatory structural and behavioural similarities between australian food alcohol and gambling industries these included industry integration via organisational structures supply chains and logistics and regulatory structures industries were described as employing similar strategies from the same playbook … the same key peak bodies can cover different industry sectors food soft drinks and alcohol hotels gambling … it seems to me that there is a very similar playbook … working in their own best interests through lobbying politicians through political donations either directly or indirectly participants also differentiated between industries almost all participants compared food alcohol andor gambling industries with the tobacco industry most highlighted differences between these however some phfocussed participants emphasised similarities between these industries harms andor tactics participants implied a hierarchy between industries based on perceived need utility and harm where food is least harmful and most necessary while tobacco is most harmful and least necessary food we actually need and so thats a much more complex … they get more and more complex in that hierarchy … from tobacco through alcohol to food and probably gambling is closer to tobacco perceptions of the existence and nature of power and influence participants reported mixed perceptions of the extent of food alcohol and gambling industries power industry participants and some with political experience downplayed the influence of this power over policy decisions researchers journalists regulators and some others took a contrary view hard power as for power overall industry participants and some political participants disputed the exertion of hard power over political decisions or processes i dont think that theres … coercive power because at the end of the day advisers are people theyre going to make their best judgment to benefit obviously their minister and its just politically stupid if anyone favoured one group over the other phfocussed participants instead described many cpas as exertions of hard power including financial power economic threats and legal threats talking about monopolies and i guess oligopolies is i think thats another power that food and probably alcohol companies have … almost by the size of them shift any other competitors out of the market participants discussed industries making legal threats against individual politicians political staffers journalists news outlets and wouldbe industry whistleblowers these were particularly discussed for the gambling industry significant financial resources were said to allow industry to readily take legal action including fighting policy reform money is a big one so theyve got the money to legally fight reform if you think of tobacco for example the money numbers may total more than column totals due to participants experience in multiple areas a four unavailable due to leave or scheduling issues one was not confident of expertise in australian context one responded after recruitment completed b two industry representatives cancelled their interviews on the day they were scheduled to be conducted due to concerns about conflicts of interest with their work c australia has a relatively narrow definition of lobbyists any person company or organisation that conducts lobbying activities on behalf of a third party client or whose employees contractors or persons otherwise engaged by the person company or organisation conduct lobbying activities on behalf of a third party client 34 there are some exclusions for charities memberbased notforprofit organisations trade delegates professional members and some others lobbyists must be registered and australian government representatives can only meet with registered lobbyists it is important to note that not all undertaking lobbying activities are considered lobbyists under australian legislation they spent on fighting plain packaging or if you think of the food industry the money and resources they allocate towards fighting more clear packaging and labelling of their products alcohol the amount of money they spend on trying to stop pregnancy labels from being placed on their products they will invest in legal teams to do that economic power was said to arise from corporations size market power and revenues which frequently exceed those of national economies economic threats in response to policy reform were widely described by phfocussed participants threats of job losses and corporations shifting operations offshore were highlighted some emphasised that industry often overstates these their economic power is why there is so much power to thwart governments because therell be the power to withdraw the operations to offshore … all a corporation needs to do is say well well take our bat and ball and well go somewhere else and theres capitulation from governments significant financial resources were said to make corporations resilient facilitate media buying including largescale advertising to shape public narratives and facilitate political donations commercial entities rights such as corporate personhood rights or rights afforded under trade agreements were also described as exertions of hard power soft power while almost all participants alluded to soft power perceptions of influence again differed by participants experience power to shape narratives and frame issues was most commonly described these often related to reinforcing cultures normalising alcohol and gambling products and occasionally ultraprocessed foods alcohol and gambling were described as part of australias cultural history originating in the colonisation australia modern industry narratives promoting products as fun and social were described as pervasive and ignoring health concerns i dont think theyre promoting alcohol abuse by any means but they are certainly creating a culture and its a culture of gambling is fun and just part of this experience and is sort of definitely quite pervasive most participants agreed australia has a drinking and gambling culture within this participants implied there is a right culture of moderation while cultures of excess should be discouraged culture was often described in connection with underlying narratives of individual responsibility where individuals were expected to ignore normalising social cultural marketing and other influences to make informed healthy responsible choices some discussed soft power as perpetuating broader neoliberal capitalist discourses including roles of government business and consumers perceptions of sources of power participants described sources of power including relationships social responsibility and others relationships power was widely described as arising from close relationships between industry and government facilitators of these reportedly include advisory roles committee memberships revolving doors between industry and government formal lobbying activities political donations gifts and other cpas all participants discussed lobbying communication consultation andor stakeholder management between industry and government making lobbying the most described cpa even participants who disputed industry power emphasised government relationships as important for prosperity one industry participant discussed not undertaking lobbying activities before emphasising the ease of forging government relationships i think anyone if they actually take the time and effort can build a relationship with a ministerial adviser if you wanted to go and form a relationship with a ministerial adviser youve just got to go up and make your case and ask and i honestly dont think im being naïve in that political donations were commonly described as facilitating relationships between industry and government phfocussed participants described the political donations system as a real mess and lacking transparency some went further describing donations and gifts as exerting influence over politicians constituting corruption well the donations thing is very complicated and the money in itself doesnt explain everything… its about the whole political system really… but if you ban donations or you reduce them to the level that theyre relatively unimportant then you do take a lot of pressure off politicians therefore off bureaucrats and so on some participants primarily industry representatives said access to politicians afforded by political donations has been overstated while discussing the ease of accessing politicians via other means revolving doors were described as fostering close working relationships between industry and government this was positively described by industry participants and some political participants but negatively from phfocussed participants this was also true for views on industry participation in advisory committees and industry influence over science relationships between industry and government were described as being fostered within formal and informal settings alike one participant described relationships as the single biggest mechanism of power … the kinds of relationships that are really influential are not the formal public ones theyre the things that happen in private quite often in boardrooms in airport lounges in parliament too… and theres just no comparison in terms of the amount of contact… how can you help but be influenced as a human corruption corruption was described as the power to prevent warranted policy development or implementation and turning a blind eye to malpractice this was seen to result from excessively close influential relationships between industry and government you know there is no political problem in the world that doesnt exist except for the fact that somebody is making money out of it everything else can be fixed everything would get fixed tomorrow except someones making money and somebody then passes that money on to somebody with enough power to either do the right thing or prevent the right thing corruption was seen as concerning the integrity of elected officials policy systems and regulatory bodies alike its quite alarming how so many agencies at state and federal levels have failed us in this corruption this framing is broader than legal definitions of corruption one participant discussed this further you know what we need at a federal level is a very broad definition of corruption but not just criminal corruption but you know the definition of what is seriously improper conduct what is corruption that may not be a criminal offence but its wrong and someone should be held to account social responsibility social responsibility was a prominent theme participants described industry as socially responsible and part of the solution and corporate social responsibility activities as important for maintaining industries social licence to operate some said this brings significant industry power activities described included providing employment financially supporting community organisations and providing enjoyment and leisure some participants emphasised that this involves industry downplaying the extent of the problem and their contribution to it andor reframing the problem on their terms industry are using the statistics about how good it is for the community and what goes back to the community how many jobs there are but they dont count or put a dollar amount on the destruction thats caused by gambling alcohol you know weve got people with gambling addictions that are hospitalised suicides 400 suicides a year none of that is taken into account overall individual consumer responsibility and consumer choice were emphasised food and alcohol industry representatives particularly denied or downplayed links between consumption and ncds discussions of product safety focused on the mitigation of shortterm harms for gambling this included emphasising the small proportion of problem gamblers or an individuals problem i think the system thats the policy and the regulatory system is very much framed in terms of more immediate acute impacts on health and we dont tend to look at the far more important and significant areas from a health and economic perspective of poor sustainability what its doing to undermine the ecological basis to the food system as well as the chronic diseases and so on that come along some participants described social and financial benefit to industry from promoting csr activities these csr activities were at times described as strategically designed to avoid further industry regulation or government intervention you can make the judgment that you should probably assume that half of this is actually motivated by good corporate social responsibility and half of it is motivated by doing it yourself and being seen to do it so that the government doesnt step in and do it in a much more heavyhanded way other sources of power other sources of power included overblown claims of economic importance including providing jobs important for the national economy however some participants criticised these claims so and they use the normal you know itll cost jobs itll hurt it wont work all the slogans yeah which theres no truth in that some participants emphasised the role of media in shaping public and political opinions and described the extent to which industry utilises this i think a lot of people dont realise how influential the media is and its ability to change public opinion needs and opportunities for intervention needs for intervention were framed primarily through neoliberal ideologies with varying support for government intervention similarly the importance of individual freedom and choice were emphasised to a greater or lesser extent views expressed differed notably based on positions participants had held and for those with political experience political orientation role of governments participants with industry lobbying andor conservative government experience including politicians and political staff more commonly advocated for handsoff government approaches and industry selfregulation they instead indicated that consumers should take responsibility for their own health but the government can only do so much and i think a lot of people put a lot of emphasis that oh i have a problem the government should fix it and its like well no you have two arms and two legs you fix it yourself phfocussed participants were more in favour of regulatory intervention these problems are not unique to alcohol and tobacco … theyre suffering the same problem of peoples private profit motives theres nothing wrong with a profit motive whats wrong is failing to regulate it so i get a bit annoyed when i hear people saying well industry needs to do better its not industry its government needs to do better in regulating industry … this idea of selfregulation … is just utterly ridiculous industry representatives more often asserted that current regulation is adequate some phfocussed participants indicated that industry reluctance for further regulation arises from wanting to maintain profits the more effective you are at minimising harm the more you reduce gambling addiction and that wipes out the profit … but i say to businesses that if youre relying on gambling addiction you shouldnt be in business all participant groups discussed value in working relationships with government industry members favoured all working together where government industry and ph work together to develop effective policy and practice conversely phfocussed participants advocated against this approach saying industry uses these relationships to coopt agendas and promote industryfavoured outcomes instead phfocussed participants recommended restricting industry access to government personnel and processes perceptions of necessary reforms also differed by perspective ph personnel regulators and journalists alike advocated for increased regulation these participants emphasised more closely regulating relationships between industry and government particularly for political donations lobbying revolving doors and corruption these participants described the need for greater emphasis on integrity and the need to pass the pub test addressing corruption was a key priority for these participants although not all used this terminology those who did argued that australias narrow legal definition of corruption should be expanded to better promote the integrity of political and policy systems others advocated for a federal anticorruption watchdog with enforcement abilities role of education participants from all groups emphasised needs for additional public education to minimise harms andor promote health this included educating consumers and politicians alike participants generally described the need for broad education campaigns public education needs were often described within broader individual responsibility narratives industry representatives and some political participants emphasised the need to inform consumers about products so they can make good health choices some participants discussed needing to increase politicians and political staffers health literacy phfocussed participants more often advocated for educating consumers on industry activities and how to protect themselves from these freedom and choice arguments about interventions government roles and overall responsibility for harms caused were also underpinned by freedom and choice arguments participants cited consumer sovereignty an important element of neoliberal economic discourses 35 underpinning this is the idea that consumers should be free to make choices and that government should educate and therefore empower consumers with knowledge to make the best decisions for themselves some phfocussed participants emphasised that consumers rarely make truly informed choices factors discussed as restricting individual agency included commercial nudging and choice architecture tactics omnipresent marketing and markets flooded with unnecessary andor unhealthy products while addictive properties of alcohol and gambling products were raised by approximately half the participants effects of addiction on capacity for rational and informed choices and behaviours were rarely emphasised instead a few participants indicated that even those experiencing addiction are responsible for their behaviour i know that theres problems with gambling and people have issues that goes across any addiction but a lot of that money floats back into the regions … i wouldnt call it a necessary evil but its a humans choice and its like anything anyone can have an addiction even an addiction to food but do i think that there should be that kind of stringent regulation on food alcohol no because its a legal substance some phfocused participants emphasised that people experiencing addiction need additional help managing behaviours and mitigating harm like any kind of addiction if you have a gambling addiction then its very hard to control and to manage on your own so we need to help those people so we have all these rules around what venues cant do two phfocussed participants linked arguments about choice with health first paternalism the right to freedom and liberty and the right to choose may be a detrimental path but live with the consequences so healthfirst paternalism is a way of saying leave me to make my choices get out of the public health domain and give us all our freedom another described the freedom that industry advocates for as another form of domination industry always comes back to we should be free and what they want is freedom from interference … thats not freedom freedom is about domination when you frame things in terms of domination what the tobacco industry the alcohol industry the food industry wants to do is to maintain their domination … so thats why governments not only have a role to regulate they actually have a responsibility to regulate in this area and theyve failed in that responsibility with regard to junk food they have failed in that responsibility largely with regards to alcohol and theyve failed in that responsibility with regard to gambling discussion this study examines aspects of the power of australian food alcohol and gambling industries within a cdoh frame this includes social political regulatory and other mechanisms and the influences these exert on public policy and ph food alcohol and gambling industries significantly affect the health and wellbeing of australians together industries power shapes consumers relevant decisionmaking environments 36 37 38 39 and important health social and political discourses 18 40 41 42 43 the following sections discuss the findings of this study in the context of wood and colleagues framework 16 manifestations of corporate power cdoh literature has arisen largely from concerns about manifestations of power 28 the most visible forms of power participants primarily described manifestations of corporate power as negative industry participants more often suggested positive or neutral outcomes participants largely focused on social outcomes while phfocussed participants described health social political system and other harms industryfocussed participants touted societal benefits these centred on providing valued goods and services and social and economic benefits via jobs economic participation and similar this is consistent with previous analyses of industry discourses 2 3 4 5 6 and to be expected based on participants perspectives and interests corporate outcomes such as profit maximisation were primarily described as negative this is consistent with broader cdoh literature 22234445 only a few phfocused participants described ecological implications of unsustainable food systems and broader unsustainable production systems this is consistent with shortterm framings of harms noted here and more broadly as discussed further below nature of corporate power fuchs three forms of corporate power can be used to describe the different natures of corporate power discussed above 27 instrumental power instrumental power includes political and policy influences arising from mechanisms like lobbying and political donations also described as cpa 46 47 participants and particularly phfocussed participants indicated that australian food alcohol and gambling industries wield considerable instrumental power industry and political participants widely described cpas while denying their influence regardless of whether cpas convert into policy favouring industry industry actors unequalled access to politicians and their staff demonstrates significant instrumental power however the casual language used by industry and political participants downplays this these participants views reflect orthodox discourses normalising industry relationships with policymakers as natural and essential concepts of political corruption framed narrowly and in a strict legal sense similarly reinforce these orthodox discourses shifting focus from broader integrity issues including acting with honesty and morality corporate influence relies on abilities to influence the institutions of government arguably creating less democratic more plutocratic institutions 4849 exerting disproportionate corporate power and prioritising commercial interests above ph many participants downplayed or denied the influence of relationships and other power dynamics logic dictates these instrumental power mechanisms would have limited investment if they were truly inconsequential instead these mechanisms are evident across multiple intentional activities for instance dark money donations or donations where the source is not published are often dismissed as inconsequential 5051 as also noted in this study if indeed unimportant transparency would not be an issue however available evidence suggests these and other cpas are indeed globally powerful 6101113145051 this influence distorts the institutions of government and regulation mechanisms for disrupting instrumental power were priorities for phfocussed participants including some with political experience regulators and journalists the interventions discussed focused on reducing cpas and relationships between industry and government and therefore increasing integrity in policymaking and politics these approaches including restrictions on lobbying political donations revolving doors gifts and others with proper enforcement of these have been discussed widely in the cdoh literature 455253545556 however australia has relatively weak requirements for transparency in these areas and weak enforcement of existing regulation 5758 the lack of transparency and the lack of consequence for those breaching or noncompliant with regulation in these areas is a prominent barrier to reducing the exertion of instrumental power in these areas legislation for a new australian national anticorruption commission passed the parliament in november 2022 59 however the effects of this remain to be seen participants also placed some emphasis on upskilling the public and officials in recognising and recognising the effects of cpa as a means to delegitimise these tactics and reducing instrumental power there has been emphasis on monitoring and exposing corporate activities in recent literature as a means counter the corporate playbook 465356576061 with a range of organisations undertaking corporate watch activities this work is essential to counter the orthodox discourses that reinforce cpa as essential or normal as are research translation activities around this to make this work accessible in the policy and broader public environments further continuing pressure needs to be applied to achieve realtime disclosure of political donations reduce the threshold for disclosure of such donations 62 and make parliamentarians diaries available for public scrutiny certain types of donors are prohibited from donating to political parties in one state including property developers and commercial gambling operators 63 but no such restrictions exist at the national level meanwhile industry and political participants denying the influence of instrumental power did not suggest any need to address this this is entirely in line with previous observations about industrys use of instrumental power and the prominent industry discourses 23525356 structural power structural power allows political agendasetting and shaping markets and other environments using institutional processes involving private investment employment taxation economic activities legal action and others 27 this power derives from commercial and economic capital accrued via reflexive processes entities exercising this power promote and benefit significantly from favourable policies participants widely described structural power when discussing hard power while some industry representatives disputed the use of hard power others described industries economic threats to withdraw from australia to avoid reforms shift competitors out of the market and emphasise their economic importance within australia some described industries use of legal structures including trade agreements and broader legal structures to pursue business goals and avoid restrictive regulation examples of this structural power have also been described elsewhere trade agreements between the united states mexico and canada reportedly favour industry by expanding intellectual property rights that will increase pharmaceutical costs and weaken health and food safety oversight 64 analyses of mcdonalds australia reported that while they emphasise offering significant employment opportunities these are predominantly for younger people lower wages and insecure employment contracts 65 meanwhile tobacco industry legal challenges to plain packaging policies in australia the united kingdom canada and the netherlands presents another example 66 structural power may be a consequence of access to power via resources including capital control of orthodox discourses and access to politicians and political processes these appear structural because they produce material effects and are enhanced by processes increasingly reliant on commercial actors resources and inputs 27 ongoing privatisation of goods and services that have traditionally been government responsibilities 26 may likewise contribute to these further globalisation has expanded the market dominance of ultraprocessed food tobacco alcohol and other products deriving significant private profits while contributing substantially to population harms and therefore public costs 26 meanwhile increased privatisation of public systems enhance private profits 26 these effects arise from orthodox discourses promoting the value and necessity of privatisation and globalisation facilitating what can be observed as structural power structural power cannot be examined in isolation and particularly not in isolation from discursive power 67 there are several examples of the reduction of structural power this has included using structures like financial power and disinvestment practices perhaps the most prominent of these are in tobacco and arms tobacco free portfolios have worked to divest from tobacco in some of the worlds largest financial markets including banking insurance pension funds wealth management and others 68 similarly quit nukes and dont bank on the bomb work for divestment from nuclear weapons among financial institutions and have seen good success 6970 however these shifts have happened in line with international shifts in the legal environments 7172 and broad societal shifts in discursive power surrounding the tobacco and arms industries in particular 73 therefore approaches to addressing structural power need to be considered in conjunction with discursive power discursive power discursive power was highly observable in this study that is the power to pursue and shape interests by shaping societal values norms and ideas 27 this is observable via participants adopting and promoting neoliberal concepts discourses of industry selfand lighttouch regulation and emphases on individual responsibility and freedom of choice these discourses fundamentally shape relationships between populations industries and government 264174 and the distribution of power varying participant perceptions were expected given that experiences and subjectivities shape perspectives 75 industry and some political participants narrow framing of health focussing on shortterm over longterm or cumulative outcomes and individuals over populations is consistent with regulatory approaches focussing on shortrather than longterm harms and orthodox discourses underpinning these meanwhile ph perspectives of harms and health represent generally heterodox discourses opposing this orthodoxy 20 the lifestyle drift phenomenon may partly explain participants tendency to describe upstream determinants of health including cdoh and then propose interventions targeting more proximal determinants 76 this suggests it is challenging for participants to articulate interventions transcending orthodox discourses orthodox discourses perpetuate and reiterate the reasonableness of industry actions legitimising industrys inclusion in regulatory and decisionmaking processes by emphasising industry benignity and neutrality 76 meanwhile those questioning the usefulness andor conflicts of interest involved in these are portrayed as unreasonable orthodoxy pursues its own logic adhering to and reinforcing orthodox power 20 these powerful actors thus shape what is and is not deemed reasonable within this choice and individual responsibility are often prioritised above protecting people from harms individual responsibility discourses manifest as promoting drinking responsibly 7778 or gambling responsibly 404179 emphasising personal or parental responsibility for diet 8081 in these products are portrayed as benign while the industries producing promoting and distributing these are portrayed as neutral actors promoting consumer autonomy enjoyment and choice 4182 while participants conceded that alcohol and gambling were probably not essential food was disputed some emphasised that not all food products are essential and once longterm harms are considered the harms arising are often significant this claim is supported by previous evidence 58384 orthodox discourse likewise constructs image and harm participants frequently framed social drinking or social gambling as good and responsible behaviours while drinking or gambling alone or to excess are bad and irresponsible participants also made arbitrary distinctions between types of alcohol and consumption settings reinforcing discourses such as individual responsibility discourses regularly articulated by industry these framings are strategically frequently at odds with true harm for instance there is good evidence of longterm harms from regular alcohol consumption 85 86 87 regardless of setting or type of alcohol consumed this is consistent with the broader pattern of industry discourses that insist there is no problem or admit there is a problem but insist it is less severe than other problems or less severe than people assert 3 this works to obfuscate the issue and generate doubt the generation of doubt is of course a tobacco industry tactic adopted by others while participants were not asked about the tobacco industry almost half discussed this the implied hierarchy this reveals with tobacco as most harmful followed by gambling and alcohol with food the least harmful is consistent with previous research 33 and entirely consistent with industry discourses while this hierarchy may truly exist it is unlikely that the differences from tobacco are as stark as implied by some participants some authors describe this hierarchy as giving some industries unfair advantage to promote their products and avoid regulation 2333 unsurprisingly food alcohol and gambling industries reportedly adopt these comparisons to avoid the regulation placed on tobacco 14688 however ph evidence generally favours further regulation 5 89 90 91 92 australia has seen successes in implementing relatively strict tobacco control including tobacco plain packaging laws introduced in 2012 93 these laws are the latest in australias tobacco control policies implemented incrementally since the 1970s 94 which have been quite successful despite multiple legal challenges the tobacco industry has been unsuccessful in overturning these laws 93 these tobacco control policies have gradually decreased the capacity of the tobacco industry to promote their products and interests in the public domain meanwhile the revelation of documents from within the tobacco industry detailing the industrys tactics and increasing awareness of the true harms caused by tobacco likely contributed to a denormalisation of tobacco increasing scrutiny highlighting bad behaviour and decreasing contact to policymakers for the tobacco industry 95 however the tobacco control approaches taken within australian and global contexts has fed a discourse of tobacco exceptionalism where tobacco is portrayed as a product unlike any other presenting a unique threat to health and therefore warranting special regulation while other products causing similar harm do not 9697 tobacco exceptionalism plays well into other industries discourses and is not unique to australia 98 meanwhile the example that has been made of tobacco has served as a warning and a learning opportunity for other industries who do not want to suffer the same fate of becoming persona non grata 5 together these have at least in part contributed to australias regulatory failure in a range of other policy areas including the failed carbon pricing scheme and the failed introduction of gambling machine precommitment in both these instances the respective industries were highly effective at mobilising against further regulation controlling discourses drawing on personnel and significant financial and other resources acting aggressively and increasing efforts to maintain their collaborative position with government 99100 similarly taxing sugarsweetened beverages has been proposed several times but has never seriously been on the policy table because these products are not as bad as tobacco the relationships between the products and the harms are arguably more complex and ph responses have not always been clear or singularly focused these industries have fostered sufficient doubt to maintain policy inaction the discursive lessons in this are that tobacco should not be the benchmark against which all harms are measured it is important for ph actors to improve communication of complex causal relationships relevant policy advocacy efforts need to be clear and consistent origins of corporate power fuchs and glaab describe two sources of corporate power 30 material power originates in economic capabilities and is used to influence political processes inputs and outputs 30 financial means enable many cpas inducing financial dependence on corporate actors amongst political decisionmakers and others 30 other interests are often unable to match this while corporate actors further expand their financial resources as a result of political activities 30 participants prominently identified material origins of power how material resources translate into political influence are important considerations ideational power includes framing political issues shaping discourse surrounding policy definitions actors norms and processes 30 and defining what is not on the political agenda this power constrains or engrains behaviour and action by controlling symbolic meanings within social practices and institutions 30 knowledge and how knowledge is processed and interpreted is key to this 30 ideational power is the ability to shape orthodox discourses to determine what is meaningful or normal and generate selfperpetuating logic many participants discussed this participants also described relationships as a prominent source of power while some relationships may be ideational and some material some relational power likely lies outside the materialideational binary commercial actors have power however some individuals also articulate power often these people are sought for the power they bring to industry and other roles thus the appeal of revolving doors between government and industry 13 for corporate power it is important to acknowledge relevant orthodox power possessed by individuals who know how to identify articulate and deploy power another origin of power some participants touched on is the interconnection between food alcohol and gambling industries and other related industries including media organisations like trade associations advertising agencies public relations firms consulting firms corporate law firms financial firms major retailers logistics and warehousing companies and some trade unions also have codependent relationships with these industries in this food alcohol and gambling industries power is bolstered by powerful and often mutually supportive industry networks aligned interests between industries and associated actors translate into generally aligned discursive structural and instrumental power meaning policy advocacy efforts are likely to be successful in this study participants emphasised that power provides access to policymakers and political processes while influence is the ability to use or convert power into action this aligns with previous power and influence framings 30101 however this conversion is not always direct often influence is exerted by shaping orthodox discourses and therefore shaping what is viewed as problematic reasonable and otherwise this is highly reflexive as power begets and embeds power constantly that is not to say that orthodox power is insurmountable but that it dominates social and political spaces implications for public health power cannot be ignored when analysing ph challenges arising from food alcohol gambling or other industries these products have significant health implications and these industries have considerable power over social commercial and political environments consistent with orthodox discourses prevention and harm reduction efforts cannot succeed without addressing this power determinants of health and especially cdoh are constituted via complex orthodox systems underpinned by supportive discourses and ideologies opposing or amending these systems to better serve ph requires adopting a heterodox position and proposing interventions to amend each element of the orthodox system however this rarely catalyses a complete heterodox system it is usually ad hoc addressing individual orthodox components exceptions arguably include tobacco control and road safety systems which saw incremental changes within lengthy timeframes 102 103 104 105 systems responses are necessary to reduce cdoh harms 725106 these require recognising all elements of the orthodox system developing a heterodox critique of dominant discursive elements identifying interventions and closely monitoring these for ongoing effectiveness all of this must be supported by focused well implemented and clearly articulated research this can be very effective if translated into forms readily accessible by concerned citizens as has been demonstrated by recent revelations in relation to australias casino businesses the media has a major role to play in achieving reform those advocating for reform must engage regularly and consistently with media outlets this was also a major lesson from the tobacco control movement the avenue for articulation of heterodoxy is arguably the media food alcohol and gambling industries are powerful institutions formed by complex relationships powerful orthodox discourses and largely imaginary elements dependent on orthodox discourses 107 all institutions are in flux subject to change and reconception they are not immutable structures despite contrary appearances they can be modified through application of heterodox discursive elements the product of imaginary processes operating to critically pursue alternative institutions that are less committed to profit at all costs and more committed to better population health and wellbeing successful harm prevention will necessarily involve disrupting relationships between industry political processes and regulation the relationships between industry government and regulators and the mechanisms and institutions that perpetuate these are a prominent quality of industry power while this research focused on australia these industries are highly globalised 108 and previous work has also emphasised these issues 88106109110 one key heterodox initiative is to encourage greater distance between policy and decision makers and industry and greater integrity within political processes this would likely require an ideological shift and a redefinition of government roles toward protecting and promoting population health similarly this work highlights the importance of careful interrogation of all food alcohol and gambling industry relationships for researchers ph professionals and civil society alike industry funding and collaborative relationships present complex challenges alignment of these industries commercial interests with public and institutional interests requires careful consideration to avoid inadvertently exacerbating cdoh harms we need broader recognition of cdoh at policy and regulatory levels clear cdoh framings are essential for this 25 cdoh represent complex dynamic systems shaping health at supranational regional national and local levels heterodox discourses should focus on disrupting orthodox discourses supporting these such as endorsements of key elements of neoliberal capitalist ideology this is particularly so where these are normalised as the way things are a market society can operate with fair regulation profits can be extracted from wellregulated market transactions within all this ph professionals need to develop political understandings and practice skills in this we can learn from and work alongside those with complementary skillsets and aligned public interests such as political scientists investigative journalists civil society activists business analysts lawyers and others 46111112 health and particularly ph has always been deeply political however health arguments are rarely at the forefront of major policies like industrial relations trade taxation and despite piecemeal commitments to health in all policies 113 commitments are mostly for downstream treatment therefore looking for allies and aligned causes outside of ph is highly beneficial notably drawing on arguments from economics law business and other areas are needed to support heterodox responses to harmful orthodox discourses ph advances are won by continued and ongoing engagement in political processes 114 advocacy is an essential role in this respect while political access for ph personnel may not be as straightforward as some industry participants indicated in this study organised advocacy efforts are essential and can be bolstered through wellaligned collaboration the cdoh underpin most pressing global health challenges formulating ph responses addressing these will require an end to siloed ph approaches and adoption of widespread collaborations and broader systems thinking strengths and limitations this study sought diverse perspectives from participants with experience of the food alcohol and gambling industries including current and former politicians and political staffers regulators and other public servants industry representatives lobbyists journalists and researchers invitations to participate received good response rates and most invitees who declined provided a reason participants represented each target group and each industry and held diverse political perspectives these brought rich perspectives however this meant reaching data saturation was unlikely and subsequently was not achieved this paper seeks to elevate theoretical conceptualisations of power relevant to cdoh by framing analyses using wood and colleagues integrated corporate power framework to inform analysis of the cdoh 16 this application of a theoretical frame within an empirical cdoh study is relatively novel future research would benefit from incorporating similar frames in all aspects of study design and implementation conclusion the australian food alcohol and gambling industries are powerful together these have significant impacts on population health and wellbeing these industries seemingly have high levels of instrumental structural and discursive power 27 with origins in material ideational 30101 and relational sources of these discursive power appears the most prolific power and its manifestations represent central aspects of the cdoh forming seamless links to dominant systems and institutions of neoliberal capitalism globalisation cpa and others it is important to recognise this power and take steps to reduce it to strengthen governance systems and improve population health importantly this requires ph advocates and researchers to adopt a political lens with the intention of disrupting the comfortable orthodoxy that harmful commodity industries articulate and which permeates government and regulatory systems population health will not be advanced with business as usual business as usual is the cause of the pandemic of ncds that now confronts the global population addressing this requires disruption of orthodox discourses and ideologies underpinning it competing interests authors declare that they have no competing interests supplementary files supplementary file 1 sample frame supplementary file 2 interview guide

background commercial determinants of health cdoh represent a critical frame for exploring undue corporate and commercial influence over health power lenses are integral to understanding cdoh impacts of food alcohol and gambling industries are observable cdoh outcomes this study aims to inform understanding of the systems and institutions of commercial andor corporate forces working within the australian food alcohol and gambling industries that influence health and wellbeing including broader discourses materialised via these systems and institutions methods twenty semistructured interviews were conducted with keyinformants on australian public policy processes interviewees were current and former politicians political staff members regulators and other public servants industry representatives lobbyists journalists and researchers with expertise and experience of the australian food alcohol and or gambling industries interviews sought participants perceptions of australian food alcohol and gambling industries similarities and differences power and influence relationships and intervention opportunities and needs results strategies and tactics used by australian food alcohol and gambling industries are similar and similar to those of the tobacco industry they wield considerable soft eg persuasive preferenceshaping and hard eg coercive political and legaleconomic power perceptions of this power differed considerably according to participants backgrounds participants framed their understanding of necessary interventions using orthodox neoliberal discourses including limiting the role of government emphasising education consumer freedom and personal choice conclusion food alcohol and gambling industries exercise powerful influences in australian public policy processes affecting population health and wellbeing per wood and colleagues framework these manifest corporate social and ecological outcomes and represent considerable instrumental structural and discursive power we identify power as arising from discourse and material resources alike along with relationships and complex industry networks addressing power is essential for reducing cdoh harms disrupting orthodox discourses and ideologies underpinning this should be a core focus of public health ph advocates and researchers alike

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drinking games are social drinking events in which alcohol consumption is guided by a specific set of rules related to the performance of a physical or cognitive task and facilitate intoxication via intake of large amounts of alcohol in a limited window of time between 57 and 65 of college student drinkers participate in dgs which is linked to increased quantity and frequency of alcohol use heavy drinking and getting drunk dgs are also associated with alcoholrelated harm and this association may be moderated by gender and typical alcohol consumption collectively past research indicates that dg play signals greater risk for hazardous drinking and related harm what is relatively less known is whether dg play increases ones risk for drinking and alcoholrelated consequences on occasions he or she drinks adjusting for their typical patterns of alcohol use and dg play previous research in which daily dg play and alcohol consumption were assessed retrospectively for three months found that individuals on average consumed more alcohol on days they played dgs relative to nondg drinking days however because of the inherent association between dg play and alcohol consumption it is important to separate typical patterns of alcohol use and dg play to precisely characterize the role that dg play has on alcohol consumption on a given drinking event controlling for individual dg and alcohol use tendencies further there are no studies to our knowledge that have examined individuals risk for alcoholrelated harm on occasions they played dgs controlling for either typical patterns of alcohol use or alcohol consumed on those same occasions this is particularly important for firstyear college students who are relatively new to drinking and college environments firstyear students tend to play dgs more often relative to older students perhaps due to the central role of dgs in parties or other socializing events with alcohol they are likely to attend also for some students dg play during the first semester of college is likely a continuation of risky drinking behavior established prior to college matriculation accordingly this study utilized an eventspecific repeatedmeasures framework in order to examine the associations of dg play with alcohol use and related consequences among students in their first semester of college our assessments targeted weekend drinking events as weekend drinking accounts for the majority of alcohol consumption among firstyear students the first aim was to examine whether firstyear students consumed more alcohol on drinking events in which dgs were played controlling for typical frequency of dg play the second aim was to examine whether students were more likely to experience alcoholrelated consequences on events they played dgs above and beyond what could be explained by the amount of alcohol consumed as well as their typical patterns of alcohol use and dg play gender was included as a covariate in all models as well as a moderator of eventspecific relationships as some research indicates that men drink more than women when playing but women may experience more consequences method participants and procedure seven hundred firstyear students between the ages of 1820 were randomly selected from the registrars database at a large public university in the northeast united states students were mailed a letter inviting them to complete up to six webbased surveys assessing friday and saturday drinking behaviors during the fall of 2010 an email invitation followed to their university email address and included a url and personal identification number to access the consent form and first survey yielding a 680 response rate individuals who reported past month alcohol use were subsequently invited to complete five additional surveys throughout the semester survey invitation emails were sent on sundays with up to three reminders and survey access was disabled after four days surveys 1 and 6 lasted 4560 minutes and included both event and nonevent measures surveys 25 included only eventspecific measures and lasted 1015 minutes to help ensure accurate recall each survey was structured so that questions specific to the previous friday were asked first followed by a separate series of questions for saturday participants were compensated 30 each for surveys 1 and 6 and 10 each for surveys 25 response rates ranged from 930 983 for surveys 26 the universitys institutional review board approved all procedures of the 358 students who reported past month alcohol use 22 did not report any consumption across all 12 measured days and were excluded from further analysis this yielded a sample of 336 firstyear student drinkers with a mean age of 1820 years the majority of the sample identified as whitecaucasian with 51 asian 24 blackafrican american 21 multiracial or other and 86 identified as hispanic participants resided primarily in oncampus residence halls measures alcohol useeventspecific alcohol use was assessed with an openended question asking participants to indicate the number of drinks they consumed on the previous friday and saturday a standard drink definition was provided to help with their estimate a typical drinking variable was also calculated based on eventspecific alcohol use data as the average number of drinks consumed across all drinking events drinking game playto assess eventspecific dg play participants were asked to indicate dg participation on each event they reported alcohol use typical dg play was calculated as the proportion of events on which dgs were played relative to an individuals total number of drinking events alcoholrelated consequencessimilar to dg play eventspecific consequences were assessed by asking students to indicate if they experienced consequences on events they consumed alcohol items were adapted from the young adult alcohol consequences questionnaire to indicate whether consequences were experienced during or after a specific drinking occasion as opposed to over an extended period of time we examined consequence items likely to be related to eventspecific drinking including socialinterpersonal risk behavior and blackout drinking consequences because items were dichotomous we obtained tetrachoric interitem correlation estimates via prelis and used those values to calculate the coefficient alpha for each subscale items within each category were summed and the sum score was dichotomized for each domain analytic plan descriptive statistics were analyzed using ibm spss statistics 20 hierarchical linear models were used to address study aims and were analyzed using hlm 608 for all models we only included days in which alcohol use was reported which consisted of 1860 drinking events across the 336 participants days with missing data on one or more eventlevel variables of interest were further excluded resulting in 1838 total drinking events for hlm analyses to address the first aim we tested a model with eventspecific alcohol use as the outcome the level 1 covariate was whether an individual played dgs on drinking events and level 2 covariates were gender and ones typical dg play in addition we tested a crosslevel interaction between gender and eventlevel dg play across all drinking occasions number of drinks consumed ranged from 1 to 40 and was fairly normally distributed thus an identity link was utilized for the hlm analysis for the second aim a logistic model was used for each of the dichotomous consequence outcomes using the bernoulli option in hlm for these models we included all covariates used to predict alcohol use and added eventlevel alcohol use typical alcohol use and the interaction between gender and eventlevel alcohol use all level 2 predictors were grand mean centered so that values represented how individuals differed from the population mean indicating relative individual differences level 1 predictors were person centered so values reflected eventspecific variation relative to ones average or typical behavior all models were randomintercept models with fixed slopes for the level 1 predictors results descriptive statistics across the 12 weekend days participants averaged 554 total drinking events and 225 dg events 756 of participants reported at least one dg event descriptive statistics for typical alcohol use dg play and consequence variables averaged across drinking events are presented in table 1 eventspecific alcohol use table 2 shows men consumed higher levels of alcohol on drinking events compared to women and those who participated in dg more frequently across events consumed more alcohol at the event level dg participation was significantly associated with greater alcohol use such that on occasions when individuals played dgs they consumed an average of 112 more drinks compared to drinking events they did not play dgs gender was added as a crosslevel interaction with event dg play in model alc2 and it was not statistically significant eventspecific alcoholrelated consequences table 3 shows that those who consumed higher levels of alcohol quantity across events were more likely to report any socialinterpersonal risk behavior or blackout drinking consequences controlling for individual differences in typical drinking those who played dgs more frequently were more likely to experience any blackout drinking consequences women were more likely to experience any socialinterpersonal and blackout drinking consequences in addition to the betweenperson variability eventspecific alcohol use was significantly related to the experience of all consequence types the odds of experiencing any socialinterpersonal risk behavior or blackout drinking consequences were higher on events when individuals consumed one more drink than their typical amount further dg play increased their chances of experiencing any blackout drinking consequences on that same occasion moderated associations of eventspecific alcohol use and dg play by gender in table 3 models soc2 rsk2 and blk2 include crosslevel interactions of gender and both eventspecific drinking and dg play there was a significant interaction between gender and dg play for socialinterpersonal consequences such that for women their chances of experiencing this type of harm on occasions they played dgs were much greater than those of men there was also a significant interaction between eventspecific consumption and gender for blackout drinking consequences when women compared to men drank one more than their usual their odds of experiencing blackout drinking consequences were increased by a factor of 13 1 additional analyses with blood alcohol concentration we also ran a series of alternative models similar to the ones reported above with the exception that bac was substituted for number of drinks first as an outcome variable and then as a both a level 1 and level 2 predictor of the consequence 1 in addition to the three consequence types we also examined total consequences as an outcome a total consequence score was calculated for each event by summing all items poisson hlm models were utilized because this variable was positively skewed with a considerable amount of zeros results indicated that women students who consumed more alcohol on average and students who consumed more than their typical amount on a given drinking event reported higher total consequence scores however neither typical dg tendencies or eventspecific dg play was significantly associated with ones overall experience of harm on a given event in addition there were no significant crosslevel gender interactions for these models outcomes participants reported their weight in the first survey and the duration of each reported drinking event across all assessments which allowed us to calculate both eventspecific bacs and a typical bac across all drinking events with bac as the outcome dg play remained a significant predictor at both the typical and eventspecific level however gender was not significantly associated with bac which is not surprising given that men reported drinking more than women across all occasions and bac accounts for gender differences in alcohol metabolism in addition the crosslevel interaction between gender and event dg play was not significant similarly for the model predicting blackout drinking consequences gender was no longer a significant predictor at level 2 and there was no significant crosslevel interaction between gender and eventspecific bac for models predicting socialinterpersonal and risk behavior consequences results were similar to those shown in table 3 discussion this study examined the risks associated with dg play among firstyear college student drinkers using an eventlevel repeatedmeasures framework four primary findings emerged first students consumed approximately one additional drink and reported higher bacs on events they played dgs controlling for typical gaming tendencies thus regardless of how often firstyear students play dgs they are likely to consume more when doing so which underscores the highrisk nature of dgs for all student drinkers although one drink may not seem like a substantial increase it is concerning in the context of our sample of students who consumed about six drinks when drinking further a onedrink increase from typical drinking behavior was associated with much higher odds of experiencing all consequences types second men consumed approximately two more drinks than women on all drinking events regardless of whether they played dgs resulting in similar bacs for men and women on those occasions that men drink more than women when playing dgs is consistent with some research on gender differences in typical alcohol consumption related to dg play conversely two recent dg simulation studies in which students played dgs in a lab environment with water substituted for alcohol use found that men and women consume similar amounts when playing dgs which would result in higher bacs for women when alcohol is consumed notably men and women were instructed to drink similar amounts during the simulations which could also account for differences in results as compared to selfreport studies third both personal dg tendencies and eventspecific dg participation were related to blackout drinking consequences this is consistent with the notion that dgs consist of consuming drinks in a short timespan resulting in elevated bacs and in turn higher odds of getting sick and experiencing blackouts after drinking specifically research suggests that gulping drinks a behavior consistent with dg play can lead to a more rapid rise in bac and an increased likelihood of experiencing a blackout in contrast typical dg tendencies and eventspecific dg play were not significantly associated with risk of experiencing any socialinterpersonal or risk behavior consequences controlling for typical and eventspecific consumption however given that students were more likely to experience those consequences on occasions when they drank more than their typical amount it is plausible that dg play may increase students risk for harm during or after a drinking event in a more indirect manner via increasing eventspecific alcohol use on those occasions thus findings from the present study collectively suggest that dg play places all individuals at increased risk of harm fourth we found event dg participation was related to an increased risk of experiencing socialinterpersonal consequences for women that dg play was uniquely related to socialinterpersonal harm makes sense given the social context of dgs the competitive nature of dgs coupled with the social setting and increased alcohol use provides an opportunity for individuals to express themselves in unbecoming ways within their peer groups whereas all gamers may make antagonizing comments to fellow players to entice them to drink more women may retrospectively perceive those actions to be embarrassing or regretful whereas men may perceive such actions in a neutral or even positive light no gender differences were observed in the association between event dg play and risk behavior or blackout drinking consequences this is contrary to a previous study that found a stronger association between past month dg play and social risk behavior consequences for women betweenstudy differences in findings may be due to differences in measurement or that both typical and eventspecific alcohol use was controlled for in the current study this study has some limitations including a singlecampus sample of firstyear student drinkers in their first semester the extent to which results would generalize to comparable students on college campuses with different drinking environments is unclear our sample may be considered highrisk based on the average levels of reported alcohol use however alcohol use levels in our study are similar to levels of past month use reported in previous dg research with a similarly aged college sample this study relied on selfreport data and accurate recall could be affected on nights of elevated alcohol use students may have underestimated their alcohol use on dg events and in turn the risks associated with dg play could be underestimated future eventspecific studies could be designed to distinguish between the number of drinks consumed during and after dgs to gauge how dg play leads to subsequent rises in alcohol use or bac incorporating measures of eventspecific motives and intentions for dg play could offer further understanding as to why dgs influence risk for example individuals who intend to get drunk on a given occasion might participate in dgs as a way to achieve that goal prevention efforts targeting incoming students may benefit from components related to both typical and eventspecific dg play in addition to discussing students past experiences with dgs it could be useful to help them understand the risks associated with dg play on any occasion regardless of their typical dg play tendencies for women it may be particularly beneficial to emphasize the increased risk of socialinterpersonal consequences especially given that dg play is often motivated by social reasons highlighting the discrepancy between playing dgs to fit in with peers or meet new people and in turn being more likely to insult or offend others could be particularly relevant for women overall our findings provide evidence that eventspecific dg play is a contextual risk factor for all firstyear student drinkers regardless of individual alcohol use and dg play tendencies event dg play × gender interaction effect on the probability of experiencing any socialinterpersonal consequences on drinking occasions data points represent likelihoods for participants when values of typical alcohol use and dg play across events are equal to the population average and event alcohol use is equal to an individuals average event number of drinks × gender interaction effect on the probability of experiencing any blackout drinking consequences on drinking occasions data points represent likelihoods for participants on nondg events and when values of typical alcohol use and dg play across events are equal to the population average note eventlevel n 1838 personlevel n 336 significant effects are indicated when the confidence interval does not contain the value of one and are presented in bold soc1 rsk1 and blk1 are models with no crosslevel interactions between eventlevel behaviors and gender whereas soc2 rsk2 and blk2 are models in which those interactions were included

backgroundcollege students who play drinking games dgs more frequently report higher levels of alcohol use and experience more alcoholrelated harm however the extent to which they are at risk for increased consumption and harm as a result of dg play on a given event after accounting for their typical dg participation and typical and event drinking is unclear objectiveswe examined whether firstyear students consumed more alcohol and were more likely to experience consequences on drinking occasions when they played dgs methodsparticipants n 336 completed up to six webbased surveys following weekend drinking events in their first semester alcohol use dg play and consequences were reported for the friday and saturday prior to each survey typical dg tendencies were controlled in all models typical and event alcohol use were controlled in models predicting risk for consequences resultsparticipants consumed more alcohol on dg versus nondg events all students were more likely to experience blackout drinking consequences when they played dgs women were more likely to experience socialinterpersonal consequences when they played dgsplay is an eventspecific risk factor for increased alcohol use among firstyear students regardless of individual dg play tendencies further event dg play signals increased risk for blackout drinking consequences for all students and socialinterpersonal consequences for women aside from the amount of alcohol consumed on those occasions as well as typical drinking behaviors prevention efforts to reduce highrisk drinking may be strengthened by highlighting both eventand personspecific risks of dg play

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vector 1 what structures of communicative networks enhance or retard the diffusion of social influence networks with dense interpersonal connections may yield limited social influence one truism of mass communication effects research is that exposure is the sine qua non of media effects and communication campaigns often fail because of inadequate levels of exposure as social media have become a fact of everyday life various voices have argued loudly that exposure to information through social that is interpersonal contacts is an increasingly consequential source of information and influence one obvious consequence of the exposureeffects linkage is that the greater the connections among persons in a social network the greater the chances for information sharing among network members and therefore the greater the impact of the information shared networks that are densely interconnected should yield more information sharing and influence the greater the connectivity between persons within a networks communities and between communities would lead to information sharing and social influence under simple assumptions of diffusion and retransmission within and between members of the communities however these commonsense conclusions have been challenged by recent data the availability of largescale behavioral social media data allows unprecedented network analyses of who communicates with whom about what and to what degree rather than simply assuming or simulating patterns of information transmission and retransmission recent network research has been able to focus on largescale networks with certain kinds of behavioral data allowing empirical reevaluation of core ideas about network structures and social influence processes these big data studies of network influence have produced some conclusions suggesting that dense networks can yield less social influence than sparse ones a variant on this theme is the observation that those on the periphery of a network may be as important in some contexts as those who are highly connected and reside in central communities of the network we will explore both of these insghts below short versus long chainsthe core idea behind most studies of diffusion is that the adoption of an innovation or an idea will move throughout a network beyond several steps removed from the initial source cascading to other recipients from the initial adoption or acceptance of the idea goel watts and goldstein take issue with this notion in network research they argue that modeling the transmission of an idea or an innovation like an infection moving through a population is misleading when applied to more complex contagions this core assumption of information transmission in a connected network is simply incorrect when applied to a variety of examples of information transmission for adoption and acceptance in the online world the authors examine seven different diffusion data sets three having to do with the acceptance of an action by another person in the network the other four involve transmission of news stories videos political views or voice credits for a new protocol the most important finding for the world of interpersonalmass communication is that the overwhelming proportion of transmissions occur in one step in the network diffusion process this result is consistent across all seven data sets there is a very small proportion of diffusions that occur beyond that initial transmission but these number far less than 1 the authors consider various objections to their findings including the idea that there are data sets in which transmission will occur beyond one step and through several generations as is the case with biologically based viral infections and pandemics they consider for example some particular twitter elements and events that had a virality greater than some of the other examples that they used but still find no strong evidence for transmission beyond one step they also reject the hypothesis that the usual transmission assumption in network influence models does not work for most cases of real social influence which require acceptance on the part of the receiver and deliberate acts of transmission and retransmission by senders effects research in communication is concerned with innovations and ideas and memes and their acceptance and rejection and not simply passive exposure as network researchers have gained access to larger sets of behavioral data from social media the random mixing models of early diffusion research and their implications about interpersonal communication have fallen by the wayside in favor of quite different assumptions about how interpersonal communication is important in social influence processes and network goel et al acknowledge that much of the early work on the transmission of media messages in a twostep flow model may in fact be reasonably accurate and all that is necessary to make the modeling of social influence work to capture media plus social influence activists vs slacktivistsanother line of research that raises questions about the importance of dense interpersonal connections for social influence is the research on political movements and political activism under the name of slacktivists vs activists the implicit assumption in network studies has been that social influence advances when interpersonal connectivity is high the more sparse the connections the less likely the social influence while this would certainly be true in the extreme case where the complete absence of social connectivity makes influence impossible recent work has suggested that macrosocial influences can occur even with relatively nondense connections at the periphery of networks gonzálezbailón and wang studied a 1month period close to the development of the occupy movement in the united states and in response to a similar movement that developed in spain the data for the networks they studied come from the twitter sphere involving tweets and retweets in the networks that are created by sending and resending information about the movements algorithmic methods identify communities are identified using algorithmic methods individuals who bridge between communities serve to connect them the relevance and importance of weak ties and the brokering of information between communities within the network occurs through the interpersonal mechanism of tweeting not necessarily as a mechanism of social and political influence but rather as an almost indiscriminate broadcasting of available information that may or may not be influential nevertheless communities pass on the information perhaps in part due to the low cost of doing so barberá et al reach the empirical inference that those on the periphery of a network are crucially important in social protests the very small number of individuals who are at the core of the social protest are extremely active but have limited reach because of their numbers and connectivity the periphery which is behaviorally and cognitively less involved in social activism is much larger in its numbers but less committed they are sometimes called slacktivists in service of the idea that they are not active in the world of social protest but instead are passiveyet not disinterested their sheer number and at least passive involvement in the particulars is important to the protest movement the number of peripherally connected individuals outweighs their lowered centrality within the network and their influence in the social system is their number not the density of their connections the authors show these effects in three different protest movements largescale social media data that are primarily behavioral rather than selfreported allow the examination of interpersonal connections and communication in ways that are unprecedented these data in turn allow an examination of established assumptions about the importance of dense connections the likelihood of the activation of long chains of connection the appropriateness of assumptions such as simple contagion these new data sources and methods allow research into communication that blurs the distinction between interpersonal and mass influence allowing the evaluation of established ideas such as simple contagion the direction depicted in this first vector is itself too simplistic as what is accepted will likely differ by topic and network the particular findings discussed in this section while provocative and in some senses at odds with conventional wisdom are less important than the fact that macrosocial influence and exposure occur through mechanisms that are obviously at the interface of interpersonal communication targeted to individuals and to broader reach through the same social media mechanisms unprecedented and detailed data are available to examine the microand macrosocial influences and patterns of exposure through these massinterpersonal sources the possibility of reexamining our long established hypotheses about networks and interpersonal influence at a much larger scale is a real option vector 2 how can our theories and models of media effects simultaneously incorporate both interpersonal connections and mass communication effects moving from factors to actors this vector has two prongs the first is the general idea about how to best model human social behavior using modern techniques such as agentbased modeling and the second is using such applications to support the claims of vector one namely that dense network structures may not be the most likely routes to social influence the typical approach to statistical modeling that most of us have used for eons uses variables that the targeted population measures and models one can build statistical graphical or computational models around such variables variables or factors are prominent and focal the actors or persons are assumed to be independent of one another rather than connected and the research is usually designed to insure independence in these cases the factors approach is appropriate but when the actors are connected or interact in some way not only is there statistical dependency in need of correction but additionally a modeling opportunity focused on actors each of whom possesses the factors of interest developments in software and modeling technology allows complex personbyvariable models the basic idea here is that every person in the system under investigation is a carrier of all of the variables that are a part of the modeling effort so instead of having an n variable model applied to k independent people we instead have an nbyk variable model in which every person interacts with those to whom they are connected through the n variables that are part of the modeling process what is unique about such computational models is that the interpersonal influence components and degrees of connectivity must be modeled explicitly rather than bypassed in the modeling endeavor or statistically adjusted macy and willer have argued that core questions in sociology have or will move in the direction of studying the interaction of actors influence patterns and connectivity rather than the aggregating interaction of variables across actors treating clustered actors as if they were not connected or controlling connected actors connectivity out of the modeling agent based modeling provides a route to such theorizing important publications using this approach make clear that both the structures of connectivity and the variables pertinent to social influence must be considered simultaneously the invention and dissemination of powerful modeling tools such as agentbased modeling and statistical approaches that model at both the factor and actor levels within the same analysis offer methodologies to bridge the factors of mass communication effects and the actors who carry out interpersonal influences one application of the factors and actors approach is that of centola and macy they carried out formal models of complex forms of social influence they were able to show that complex contagions require multiple sources mimicking norms credibility and other components of social influence and that complex innovations will not move as readily across weak ties as simple ones do instead requiring wider bridges across network enclaves the upshot of these studies argues that the classic strength of weak ties is itself problematic when considering complex rather than simple contagions other formal modeling efforts have shown that even highly unpopular norms can in fact cascade throughout a network even when the vast majority of actors oppose the convention and that very high and very low levels of consolidation and homophily are problematic in the diffusion of behaviors these findings are not confined to the world of formal modeling centola tested the idea that networks with tight clusters of interpersonal connection and separation between clusters would be worse than networks with more connectivity for complex behaviors such as adopting a health behavior the resulting models and data show the opposite to be true this study involved a decision to register for an internetbased health forum participants were randomly assigned to one of two experimental conditions based on the kinds of contacts that they had available to them one was a clustered lattice network and the second was a random network of contacts the number of contacts that each person had regardless of network that they were assigned to was the same the set of connections was not able to be altered by the participants in any way and the communications that they got from each other were mediated by the experimenters so de facto everybody in each condition had the same social neighborhood so to speak as everyone else any differences in the acceptance of the idea of participating in the internetbased health forum would be the result of the structure of the networks to which people were assigned the key findings show that the more clustered networks yielded more rapid and more extensive adoptions than the random networks across six different trials this conclusion obtained with networks of different size as well centola concludes that the diffusion and adoption of complex health behaviors are best suited to clustered networks rather than casual contact networks and that this would especially be true for behaviors that are costly difficult or contrary to existing social norms the factors to actors approach has two consequences for the massinterpersonal distinction the formal modeling of factors affecting social influence within various network structures has challenged core assumptions in interpersonal communication such as the strength of weak ties and toosimple assumptions that contagion equals influence for complex issues the vector also can have an orienting effect inviting researchers to employ available formal and statistical models that simultaneously treat factors and actors the consequence can be more representative models and tests of the real world of social influences that have both mass processes and interpersonal structures vector 3 how can the efficiencies of mass communication campaigns begin to match the effectiveness of messages tailored to the personastarget recommendation systems offer new venues for normative influence recommendation systems refer to a broad array of input from users of online content included are comments in response to online news products or other social political cultural or entertainment stimuli simple likes and dislikes for these items and other forms of flagging of these same items one can view each of these forms as information indicative of existing social norms approving interpreting and disapproving sociocultural entities as diverse as news articles restaurant menus and commercial products of every stripe in this sense these recommendations are kinds of interpersonal communication although displayed in and through mediated platforms they are and should be studied as representations of the world of social influence through pseudointerpersonal forms this space of horizontal communication representing views by elements of the public has already been widely studied within the communication discipline and even extended to consider the possibility that this arena has the potential to be a habermasian deliberative space rather than an uncivil freeforall there is another form of recommendation system whose connection to the world of interpersonal communication is less obvious and that offers the kind of recommendations provided through algorithmic computations such as collaborative filtering the most wellknown examples of such approaches are the recommendations provided by commercial vendors such as netflix and amazon but what is collaborative filtering and what does it have to do with interpersonal communication collaborative filtering is one element of prediction used to design recommendation engines whose purpose is to offer selections of future items based on a persons past selections and on selections made by others who are computationally similarthat is are structurally similar in some way to the targeted individual this process is a surrogate for direct social influence processes in which individuals actually recommend similar choices by their own choices but do not advocate their recommendations explicitlyonly implicitly recommend them through similar patterns of prior choices many commercial vendors including some news sources use such recommendation algorithms to offer suggested products and content recommendation systems all have the same goal to estimate ratings of items in a universe by a target person even though that item has not been seen by the target user the research on effective recommendation machines in commercial applications has been extensive adomavicius and tuzhilin for example classify these machines into three categories those based on content of the items being recommended those based on collaborative recommendations and hybrid or combined methods using both types of data in contentbased recommendation a user will be recommended items similar to the ones preferred in the past the value of a new item for a user is estimated based on the value of items of similar content as assigned previously by the same user the items recommended are typically those that have a high degree of similarity to past preferences in collaborative recommendation items recommended are those that people with similar tastes and preferences selected in the past the value of a new item is estimated based on the values assigned to that item by other raters who are similar to the user for example in order to recommend a message to a user a collaborative recommendation system tries to find the peers ie those other users that have similar preferences only the messages preferred by the users peers would be recommended collaborative recommendation methods collect ratings of artifacts from many individuals and use nearestneighbor techniques to make recommendations to a user concerning new artifacts the recommender system compares the users ratings to those of other users finds the most similar users based on some criterion of similarity and recommends items that similar users have preferred the types of collaborative recommendation fall into two broad groups memoryand modelbased memorybased collaborative algorithms develop a set of recommendations based on the ratings of other users other users can include all other users or the set of other users who are most similar to the target user in their pattern of previous ratings scholars have proposed a variety of measures of similarity that include different clustering procedures for users weighting of individual ratings and adjustments for variation in rating scale use among many other possibilities modelbased collaborative recommendation is based on various approaches including machine learning bayesian linear regression and others while commercial practices widely deploy collaborative filtering approaches generating much research their application to problems in communication is just beginning our lab has successfully tested a message selection recommendation system for antismoking psas the models have been able to add unique variance to preferences over and above that due to aggregate message content and targeted features the promise of collaborative recommender systems lies in the fact that items selected for a given user are a good fit to the user because a clone of the target person hs previously selected or positively rated them the process of tailoring the choice is automatic once the prediction algorithm is developed so the process optimizes the effectiveness of tailored choice with the efficiency of automatic selection from a pool of choices the collaborative filtering process takes the place of personalized recommendations delivered by peers with similar tastes miller and steinbergs approach to interpersonal communication highlighted the importance of the tailoring of information in unique ways to those with whom personal relationships developed the personspecific nature of communication made trust possible subsequent work in tailored communication made clear that tailoring made for more effective forms of social influence but tailoring is intensive in terms of information gathering and requires the cooperation of the person targeted in tailoring it is very effective but costly and inefficient algorithmbased recommendation systems are in some senses substitutes for the informationgathering and fitting that takes place in more traditional interpersonal tailoring allowing the selection of information wellsuited to the target the fact that a version of tailoring is able to be deployed automatically means that the effectiveness of influence delivered at the interpersonal level using surrogates of personspecific selection can be accomplished efficiently with much larger audiences the ideal of a mass distribution of personspecific choices can at least be entertained vector 4 how does the content of interpersonal communication change as it moves from traditional personal exchanges to broader audiences social media messages can be narrowcast or broadcast social media allow options for messaging that are narrowly targeted or broadly targeted even on the same platform in the presocial media era interpersonal communication was to a welldefined often wellknown specific other whose needs like and dislikes and other idiosyncracies were clear to the communicator as interpersonal communication has migrated into the social media sphere targets can be more amorphous sometimes quite specific and personal and at other times quite extensive friends on social media can be more broadly defined than friends presocial media effective and ineffective messaging choices depend on appropriate targeting failing to take the distinction into account can create unhappy results interpersonally and at macrosocial levels as well the distinction also affects the decision of a potential sender to transmit or retransmit information in this sense what has traditionally been an interpersonal decision becomes a decision with implications for largerscale distribution we have all come to appreciate that the distinctions between mass and interpersonal communication are becoming increasingly blurred mass communication has always been associated with broadcastingsending messages to a large number of undifferentiated individuals facebook and twitter transmissions are mostly broadcasting interpersonal communication has always been associated with narrowcasting berger examined the range of motivations that drive individuals to share information via word of mouth and in a delightful bit of wordplay word of mouse he concluded that the motivations for information sharing included selfenhancement that is the rewards of selfdisclosure and sharing ones positive experiences emotion presenting intense positive or negative events that allow catharsis disambiguation dissonance reduction empathy and bonding utility leading to clarification of ambiguous events simplification of complex events enacting altruism and future quid pro quo and accessibility offering topofthemind or salient events ideas and commonalities with others bergers useful delineation of motivations for sharing information led to the speculation that people would communicate differently to broader and narrower audiences this observation is certainly commonsensical but takes on greater urgency in the era of mediated social interaction in a series of five studies the authors showed that selfpresentation of negative information was reduced in broadcasting versus narrowcasting conditions and that useful information was more likely to be shared with specific narrow targets this latter effect was ameliorated by increasing the psychological connection to the larger audience through name listing despite the analogue nature of the experimental tests the research consistently shows that what is communicated depends on the size and closeness of the targeted audience in dissertation work kim obtained results on retransmission of health news stories consistent with barasch and bergers hypotheses but in more naturalistic contexts and with very different topics kim followed the retransmission of 760 health news stories from new york times data of sending those stories via email to targeted individuals versus posting them on social media sources such as facebook and twitter he concluded that stories sent to specific sources included more efficacy information and were coded as more useful than when the targets were broader stories with emotionally evocative information were more likely to go to social media than email targets as were stories with exemplars health news that was novel tended to be shared via email while novel health stories were less likely to be posted on social media together the results from barasch and berger and from kim make clear that when accounting for the breadth of ones informational targets the content of what is to be communicated as well as the motivations of the sender and target must come into play what is not at issue is the notion that in the modern world of social media interpersonal sharing of information is common and of potentially greater impact than the presocial media era what exactly gets communicated and by whom with what range of targets is a crucial issue necessitating intensive research as we try to understand the effectiveness of social media narrowly or broadly cast people seem to be conscious of the personalness of their communication even in the face of mediated platforms that mute the character and visibility of the target in the new media world where interpersonal communication contributes substantially to public information exposure and potential influence what is communicated narrowly through platforms designating specific others and what is communicated broadly to a wider spectrum of others is more important than ever as researchers such as berger and kim seek to understand the messages that circulate widely with increased probability of sharing the platforms that senders use and the motives driving them come into play conclusion the new world of computational communication science social media and big data are remaking what counts as interpersonal communication and social and normative influence the size and dynamics of our interpersonal data allow us to evaluate or reevaluate existing assumptions about connectivity exposure and social influence new methods for modeling allow the testing of both persons and variables in more complex combinations than could have been imagined even a couple of decades ago tools such as collaborative filtering create pseudopeers providing advice to individuals that is tailored to their past choices the interplay of media and interpersonal influence has changed at its core and continues to do so these lines of research are the objects of inquiry in many different fields vibrant and relevant communication research needs to be open to these developments because the discipline has studied these questions in some cases for decades we will continue to contribute more complete and accurate answers by remaining open to the widest possible array of methods and models

simultaneous developments in big data social media and computational social science have set the stage for how we think about and understand interpersonal and mass communication this article explores some of the ways that these developments generate 4 hypothetical vectorsdirections into the next generation of communication research these vectors include developments in network analysis modeling interpersonal and social influence recommendation systems and the blurring of distinctions between interpersonal and mass audiences through narrowcasting and broadcasting the methods and research in these arenas are occurring in areas outside the typical boundaries of the communication discipline but engage classic substantive questions in mass and interpersonal communication

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introduction data to the world health organization on may 3 2021 the number of confirmed cases of covid19 in the world was 152534452 with 3198528 people dying in indonesia there were 1682004 confirmed positive cases of covid19 with a total of 1535491 recovered and 45949 died covid19 has become a serious world problem because the number of covid19 cases is increasing daily covid19 affects everyone regardless of age or gender covid19 has been categorized as a global pandemic the increase in the number of cases of covid19 occurs in a speedy time so it requires handling factors that can affect health are behavioral and nonbehavioral according to green health behavior can be influenced by three factors namely predisposing factors enabling factors and reinforcing factors then when viewed from the predisposing factors the community has sociodemographic factors such as differences in age gender education occupation and background and reinforcing elements such as family support and support from community leaders based on these factors can influence peoples behavior so for the prevention of covid19 it is necessary to have family support and the support of community leaders family support is a form of attitude or action of family members to protect from stressors the support that the family can give is in the form of informational appreciation emotional and instrumental support the support obtained can be seen from information support where families look for a lot of information about covid provide understanding to family members provide advice and remind them every time they leave the house to comply with health protocols such as wearing masks and carrying hand sanitizer in instrumental support the family can provide equipment for the prevention of covid19 such as masks hand sanitizer vitamins etc emotional support namely giving attention encouragement and enthusiasm to consistently apply the health protocol and the last one is appreciation support where families give each other praise or reward for implementing the health protocol abidin explained that family functions have an essential role in maintaining the health of their family members they provide a support system financial balance and health control so that it affects the health problems faced family participation in health protocols still needs to be improved and improved families must be more sensitive in facilitating and always apply suitable health protocols family support is an attitude action and acceptance of the family support can come from other people who are close where the form of support can be in the form of information certain behaviors or materials that can make individuals feel loved cared for and loved a research shows a significant effect between family support and covid19 prevention behavior in the jabodetabek community from 424 respondents 183 respondents received adequate family support around 661 of them have good covid19 prevention behavior the support of community leaders is a very dominant factor in the implementation of clean and healthy living behavior because the role of community leaders in efforts to prevent covid19 is significant the part of these community leaders is perfect and essential social support in the context of avoiding covid19 community leaders have a significant role because in essence community leaders are people who have a substantial role in a community group and have power namely the ability to influence other people or groups according to their wishes the part of community leaders among others are social controllers guardians and enforcers of values and norms that apply in society in addition community leaders also play a role in solving various problems that occur community leaders must provide support guidance motivation and direction to the community community leaders also act as support providers during this pandemic community leaders also play an essential role in preventing the spread of covid19 through proper management of social distancing using masks not making physical contact maintaining a minimum distance of 2 meters diligently washing hands using soap and running water carrying antiseptics using hand tools selffeeding and other measures that can prevent the spread of covid19 the research that has been done is that there is an influence of community leaders on community compliance in preventing covid19 in the community with a pvalue of 0040 research conducted by lilis a public figure on the prevention of covid19 is known to have a less than good role by 50 respondents in comparison their behavior towards preventing the transmission of covid19 is mostly good by 67 respondents based on this a study was conducted on how research carried out the relationship between family support and community leader support with covid19 prevention behavior research method this study uses a quantitative method with a crosssectional design and sampling technique with purposive sampling with inclusion criteria willing to become respondents by filling out informed consent aged over 18 years indonesian residents can access google forms and understand indonesian based on this 2700 samples meet the inclusion criteria a semiaprianti haikal yusthin meriantti manglapy muhammad iqbal fakultas kesehatan universitas dian nuswantoro corresponding author email doi 138 structured online questionnaire was developed using the kobotoolbox with a consent form also available the researcher sent respondents questionnaire links via email whatsapp facebook or other social media the community leaders support variable questions consist of 11 questions with the answer choices of never rarely often and very often while the family support questions consist of 10 questions with answers never rarely often and very often the questions have been tested for validity and reliability the researcher analyzed the data descriptively to see the distribution of frequency and percentage of support from community leaders and family support the following analysis uses the spearman rank test to determine the relationship of each variable to the covid19 prevention behavior with a significance value of 5 this study approved by ethical research committee from universitas dian nuswantoro no 272eakepkfkesudinusvi2022 results based on the data that has been collected from 2700 respondents it is found that the distribution of the frequency and percentage of the variables of community support and family support is found the frequency distribution and rate of community leaders support variables are listed in table 1 on the next page based on the table the research found that as many as 63 of respondents felt they had never received information or explanation about how to increase their immune system and community leaders had never reminded 53 of respondents to wash their hands with soap regularly when traveling out of the house and community leaders never urges residents who have just returned from out of town to report and selfisolate the distribution of the frequency and percentage of family support variables is shown in table 2 based on the table research also found that their families had never asked 62 of respondents about fever flu or other symptoms of covid19 that they had experienced were experiencing or felt the current condition a total of 33 of respondents families explained how to spread covid19 and 31 recommended that i stay at home if there is no urgent need the analysis results see the relationship between the variables of community support and family support can also be seen in table 3 based on the table the research found that the support of community leaders with behavior was 0296 with a sig of 0000 it can be concluded that there is a significant correlation with the correlation coefficient very high strongperfect while on the family support variable with behavior the result is 0402 with a sig of 0000 it can be concluded that there is a significant correlation with an extremeperfect correlation coefficient discussion the study results show a strong relationship between the support of community leaders and families with covid19 prevention behavior this is in line with research in the city of semarang which states that community leaders have an essential role in social distancing behavior during the covid19 pandemic another study in depok city stated that differently public compliance with largescale social restriction policies in preventing covid19 was not directly related to community leaders in the area most respondents stated that the role of community leaders was not good namely 545 compliance with the application of health protocols in respondents who noted the role of community leaders was good was 670 this proves that the part of community leaders is significant in supporting community compliance in behavior including using masks when leaving the house constantly washing hands when going home and keeping a distance when doing activities outside the home research from nigeria showed that support from religious leaders helped to reinforce the maintenance of handwashing disinfection of hands and surfaces and social distancing while community based opinion groups helped intensify covid19 risk communication efforts the community needs the role of community leaders in complying with health protocols because not all people already have a good understanding of 3m community leaders help provide knowledge to the community and socialize government programs so that other people can also be exposed to the latest information in preventing covid19 in addition to community leaders strict regulations are also needed if people violate this is required to have a deterrent effect in the morning for those who disobey this covid19 prevention effort needs the involvement of various parties both critical components in the community and community leaders themselves because of the habit of people who are more willing to listen to advice from those told in the community support from community leaders can be in the form of emotional support appreciation support instrumental support and informative support covid19s global presence and social transmission pathways require social and community responses this may be particularly important to reach margin analyzed populations and to support equityinformed responses aligning previous community engagement experience with current covid19 communitybased strategy recommendations highlights how communities can play important and active roles in prevention and control countries worldwide are encouraged to assess existing community engagement structures and use community engagement approaches to support contextually specific acceptable and appropriate covid19 prevention and control measures the community plays a subordinate role in administrative management systems the community in china is a functional part of state power and a fundamental unit covered by the state system another factor that influences covid19 prevention behavior is family support family support is support obtained in the form of informational and emotional the family always reminds the family to wash their hands and if they have to leave the house wear a mask keep a distance and bring hand sanitizer the role of the family is significant in implementing health protocols to prevent covid19 this is because during the pandemic most activities are centered from their respective homes therefore the family environment has a significant role in maintaining and improving covid19 prevention behavior this is in line with research that there is a significant relationship between family support and covid19 prevention behavior the family has an important role and responsibility for the health of themselves and other members families can provide vitamins fruits and vegetables to increase immunity and provide masks hand sanitizer and others families also convey information remind and are motivated to implement covid19 prevention behavior consistently from the research and supporting theories above a study can conclude that family support is essential to covid19 prevention behavior this is because if family members receive good support from the family it will produce good behavior research from china showed that strong support family plays an important role in improving individuals attitudes about sosial distancing and maintaining positive mental health during the epidemic according to friedman the family plays a critical role in shaping the character that a person can manage health in terms of how the family recognizes problems health the ability to make decisions provide aprianti haikal yusthin meriantti manglapy muhammad iqbal fakultas kesehatan universitas dian nuswantoro corresponding author email care improve and maintain a healthy home environment and be able to find the health facilities needed one of the functions of the family in the health sector is to keep the health status of family members as high as possible from prevention to rehabilitation through family support so that the existence of family support is the key to success in controlling covid 19 prevention behavior this is by research that explains that family support is an essential factor that must exist in the health care of family members starting with emotional material and information support according to bailon and maglaya explaining that in the family there are five family health care tasks which consist first the family must be able to recognize the problem where the family must understand the covid 19 disease its causes signs and symptoms its spread prevention and even treatment the second task is that the family is required to make the right decisions in handling covid 19 in their family environment one of which is the effort in prevention and the willingness to take proper care of family members who are positive for covid 19 the third task the family must be able to provide appropriate treatment efforts for members who are positive for covid 19 provide support for selfisolation and provide the availability of infrastructure in implementing covid 19 prevention behavior fourth families can modify the physical and psychological environment in this case the family must be able to create a clean and safe environment with room ventilation besides that the family can make a calm and comfortable susana in the family even in conditions of work study and worship at home in the fifth task the family must be able to choose the suitable health facilities around the family to treat family members with signs and symptoms of covid 19 study from china quality of life among chinese parents of young children during the covid19 pandemic and examined the relationship between job changes family conflict and quality of life our findings suggested that individuals with more frequent marital conflict and parentchild conflict had worse quality of life we found that job changes significantly enhanced the negative correlation between marital conflict and quality of life but did not significantly buffer the negative relationship between parentchild conflict and quality of life among the whole sample in addition both of the moderation effects differed across gender and family structure and they were only significant for fathers and onechild family conclusion the study results show a strong and significant relationship between the variables of community leader support and family support on covid19 prevention behavior family support that is still lacking is that families have never been asked about symptoms of covid19 while support from community leaders that is lacking is that they never get information or explanations on how to increase body immunity based on this there should be a need for capacity building about the need to increase body immunity during the covid19 pandemic as well as the need to provide so that families understand the signs and symptoms of covid19 references afolabi a a ilesanmi o s

background covid19 is a public health problem and has been declared a pandemic by the who in indonesia there were 1682004 confirmed positive cases of covid19 with a total of 1535491 913 recovering and 45949 27 deaths behaviorreinforcing factors namely support from community leaders and families have an important role in preventing covid19 in indonesiato analyze the relationship between the support of community leaders and family support on covid19 prevention behavior method a quantitative method with a crosssectional design and the sampling technique used was purposive sampling with inclusion criteria being willing to become respondents by filling in informed consent aged over 18 years indonesian residents could access the google form two thousand seven hundred samples meet the inclusion criteria results the results showed that there was a strong and significant relationship between the variables of community leader support p value 0001 r 0296 and family support p value 0001 r 0402 on covid19 prevention behaviorwe need to strengthen the capacity of community leaders and families to improve their behavior to prevent covid19 in indonesia

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introduction the nigerian agricultural sector is dominated by smallscale farmers whose farms vary between 010 and 599 hectares in size and constitute about 804 of all the 29800 million farm holdings in nigeria their farmers used traditional technologies called hoecutlass culture and their capital structure is in the form of small tools and predominant usage of family labor human labor is about the only main source of labor available to smallholder farmers in nigeria smallholder farmers contribute over 85 of domestic agricultural output in nigeria hence human labor accounts for domestic food supply in nigeria therefore the need to continue supplying food for the evergrowing nigerian population anchors on human labor issn 02150212 eissn 24069574 doi 1022302iccrijurpelitaperkebunanv39i3548 productivity in nigerian agriculture hired labor is predominantly used in fact it carries 88 of the total labor used on farms apart from hired labor the other types of labor that could be employed are family labor and cooperative labor the availability of labor has been found to have an impact on planting precision better weed control timely harvesting and crop processing therefore labor is a major constraint in peasant production especially during planting weeding and harvesting rapid growth in population which increases farm labor supply exerts so much pressure on land and reduces farm size per hectare empirical evidence has shown that available labor force comprised mostly of old people to the exclusion of young men and women within the active working age thus having a negative impact on agricultural productivity this is because the role of youths in agricultural production cannot be overemphasized idiakeochei assessed farm labor constraints in edo state nigeria the study identified the labor types used for farming activities and considered the constraints farmers encountered in using labor the authors purposely selected four villages and sampled one hundred and eight farmers in edo state descriptive and inferential statistical analytical tools were used the farm activities include clearing weeding planting harvesting and chemical spraying processing transportation storage and fertilizer application for clearing activity 407 family labor and 315 of hired labor was used forty three percent of family labor and thirty one percent of hired labor was used for weeding activity in chemical spraying 380 of family labor and 407 of hired labor was used in all most of the farmers used hired and family labor for most of their farming activities the constraints majorly encountered were high cost of labor and lack of finance the study recommended that farmers should form cooperatives to assist each other in labor support oluyole et al examined the labor structure and its determinants among cocoa farmers in nigeria one hundred cocoa farmers were selected in the study area using stratified sampling technique eighty percent of the respondents are smallholder farmers having between 15 hectares of cocoa farm ninety four percent of the cocoa farmers used hired labor for farm clearing while 610 and 51 used family labor for harvesting and on farm cocoa processing respectively the major determinants of labor use among cocoa farmers were wage rate farm size farm income the study recommended that infrastructural facilities should be provided in rural southwest to encourage youth involvement in agriculture with the foregoing it could be observed that human labor plays a very significant role in agricultural development especially in the developing countries in which the level of technological development is still very low in view of the importance of labor in agricultural production this study was designed to investigate the structure and use pattern of farm labor in the study area materials and methods study area the sampling technique multistage random sampling was used to select cocoa farmers ondo east local government area was purposively selected from the state and from the lga laagba community was also purposively selected because cocoa farmers are mostly concentrated in the community simple random sampling technique was used to collect data from a total of 144 farmers randomly selected from the community data were collected from the respondents with the aid of structured questionnaires and the data obtained from the questionnaire were analyzed using descriptive analysis descriptive statistics was used to describe the socioeconomic characteristics of the farmers as well as the structure and use of labor pattern in the study area analytical procedure descriptive statistics was used to describe the socioeconomic characteristics of the farmers as well as the structure and use of labor patterns in the study area results and discussion the result of the socioeconomic characteristics of the farmers is shown in table 1 the table shows that 7509 of the total respondents are above 50 years of age indicating that the proportion of old people among the respondents is very high meanwhile only 250 of the total respondents were 50 years and below the lowness in the proportion of the youths is a bad pointer to cocoa production efficiency as younger farmers are more active on farm work than the aged ones ifeoma and oluyole et al affirmed that the provision of infrastructure in rural areas would attract more youth to the rural areas table 1 also shows that 792 of the respondents were males this is quite obvious in that farm work is a tedious work and is only men that could cope effectively with it apart from this most of the farms were inherited and some traditional cultures permit only the male children to inherit farms as regards the educational level of the respondents the result of the analysis shows that 751 of the respondents were having formal education this would improve the efficiency of the farmers in as much that literate farmers would find it easier to adopt new technologies on cocoa than the illiterate ones the analysis on farm size shows that 667 of the respondents had a farm size of 5 hectares and below which shows that most of the farmers are small scale farmers table 1 also shows that 500 of the farmers had the age of their farms greater than 30 years showing that most of the farms are old and hence the farms productivity would reduce therefore such farms need to be rehabilitated this is a good pointer to increased productivity table 1 also revealed that the majority of the farmers had purchased farms while just 125 inherited their farms table 2 shows the structure of labor according to the different types of labor used for different activities in cocoa farming the table shows that contract type of labor is majorly used for most activities in cocoa farming however cooperative labor was seldom used for any activity showing that cooperative labor is no more utilized in cocoa farming in the study area family labor is also utilized for all activities but at different magnitudes activities such as land clearing planting weeding application of chemicals removal of mistletoes harvesting of cocoa pods conveyance of cocoa pods to the pod breaking point breaking of cocoa pods and conveyance of cocoa beans to the point of fermentation were majorly carried out by contract labor however activities such as drying of cocoa beans parking of dried cocoa beans and preservation of cocoa beans were majorly carried out with family labor table 3 shows the distribution of the labor used for cocoa farm activities based on the gender of the labor the table shows that male labor was mostly utilized for all the activities as indicated by most respondents on the other hand female labor were sparingly utilized for some activities such as land clearing weeding application of chemicals application of fertilizer and harvesting of cocoa pods however female labor was mostly used for conveyance of cocoa pods to the point of pod breaking breaking of cocoa pods conveyance of cocoa beans to the spot for fermentation and drying of cocoa beans of chemicals conveyance of cocoa beans to fermentation spot removal of mistletoes harvesting of cocoa pods and planting family labor is mostly used for drying of cocoa beans parking of dried cocoa beans and preservation of cocoa beans however cooperative labor is no more used as a form of labor in the study area the use of contract labor reduces the income of farmers as money that is supposed to be gotten as income has been expended on hiring labor funds should be made available to farmers to contract labor and also the need to use equipment and machineries to reduce drudgery technically farmers would be able to do more work and do it on time as contract labor is available economically the cost of hired labor would eat into the income that farmers are supposed to earn from their farming business conclusions the study was carried out on the structure and use pattern of labor among cocoa farmers the study found out that labor could be structured according to the types of labor and according to the gender of the labor the study further revealed that contract labor is mostly used for activities such as breaking of cocoa pods conveyance of cocoa pods to the point of pod breaking weeding application

smallholder farmers contribute over 85 of domestic agricultural output in nigeria hence human labor accounts for the domestic food supply in nigeria therefore the need to continue supplying food for the evergrowing nigerian population anchors on human labor productivity in view of the importance of labor in agricultural production this study was designed to investigate the structure and use pattern of farm labor in the study area the study was carried out in ondo state nigeria a multistage sampling technique was used to collect data from 160 farmers after sorting for missing data 144 cocoa farmers data were used for analysis in this study seventyfive percent of the total respondents were above 50 years of age and about 250 of the total respondents were 50 years and below the majority 792 of the farmers were men also 751 of the respondents had a formal level of education in the study contract type of labor is majorly used for most activities in cocoa farming while cooperative labor was seldomly used activities such as land clearing 750 planting 833 weeding 958 application of chemicals 917 removal of mistletoes 875 harvesting of cocoa pods 875 conveyance of cocoa pods to the pod breaking point 958 breaking of cocoa pods 100 and conveyance of cocoa beans to the point of fermentation 883 were majorly carried out by contract labor male labor was mostly utilized for all the activities as indicated by most farmers female labor was sparingly utilized for some activities such as land clearing 83 planting 0 application of chemicals 83 spraying of chemicals 42 removal of mistletoes 0 and harvesting of cocoa pods 125 the study recommended that funds should be made available to farmers to engage in contract labor and also there should be the need to use equipment and machinery to reduce drudgery

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introduction current uk policies designed to reduce health inequalities through preventing noncommunicable disease are based largely on an individualistic epistemology the dominant epistemic assumption in the implementation of public health programmes is that human behaviour is a major determinant of health and that behaviour is largely a matter of individual choice individuals are therefore responsible for their own health and for making healthrelated behaviour changes reliance on such simple linear causal explanations and of proximal risk factors in the causes of disease has consistently led to a focus on changing individual behaviour 1 2 3 4 5 6 we argue for a greater consideration of how more complex relational and dynamic factors beyond just the individual impact on health a number of disciplines including sociology 7 history 8 biology 9 neuroscience 10 philosophy 11 and psychology 12 have produced evidence of potential mechanisms the existence of interactions with place and social context power economics institutional relationships and biology over time and across generations have been widely cited 2 13 14 15 16 17 18 developments in biology include epigenetics 9 and the neuropsychology of executive functioning 12 and both are highly relevant to understanding how health inequalities are sustained these remain largely outside the purview of current policy interest while some of this evidence may sometimes find its way into policy statements it is seldom realized in interventions 31920 the six documents chosen for analysis in the study demonstrate that the main assumptions underpinning interventions to address health inequalities have not changed significantly since the mid1970s and remain focussed on individual responsibility the policy interventions put forward reflect this partial view of the totality of the evidence about the generation and amelioration of health inequalities and the social patterning of disease we highlight this constancy and propose initial steps to change the dominant view with an alternative approach we argue that the adoption of a dynamic relational epistemology is fundamental to a fuller realization of causal mechanisms and for the design and implementation of more effective interventions to address health inequalities the success of tobacco control in the uk stems from its base in the dynamic and relational aspects of practices linked to tobacco consumption this includes as well as individual choices both the role of markets and advertising and explicit action to counteract dirty tricks of the tobacco industry over time by dynamic we refer to changes over time and by relational we mean the need to consider the relationships involved in the practice of smoking which go beyond the individual just physically smoking a cigarette three themes are central to this approach power in exploring the relations between groups and between groups and institutions in society history in investigating how relations change or are sustained over time and the dynamic relationship between the biological and the social we explore these themes below we first identify evidence of the importance of relational and dynamic factors in understanding the problem of health inequalities second we examine policy approaches over several decades concerning health inequalities demonstrating the repeated focus on individual behaviour change finally we develop a set of questions which highlight this broader perspective to sensitize policymakers service developers and researchers when developing policies to address health inequalities moving towards more dynamic thinking power history and the relationship between the biological and the social power health inequalities are seldom described in policy documents in terms of power relations and competition for scarce resources between classes genders and ethnic groups or the mechanistic consequences of these power relations on biology the idea of empowering the individual to make healthier choices is a central tenet of most policy proposals but discussions of the impact of power dynamics between groups and institutions are overlooked underplayed or ignored the interactions and intersections between different groups are essential to the production of social structures and forms of inequality power is a central part of these interactions but individualistic forms of analysis are poor at elucidating such dynamics the focus on individual lifestyles for example precludes any meaningful analysis of the power dynamics in which individuals are involved and that in turn influence the types of choices they make power relations are intrinsic to social life 21 at their most basic power relations affect peoples access to resources including health services and determine the lived experience of discrimination disadvantage bullying harassment and social exclusion they influence educational and employment opportunities including the type of work people are able to do and their contracts of employment the associations between these things and their links to health inequalities have been known for decades 22 but the mechanisms of their direct impacts on peoples lives have not featured in government policy documents of course attempts to promote equality have been part of government policy but these have tended to focus on protected characteristics rather than on the nature of the damaging or health protecting nature of the relations themselves 23 following sen we should consider the degree to which health policy and its implementation enhance the capacity for health for example 24 the historical perspective likewise history and a longer time perspective are largely absent from policy discussions of health inequalities insofar as history appears it is in terms of a progressive narrative about public health advances since the 19th century 25 26 27 there is a form of institutional memory loss evident in policy where similar ideas are rediscovered and recycled over a relatively short period of time 20 and policies demonstrate historical amnesia about the processes which have led to contemporary health inequalities this leads to for example the assumption that health inequalities can be explained by current societal conditions alone and ignores endemic social arrangements which persist over decades and longer it leads to overoptimistic expectations of performance of likely effective programmes with rapid payback being expected and public health initiatives facing cuts if they do not produce results swiftly an historical perspective in policy and research informs a clearer understanding of the longerterm intertwining causes construction and maintenance of health inequalities according to raadschelders all too often history … is regarded as a past that can be recorded for its own sake but has little relevance to contemporary challenges this view of history is the product of a diminished and anemic sense of time resulting from organizing the past as a series of events that inexorably lead up to the present in a linear fashion 28 we argue that bringing a historical perspective provides a richer understanding of causation that recognizes the layered nature of how the past leaves its mark on the ways health inequalities are reproduced over time this perspective helps to illuminate the tools available to policymakers and the interventions which could have a lasting impact 29 30 social epidemiology has long shown recurring patterns of health disadvantage geographically lasting generations in many towns and cities in the uk notwithstanding policy efforts these patterns have remained stubbornly fixed generation on generation the consequences of the historical reproduction patterns of health differences remain significantly unchanged it is no longer infectious disease that causes premature mortality in the poorer parts of the country but noncommunicable disease absolute death rates are lower than the 19th century but relative differences remain meanwhile policy is fixated on simple behavioural solutions not on the reasons why the structural differences are so intractable 31 the biological and the social descriptions of the role of biology and its interplay with social factors in producing population patterns of disease was associated originally with engel 3233 and later with barker 34 35 36 37 the relationship across generations between the environment and biological moderation of gene expression is now providing new evidence of interacting social and biological mechanisms underlying the transgenerational transmission of inequalities in health 238 leading to a reconsideration of crossgenerational effects on poor health and amelioration or exacerbation through social conditions it suggests a reemphasis on programmes to support maternal foetal and child health as a key strategy in breaking the cycle of inequality in health policy we now turn to an examination of existing policy approaches to addressing health inequalities we review the extent to which evidence of the mechanisms considered above are informing policy recommendations we reviewed six key policy documents published by the uk government or the english department of health between 1976 and 2010 25273942 using bacchis whats the problem represented to be framework for policy analysis 4344 the interrogation of documents using this framework allows for comparisons over time as well as the development of an understanding of individual documents and the assumptions which underpin policy rhetoric this examination demonstrated a longstanding continued focus on individual behaviour in strategies to reduce health inequalities and more generally to prevent noncommunicable disease successive documents did show increasing reference to the impact of a wide range of factors on health nevertheless these were rarely then used for policy and intervention development or for the evaluation of programmes in both individualism remained paramount for example saving lives our healthier nation argued that the causes of illhealth are many a complex interaction between personal social economic and environmental table 1 bacchis 4344 whats the problem represented to be framework for policy analysis questions in the wpr framework aim of question 1 what is the problem represented to be in a specific policy to understand how a phenomenon comes to be understood as a problem in social policy including the causes of the problem what presuppositions or assumptions underlie this representation of the problem to understand the discursive practices surrounding the representation of the problem ie what can and cannot be said about a problem how has this representation come about to understand the history of the development of understanding of a problem what is left unproblematic in this problem representation to identify silences and highlight explanations which are not discussed and to consider why these views might be excluded from this particular representation of the problem what effects are produced by this representation of the problem to understand the creation of subjectivities produced by representations of problems in policies how individuals and population groups are conceptualized 6 howwhere is this representation of the problem produced disseminated and defended how has it been questioned disrupted and replaced to identify where this representation of the problem has been reproduced including in other policy documents the reasons for these variations are complex the government does not believe there is any panaceahere or elsewhere in the world either in terms of a full explanation or a single action which will eradicate the problem but neither difficulty is a reason for inertia progress can be made on three fronts • first through the continued general pursuit of greater economic prosperity and social wellbeing • follow a balanced diet with plenty of fruit and vegetables • keep physically active • manage stress by for example talking things through and making time to relax • if you drink alcohol do so in moderation • cover up in the sun and protect children from sunburn • practise safer sex • take up cancer screening opportunities • be safe on the roads follow the highway code • learn the first aid abcairways breathing circulation 20 we also need to look at ways to make 35 the new approaches set out in this 12 when it comes to improving peoples health and wellbeing we need a different approach we cannot just ban everything lecture people or deliver initiatives to the public this is not justified and will not work nor should we have onesizefitsall policies that often leave the poorest in our society to struggle this includes changing social norms and default options so that healthier choices are easier for people to make there is significant scope to use approaches that harness the latest factors yet the main approach offered to reducing health inequalities focused on ensuring individuals are informed about risks to their health as in most cases it is for the individual to decide whether to take the risk the responsibility falls to the individual to make the least or less risky decision here and elsewhere there is a disconnect between policy rhetoric about causes and recommended remedial actions evidence about the wider determinants of health is used to justify interventions on health inequalities which then paradoxically concentrate on individual behaviour rather than addressing the wider determinants themselves certain groups are viewed as lacking the capacity to negotiate successfully the effects of these determinants demonstrated by their proclivity for making unhealthy choices thus a number of interventions focus on the provision of opportunities to enable individuals to improve their current social and economic situation through for example education training and work opportunities 41 a common argument is that by embracing such opportunities people will have more control over their lives which would result in them being more interested in their health and therefore more likely to make healthy choices 42 the idea of the individual as a chooser dominates these discussions 45 this idea shapes the understanding of the problem as one of individuals in themselves being incapable of making healthy choices unless steered by interventions which change their attributes as individuals who will then change their behaviours the result has been described as lifestyle drift 46 in policy measures and lifestyle push from politicians and markets 20 this focus on the individual effectively neutralizes the effects of social context and airbrushes out of the picture a number of important contextual agents and institutionsspecifically the state markets and industry so the state and its retreat from interventionism consequent on neoliberal economic thinking the role of markets and the health damaging roles of the food advertising and alcohol industries are conveniently put to one side 47 actions addressing these actors and getting them to change are not central to contemporary policy focus the alternative view that the state has a duty to enable as far as possible everyone to have a fair opportunity to live a healthy life and that governments should try to remove inequalities that affect disadvantaged groups or individuals including a duty of proportionate regulation has not always been a dominant motif in policy documents 2348 following sen among others we would emphasize the importance of addressing how public and private actions and organizations shape the capability of individuals to make positive choices regarding their health 49 for example obesity as a significant public health threat and an important cause of health inequalities has become engrained in policy discourse in the last decade and a half 19 numerous policy documents and a raft of guidance have been produced on the topic including the recent 2016 childhood obesity strategy 195051 yet success in curbing obesity has been minimal this is despite compelling evidence that an obesogenic environment is generating the obesity epidemic 1550 and that its structure and dynamics should be the target for arresting the epidemic policy solutions have persistently focused on proximal determinants most prominently individual diet and exercise 52 similarly with alcohol consumption the focus remains on individual capability and how to ensure individuals make healthy choices 453 reinforced by statements by ministers past and present 54 a most important exception to this perspective was the foresight report on tackling obesities commissioned by the government office for science and published in 2007 the report presented evidence demonstrating the social and biological complexity of obesity and emphasized the need to intervene beyond individuals into processes of governance and decisionmaking to stem rising obesity and the necessity of evaluation the deceptively simple issue of encouraging physical activity and modifying dietary habits in reality raises complex social and economic questions about the need to reshape public policy in food production food manufacturing healthcare retail education culture and trade 15 the midterm review of the report at 3 years drew attention to stakeholder inertia in adopting more accurately informed perspectives of the roles of the individual and of society can hinder the development of strategies and interventions to manage the current and future obesity epidemic implementation of the report was terminated long before effects could be appropriately evaluated there are a small number of other examples where what we refer to as a relational approach has found its way into the public domain for example the nice public health guidelines on community engagement 55 social and emotional wellbeing of children 5657 healthy working conditions 58 preventing harmful drinking 59 and preventing cardiovascular disease 60 not only were these exceptions but also in the case of the cardiovascular disease and harmful drinking guidelines they were rejected by ministers one of the implications of the focus on individuals and on behaviour change is that it pushes policy interest towards proximal risk factors and the role of these in the aetiology of noncommunicable disease in particular however knowledge about risk and its links to behaviour in causal pathways of disease do not on their own provide any solutions as to how to change those things for example knowledge about the dangers of exposure to cigarette smoke or alcohol suggests that reducing exposure would be beneficial but does not explain how to achieve that a focus on the dynamics of the systems involved in the relations between industry markets advertising human preferences group behaviour as well as the individual actor provides a richer theoretical frame for developing and evaluating integrated programmes to address the problem this has been the case with the success of tobacco control in the uk we advocate a similar how to approach with respect to obesity alcohol and physical activity 31 discussion main finding of this study we have highlighted extensive crossdisciplinary evidence about the relational nature of health inequalities and causal mechanisms beyond individual choice and responsibility we have shown that this evidence rarely follows through to preventive programmes what is already known on this topic health inequalities persist in the uk driven largely by the social patterning of noncommunicable disease interventions designed to reduce health inequalities are still primarily shaped by a focus on individual behaviour yet there is substantial evidence of supraindividualistic and relational mechanisms relevant to health inequalities from a range of disciplines including sociology history biology neuroscience philosophy and psychology this evidence is not yet applied systematically in policy or action where it may inform the design and implementation of more effective policies what this study adds a perspective recognizing the complexity of the systems in which public health must practice including its politics shifts us away from narrowly focussed linear behaviour change models to a focus on reflexive systems and the power of players in those systems 61 62 63 64 65 prioritizing the study of relationships to highlight the type of evidence being used to justify solutions and to identify any gaps particularly around wider determinants of health is evidence included relating to the influence of the wider determinants of health evidence over time 3 have the recommended approaches to addressing health inequalities appeared in policy documents in the last 2 5 10 and 15 years to consider previous attempts to address health inequalities to highlight that this is a problem with a long history rather than a contemporary issue and to draw attention to both evidence of effectnoneffect and lack of testing over time to emphasise the importance of the dynamism of the problem of health inequalities from a historical perspective and to acknowledge the interface between the social and the biological 10 are there any considerations of the relationships between social and biological processes between people and groups of people how these relationships are sustained and change over time and acknowledging links between power time and the biological and social we suggest will bring into the discourse a wider perspective to complement the existing focus on individual behaviour change in order to move towards integrating this thinking into policy considerations we have developed a set of questions to use in writing and critiquing policy papers which aim to ensure that proposed interventions to address health inequalities take into account relational and dynamic factors as well as individual behaviour these questions can be used not only by policymakers and service developers but also by academic researchers to ensure that relational and dynamic factors are brought to the forefront of policy evaluation limitations of this study this is not a comprehensive or systematic review of all documents relating to english policy recommendations to address health inequalities conclusion current policies dominating efforts to reduce health inequalities through prevention of noncommunicable disease target individual behaviour change and have not worked well we have argued that an individualistic epistemology limits their impact programmes predominantly focus on individual behaviour change foregrounding individual choice and responsibility there exists strong and extensive evidence that interconnecting and interacting factors beyond the individual impact on health including place context power economics institutional relationships and biology over time and across generations the existence of such evidence however has not been sufficient to garner policy action even when existing strategies have failed to successfully address health inequalities we propose a list of questions that researchers and policymakers can use when writing or critiquing policy in order to bring this broader perspective to the forefront of their analysis of the problem this is one small step in moving from the rhetoric of whole systems interventions to longterm intervention and evaluation and towards broadening the range of approaches and evidence we use to unpack the problems of health inequalities and work towards policies to address them conflicts of interest natasha kriznik is in receipt of funding for health services research from the wellcome trust mike kelly is in receipt of grant funding for public healthrelated research from mrc esrc the wellcome trust and nihr he also has one consultancy for providing general evidencebased advice on obesity prevention to slimming world from 2005 to 2014 he was the director of the centre for public health at nice

background a strong focus on individual choice and behaviour informs interventions designed to reduce health inequalities in the uk we review evidence for wider mechanisms from a range of disciplines demonstrate that they are not yet impacting on programmes and argue for their systematic inclusion in policy and research methods we identified potential mechanisms relevant to health inequalities and their amelioration from different disciplines and analysed six policy documents published between 1976 and 2010 using bacchis whats the problem represented to be framework for policy analysiswe found substantial evidence of supraindividualistic and relational mechanisms relevant to health inequalities from sociology history biology neuroscience philosophy and psychology policy documents sometimes expressed these mechanisms in policy rhetoric but rarely in policy recommendations which continue to focus on individual behaviourcurrent evidence points to the potential of systematically applying broader thinking about causal mechanisms beyond individual choice and responsibility to the design implementation and evaluation of policies to reduce health inequalities we provide a set of questions designed to enable critique of policy discussions and programmes to ensure that these wider mechanisms are considered

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introduction the focus on adolescent health has been increasing in recent years 1 with a growing recognition that these years are pivotal in the development and maintenance of health behaviours and outcomes through the life course 23 adolescence is a key period for mental health disorder onset with half of lifetime onset by age 14 4 research over previous decades suggests that the prevalences of mental health problems are increasing in uk teenagers 56 which is mirrored in studies across different countries 78 an international systematic review investigating secular trends in adolescent mental health from the previous century into the start of this century concluded that internalizing symptoms seem to be increasing finding more consistent evidence for increases in girls compared with boys 9 most studies in this review focused on internalizing symptoms or general psychological distress making conclusions about externalizing behaviours less possible there are few studies comparing changing trends in the millennial generations and prevalence studies suggest that mental health problems in mid adolescence might have increased even further in recent years 1011 in contrast whereas prevalence of internalizing mental health problems seems to be increasing young people in the uk are becoming less likely to be underage substance users office for national statistics reports collected from secondary school pupils in england have found prevalences of alcohol use smoking cannabis use and other drug use among 14yearolds have consistently fallen since 1982 when the survey was first undertaken 12 for example in 1982 16 of 14yearolds described themselves as regular smokers in 2014 this had fallen to just 4 and the drop was consistent across genders this decrease in use has become particularly pronounced since the early 2000s 12 given that various health behaviours including but not limited to substance use are implicated in risk for poor mental health 13 14 15 16 17 18 investigating the relationships between these secular trends is important to explore causal relationships and the aetiology of mental illhealth and potentially to inform interventions to try to reverse the increasing prevalence of mental health problems it is therefore surprising that to date there has been little attempt to combine investigations of secular trends in mental health with changes in healthrelated behaviours we also know little about trends in other healthrelated behaviours such as sleep risky sexual behaviour body satisfaction and physical activity that might also be causal risk factors for mental ill health and substance use 13 14 15 16 17 18 in the current study we use two cohorts of uk adolescents born a decade apart in order to identify changes in mental health considering both internalizing and externalizing symptoms and a number of healthrelated behaviours including substance use sleep behaviours weight and physical and sexual activity in key messages • large increases are observed in some mental health difficulties obesity and poorer sleeping habits in the 10 years between 2005 and 2015 whereas antisocial behaviour and substance use seem to be decreasing or are unchanged • given healthrelated behaviours are often cited as risk factors for poor mental health our findings suggest relationships between these factors might be changing over time • the findings have important implications for policy and public health planning related to mental health and substance use • our findings also present data on changes in sleep behaviours and weight perceptions highlighting the need for further research into the role these behaviours might play in the rising mental health difficulties observed in todays adolescents particular we attempt to make the variables and datasets as comparable as possible by harmonizing the variables and performing two different techniques to increase the comparability of the cohorts the prevalences of a number of these behaviours differ between males and females and some studies report different trends in males and females 6 we therefore also empirically examine sex differences in changes over time in these outcomes methods measures the measures used in this study include sociodemographic indicators mental ill health substance use antisocial behaviours and other healthrelated behaviours in a few instances the variables of interest were not available in alspac at age 14 but were available in the sweep immediately beforehand or afterwards and where this is the case it is clearly indicated in the table table 1 also presents the details of the harmonized variables that were subsequently used in analysis some of the variables were more readily comparable than others for instance both studies used the short moods and feelings questionnaire 24 to assess depressive symptoms the parentrated strengths and difficulties questionnaire 25 to measure difficulties and the same set of questions to record sexual activity other variables were harmonized through a process of creating new comparable variables across the datasets for selfharm even after harmonization the resulting variable is not truly comparable due to different time scales of the question asked which needs to be borne in mind when interpreting findings last some healthrelated behaviours that we planned to harmonize and investigate were substantially differently measured and harmonized measures could not be derived analysis increasing comparability of the datasets to increase comparability of the samples by accounting for key sociodemographic differences between these samples participants from the larger mcs sample were matched or weighted to make them comparable to the alspac sample on key demographic factors including sex age ethnicity maternal education and maternal age at birth this was done using two approaches propensity score matching 26 and entropy balancing 27 both approaches aim to reduce the probability that differences between samples on outcomes of interest are because of sample differences on relevant demographic variables 27 table s1 available as supplementary data at ije online shows the differences in these characteristics in the samples before and after these procedures were applied propensity score matching is based on a propensity score which is derived from weighting schemes based on the criteria that are to be matched to identify individuals from the larger control group that are most like each of the individuals in the treatment group across a range of variables as specified propensity score matching was conducted in stata using psmatch2 28 entropy balancing is a multivariate reweighting method that calibrates unit weights such that two samples are balanced on a range of prespecified variables hence increasing comparability for the estimation of treatment or in this case cohort effects 27 the application of this approach creates an entropy balancing weight value for all participants in the mcs sample which is then used as a weight when estimating prevalences in the mcs sample this approach allows the use of the full available mcs cohort instead of selecting a matched subsample like the propensity score matching approach entropy balancing was conducted in stata using ebalance 29 missing data in alspac 156 of the total cells were missing in the mcs samples 1 of cells were missing in the mcs propensity matched sample and 12 in the full mcs sample multiple imputations were carried out using chained equations separately in the two cohorts estimating cohort differences four estimates of the prevalences and descriptive statistics means and percentages with 95 confidene intervals for each of the harmonized outcome variables were first estimated in addition we estimated odds ratios of the cohort effects for the prevalence of poor mental health or risky health behaviours using logistic regressions last we also examined sexintocohort interactions with the ebalancing weight to examine whether the extent of change in males and females was different for ease of interpretation for the reader throughout the rest of the paper we refer to the alspac variables year of collection as 2005 and to the mcs variables as 2015 results there were no differences between the samples in sex distribution or maternal age at birth regarding the other characteristics as expected mcs had higher proportions of ethnic minorities and higher levels of maternal higher education the propensity matching resulted in the two samples becoming more similar for example ethnic minorities were less than 4 in the alspac cohort compared towith more than 20 in the full mcs cohort whereas the propensity matched mcs cohort consisted of around 10 of minority ethnic individuals the entropy balancing resulted in matched estimates across demographic characteristics in the two cohorts estimates from the propensity score matched sample and the entropy balancing in the mcs were very similar in most cases and for most outcomes these adjusted estimates were slightly different from the mcs nationally representative estimates indicating the importance of adjusting the estimates when estimating cohort differences the descriptive statistics indicated that there were more young people with mental health problems as indicated by greater proportion above the depression threshold and reporting selfharming in 2015 compared with 2005 antisocial behaviour and substance use rates were lower in 2015 compared with 2005 parentreported difficulties highlighted higher rates of emotional conduct and hyperactivity symptoms and greater levels of problems in getting along with peers in 2015 compared with 2005 with regards to healthrelated behaviours the proportion who had tried smoking and alcohol had reduced in 2015 but rates of those smoking weekly and having tried cannabis and other drugs were similar in the two cohorts the more recent cohort had a higher bmi on average and larger numbers also perceived themselves to be overweight the data on sleep behaviours indicated that on weekdays young people in 2015 were more likely to sleep later and more likely to wake up earlier weekend sleep and wake times were more similar between the cohorts a greater proportion of adolescents in 2005 reported having had sexual intercourse by this age compared with in 2015 due to the higher comparability and complete sample size using entropy weights and the similar estimates produced with entropy and propensity adjustment entropy balancing is used for subsequent regression analyses comparing the two cohorts and the sex by cohort interactions about right weight 593 579 60 figure 1 illustrates odds of outcomes in the mcs sample compared with the alspac sample using both a direct comparison approach and estimates applying the entropy balancing weights estimates were similar for most of the mental health and some healthrelated behaviour outcomes based on the two approaches but there was some noticeable upward or downward bias for some outcomes for instance with entropy balancing the lower odds in 2015 compared with 2005 are more stark for antisocial and risky health behaviours highlighting the potential relevance of using methods to increase the comparability of cohorts when estimating cohort differences descriptives stratified by sex are presented in table 4 depressive symptoms selfharm and overweight perception were higher in females and antisocial behaviours and peer problems higher in males regression analysis with the entropy balancing weight were undertaken to examine sexbycohort interactions many healthrelated behaviours showed little or no sex differences in prevalence there were no sexbycohort interactions for most of the variables included in this study indicating that rates of change or increaseddecreased odds were similar in males and females there was evidence of sex differences in cohort effects for some antisocial behaviours eg assault odds ratio male ¼ 066 or female ¼ 045 parentreported conduct problems and having tried alcohol where odds of these behaviours in 2015 compared with 2005 were lower in females compared with males odds ratios separately by sex were estimated and are presented in figure 2 discussion the current study examined changes in a range of mental health and healthrelated behaviour outcomes in mid adolescence over 10 years using two key uk birth cohort studies importantly the study investigated this range of outcomes within the same analytical framework and employed methodological techniques to provide comparable estimates across the different health outcomes prevalences of depressive symptoms selfharm and parentreported mental health difficulties were all higher in 2015 compared with 2005 whereas antisocial behaviours were lower in 2015 changes in these mental health outcomes were substantial with a 6 increase in those above the threshold for depression and 20 decrease in those reporting physically assaulting anyone at age 14 most antisocial behaviours reported were substantially lower in 2015 compared with 2005 and there was a sex interaction whereby the cohort difference was larger in females trends in externalizing behaviours have been understudied in cohort comparisons and these data provide clear evidence for changes in antisocial behaviours in the decade between these cohorts the increase in internalizing mental health problems was consistent by sex suggesting that increases in psychological distress and selfharming behaviour are not increasing at higher rates in females this finding is in contrast to some other studies of adolescent trends that indicated that increases in internalising problems were more consistent and greater in females 6911 for instance previous research has reported odds in 2006 compared with 1986 at age 16 of 09 in males and 15 in females 6 compared with the increased odds in this study of 18 in both males and females in 2015 compared with 2005 it is striking that the rate of increase of high depressive symptoms is more than 60 in just one decade poor mental health at this age predicts a host of lifelong negative consequences such as poorer health social and economic outcomes 30 and therefore this sharp increase should cause concern results for healthrelated behaviours were mixed with less young people having tried alcohol binge drinking smoking and having sex by mid adolescence in 2015 but being more likely to have later bedtimes and wake up earlier sleep less than the recommended 8 h for adolescents 31 to perceive themselves as overweight and to have higher bmis it is relevant to note that although fewer young people had tried smoking cigarettes in 2015 there was no cohort difference in the proportion smoking weekly at this age although in absolute terms the number of individuals smoking weekly at age 14 was small in terms of sex differences in these cohort effects the odds for some antisocial behaviours and for ever trying alcohol in 2015 compared with 2005 were even lower in females compared with males indicating that for some of these behaviours the decreasing prevalences over time were more marked in females some of these findings are in line with research that demonstrates a decrease in adult activities among adolescents in recent decades 32 however this explanation does not help understand the shorter sleep times lower anti social behaviours and poorer weightrelated outcomes observed in this study the healthrelated behaviours identified in this study are all known risk factors for mental ill health 13 14 15 18 in some instances the increasing trends in risky health behaviours such as decreasing sleep times increasing weight and perceived overweight status might help explain the increasing mental health difficulties experienced by adolescents where the trends are moving in opposite directions the interpretation becomes more complicated it may suggest that the associations between these behaviours and mental health are not consistent over generations and might be changing over time this is important with regards to trying to identify causal risk factors for poor adolescent health outcomes unexpected patterns such as those seen in our study could indicate that associations between for example cannabis use and depression could be due to residual confounding rather than true causality however other factors not included in the study are also likely to have changed over the 10 years of investigation which may also impact on these associations understanding the dynamic relationships between healthrelated behaviours and mental health should be a priority as adolescent in addition to effectively using two large contemporary birth cohort studies the study makes several methodological advancements in improving our understanding of changing trends in uk adolescents variables in the two cohorts where dissimilar were carefully harmonized to ensure comparisons could be made unfortunately this harmonization could not be achieved for certain variables of interest which we were therefore unable to include similarly for other variables the harmonization is imperfect owing to either different time periods of reference in the questions or availability only at a slightly different age in the alspac cohort and this must be borne in mind when interpreting findings in both these cases however the direction of bias is likely to be an underestimation of the increased poorer outcomes in 2015 for instance with selfharm we estimate lifetime prevalence in alspac and previous year prevalence in mcs although alspac and mcs are large and detailed birth cohorts one is a regional cohort and one is a national cohort which could bias our findings however regional variation in these outcomes was estimated and was found to be minimal although we employ multiple techniques to increase the comparability of the cohorts it is possible that some of the differences observed are due to changes in demographic composition over the decade differences in the study samples or the different rates and predictors of attrition between the two studies the nationally representative estimates for the mcs at age 14 indicate that across all the investigated variables the comparable estimates were slightly different from the nationally representative ones highlighting the value of applying techniques to increase the comparability of these cohorts but at the same time limiting the generalizability of our secular trend estimates to the uk as a whole it is also important to note that missing data were higher in alspac than mcs and although we conducted multiple imputation with sociodemographic and all examined variables informing the imputation to reduce bias in estimates some estimates might remain biased due to unmeasured factors associated with missingness and their potential association with our outcomes of interest finally two of the measures used in this study are psychometric surveys and our findings assume measurement invariance for these however we have not tested this and there is a possibility that the surveys are not measuring the same constructs across the two cohorts there are a number of implications highlighted by our findings most importantly the rapidly increasing prevalence of depressive symptoms selfharm parentreported mental health problems obesity and lesser sleep in adolescents over the past decade is an important finding and the reasons why this has occurred need thorough investigation identifying further factors that have changed over the decade that might have resulted in uk young people having less support and being at higher risk should be undertaken as a public health priority a further implication arising from our findings is that although certain mental health problems are increasing other problems and healthrelated behaviours thought to predict poor mental health are decreasing understanding the nature of these associations and their dynamic nature over time could be extremely valuable in identifying causal risk factors for mental health and potential targets for interventions identifying explanations for these high prevalences and changing time trends is key to preventing further increases in poor mental health and health outcomes for future generations of young people to conclude in a large wellpowered study across two key uk birth cohorts born a decade apart depressive symptoms and selfharm behaviours have increased between 2005 and 2015 adolescents are spending less time sleeping and have higher bmis in contrast other healthrelated behaviours such as substance use and antisocial behaviours have decreased over the same time period suggesting that links between mental health problems and healthrelated behaviours might be more complex and dynamic in nature than currently predicted the data provide important evidence to help understand health behaviours in millennials and how these are changing permitting the planning of policy and public health provision the university of bristol provide core support for alspac a comprehensive list of grants funding is available on the alspac website edgementspdf the millennium cohort study is supported by the economic and social research council and a consortium of uk government departments the funders had no role in study design data collection data analysis data interpretation or writing of this report

background there is evidence that mental health problems are increasing and substance use behaviours are decreasing this paper aimed to investigate recent trends in mental ill health and healthrelated behaviours in two cohorts of uk adolescents in 2005 and 2015 methods prevalences in mental health depressive symptoms selfharm antisocial behaviours parentreported difficulties and healthrelated behaviours substance use weight weight perception sleep sexual intercourse were examined at age 14 in two uk birth cohorts avon longitudinal study of parents and children alspac n ¼ 5627 born 199192 and millennium cohort study mcs n ¼ 11 318 born 200002 prevalences and trend estimates are presented unadjusted and using propensity score matching and entropy balancing to account for differences between samples results depressive symptoms 9 to 148 and selfharm 118 to 144 were higher in 2015 compared with 2005 parentreported emotional difficulties conduct problems hyperactivity and peer problems were higher in 2015 compared with 2005 5789 to 97177 conversely substance use tried smoking 92 to 29 tried alcohol 521 to 435 cannabis 46 to 39 sexual activity 2 to 09 and antisocial behaviours 62401 to 16277 were less common or no different adolescents in 2015 were spending less time sleeping 8 h 57 to 115 had higher body mass index bmi obese 38 to 73 and a greater proportion perceived themselves as overweight 265 to 329 the findings should be interpreted bearing in mind limitations in ability to adequately harmonize certain variables and account for differences in attrition rates and generalizability of the two cohorts

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introduction it has been suggested that cultural identification is strongly associated with the expression of certain anxiety disorders there has been a surge in the number of studies focusing on minority mental health issues and increasing recognition of the need to deepen the understanding of the mental health features of nonwhite samples versus white samples in order to make the currentlydefined diagnoses more applicable to a range of individuals yet while this interest is growing there still remains a dearth of information about the mental health picture of nonwhite raceethnic groups in the united states past studies have primarily documented lower prevalence rates of anxiety disorders in minority groups as compared to their white counterparts the national epidemiologic survey on alcohol and related conditions is a large epidemiological sample which surveyed over 40000 people across all 50 states of the united states and oversampled african americans and hispanic americans in 2001 and 2002 using the alcohol use disorder and associated disabilities interview scheduleiv it has been reported that the 12month and lifetime national prevalence of dsmiv social anxiety disorder were 28 and 5 respectively and that being of asian hispanic american or african american ethnicity is associated with a lower prevalence rate for sad other results from this dataset have indicated a similar pattern in the prevalence of dsmiv generalized anxiety disorder and panic disorder other surveys have found evidence for an elevated rate of posttraumatic stress disorder in hispanic cohorts as compared to other minority groups in the us in contrast some findings indicate no differences in prevalence rates between groups of hispanics and white americans with regards to panic disorder or sad thus there remains quite a mixed picture about how minority mental health relates to the overall prevalence of anxiety disorders in the united states the purpose of the present study was to examine differences in the lifetime prevalence rates of anxiety disorders between ethnic and racial minority groups in the us we used the collaborative psychiatric epidemiology survey database an integrated dataset consisting of three national epidemiological studies to examine reporting of lifetime dsmiv social anxiety disorder generalized anxiety disorder panic disorder and posttraumatic stress disorder across four raceethnic groups white americans african americans hispanic americans and asian americans the cpes integrated datasets did not screen for obsessivecompulsive disorder and specific phobia across all three surveys therefore these two anxiety disorders were not included in the analyses method participants the present study utilizes data drawn from the collaborative psychiatric epidemiology studies as described elsewhere the cpes consists of three national surveys of americans mental health the national comorbidity survey replication the national study of american life and the national latino and asian american study of mental health the cpes surveys were funded by the national institute of mental heath and the data was collected between may 2002 and november 2003 the survey population in the ncsr was comprised of adults residing in households in the coterminous us individuals were excluded if they were institutionalized lived on military bases or were nonenglish speakers a fourstage national area probability sample framework was used to obtain data for the ncsr which is a designed to be a crosssectional replication of the original 1993 national comorbidity survey the ncsr screening interview was completed by 11222 households resulting in an initial 98 response rate interviews were conducted in person with 9282 respondents with the mean age of respondents equaling 4473 years and a response rate of 709 the nsal is an integrated household probability sample survey of 3570 africanamericans 1006 nonhispanic whites and 1623 african american adults of caribbean descent for a total interviewed sample of 6199 participants with an overall response rate of 715 the inclusion and exclusion criteria for the nsal were identical to those of the ncsr described above moreover this survey was added to the cpes combined dataset in order to obtain information from afrocaribbean adults a group that was not represented in the ncsr a similar fourstage national area probability sampling procedure as employed in the ncsr was utilized to collect the data with the addition of the special supplement for afrocaribbean adults the nlaas a nationally representative survey of latino and asian americans residing in the us included individuals whose primary language was english spanish or 1 of 3 asian languages of note this was the only survey in the cpes combined dataset that utilized trained bilingual interviewers to conduct the full assessment in one of these five languages as compared to englishonly assessments in the ncsr and nsal moreover the nlaas survey population included latino and asianamerican adults in the coterminous us alaska and hawaii exclusion criteria were the same as for the ncsr and the nsal additionally the study utilized a similar fourstage national area probability sample with special supplements for adults of puerto rican cuban chinese filipino and vietnamese origin the latino sample consisted of 4 ethnic subgroups determined by respondents selfreported ethnicity cuban puerto rican mexican and other the final weighted response rate for the latino sample was 755 the asian sample consisted of individuals identifying as chinese filipino vietnamese or other asian ancestry the combined weighted response rate for the asian sample was 656 across the three surveys study procedures were explained to all participants and written informed consent was obtained from the respondents in english or their preferred language trained interviewers conducted facetoface interviews with all participants in the core and highdensity samples except when a telephone interview was conducted with the respondent to ensure quality control in each survey participants were randomly recontacted to validate the data an initial 50 incentive was later increased to 150 to address nonresponse the sampling procedure for all three surveys has been documented elsewhere and included 4 stages 1 core sampling in which primary sampling units and secondary sampling units were selected with probability proportionate to size 2 highdensity supplemental sampling to oversample census block groups with 5 or greater density of target ancestryracial groups 3 screening of a random selection of housing units within each designated sampling unit to determine satisfaction of study eligibility criteria followed by random selection of one respondent from each household for the study interview 4 second respondent sampling to recruit participants from households in which one eligible member had already been interviewed weighting correlations were developed to take into account the joint probabilities for selection under the 4 components of the sample design measures psychiatric disorder prevalence rates were evaluated with the world mental health survey initiative version of the world health organization composite international interview a fully structured layadministered diagnostic interview that generates dsmiv diagnosis the diagnoses in earlier versions of the english and spanish cidi diagnostic assessments were consistent with the diagnosis made independently by trained clinical interviewers in the present report we focused on lifetime prevalence rates for sad gad pd and ptsd for each of four raceethnic groups the asian american subgroup consisting of respondents identifying as chinese filipino or vietnamese the african american subgroup which included all origins with the exception of caribbean african the hispanic subgroup which included all individuals of hispanic descent with the exception of spanish and portuguese and the white subgroup statistical analyses the complex samples module of spss 170 was used to complete all analyses for the present report in order to adequately the weighted nature of the cpes data as described above logistic regressions were conducted for prevalence of lifetime dsmiv diagnoses across six ethnic comparisons white americans versus asian americans white americans versus hispanic americans white americans versus african americans asian americans versus hispanic americans asian americans versus african americans and hispanic americans versus african americans three covariates were included in the final analyses age gender and annual household income education was considered as a potential fourth covariate but seemed redundant to include in the analyses given its significant positive correlation to annual household income level in the datasets results table 1 shows the demographic characteristics of each of the four racial groups the white sample was the oldest whereas the african american cohort consisted of the highest proportion of women asian americans had the highest average level of household income each demographic variable was found to be significantly different across each racial group to account for these differences across groups all demographic variables were entered as covariates in the logistic regression analysis figure 1 shows the prevalence rates of dsmiv social anxiety disorder generalized anxiety disorder panic disorder and posttraumatic stress disorder for each individual racial group as was found across a range of psychiatric disorders asian americans consistently endorsed symptoms of all four anxiety disorders less frequently than any of the other racial groups white americans consistently endorsed symptoms of sad gad and pd more frequently than african americans hispanic americans and asian americans african americans more frequently met criteria for ptsd as compared to the white american subgroup hispanic americans and asian americans table 2 shows the comparisons of odds ratios between the different ethnic groups in diagnosis of the four anxiety disorders when controlling for gender age and socioeconomic status logistic regressions revealed that even after controlling for demographic variables that white americans were significantly more likely to endorse symptoms of all four anxiety disorders than any of the three minority racial groups with the exception of ptsd the african american cohort had a significantly higher chance of being diagnosed with ptsd than the asianamerican or hispanic sample asian americans were less likely to be diagnosed with gad and ptsd than the hispanic subgroup these differences in the reporting of anxiety symptoms remained significant even after a bonferroni correction to adjust for alpha inflation given the number of pair wise comparisons was made discussion our results indicate that individuals from minority groups especially hispanic or asian respondents are less likely to meet criteria for many of the anxiety disorders than white americans african americans are also less likely to endorse criteria for gad pd and sad but are more likely to meet diagnosis for ptsd across the board asian americans endorsed less anxiety symptomatology regardless of type whereas white americans presented with increased rates of the anxiety disorders examined as compared to the three minority groups these findings held even when demographic variables such as age gender and socioeconomic status were accounted for by including them as covariates in the analyses these results support the findings of the other few largescale epidemiological studies that have considered crossethnic differences in prevalence rates of single disorders the cpes integrated database provides a unique bank of information on a representative population of the united states along with a muchneeded oversampling of hispanic americans asian americans and african americans to directly counter the traditional methodological problems of unequal sample sizes typically encountered with research on minority racial groups to our knowledge this is the first study that systematically examined the prevalence rates of anxiety disorders where minority groups are not only compared to a white cohort but to each other as well also the cpes datasets use the wmhcidi which has been shown to be a highly reliable and valid diagnostic instrument for the assessment of dsmiv disorders which in combination with the sampling design provide true prevalence rates that are superior to simply analogue measures of various anxiety symptoms there remain however several questions regarding the mental health picture of various minority groups in the united states one important consideration is the possibility that the wmhcidi does not capture fully accurate endorsement of the disorders studied because of language or cultural differences in the conceptualization of various anxiety symptoms indeed this has been a problem in other screening instruments and methods where differences in meaning of worded prompts or biases towards diagnosis of other psychopathology resulted in a decreased validity and reliability of measures that had been previously validated in white samples the differences seen among racial groups in this study might also indicate inherent deficiencies in the actual diagnostic criteria for the anxiety disorders assessed that is perhaps the instrument correctly diagnosed cases with each disorder but the standards used to make these designations do not capture culturally specific experiences or symptoms of the psychopathology being examined which may have resulted in an artificial lowering of the prevalence rates of these disorders in certain groups that being said several other studies using nonamerican samples have found prevalence rates for the various anxiety disorders to be markedly different to the rates found in largescale epidemiological studies in the us which more readily indicate methodological flaws some type of responsebias or as mentioned above a difference in the perceived experience of these disorders one other aspect that may account for differences in prevalence rates for immigrant populations versus their counterparts in native settings is the level of individualistic or collectivist identification of the individuals assessed several studies have noted the differences between levels of anxiety in communities aligning themselves with more collectivistic values where focus on maintaining harmony within the group is of the highest priority as compared to those adhering the more individualistic cultural attitudes where individual achievement are most highly valued and rewarded by the rest of the social group thus an assessment of the degree of adherence to predominantly individualistic or collectivistic values could impact report of anxiety symptoms another area that warrants future research is the impact of acculturative stress on the development of psychopathology as well as other related variables such as group identification several studies have suggested that while a greater identification with ones minority racial or cultural status is associated with higher levels of collective self esteem it is conversely related to a higher endorsement of psychological distress such as clinical depression andptsd symptoms yet most studies have not directly studied the effects of acculturative stress on mental health outcomes and the few that have done so have indicated a limited independent effect of acculturative stress on psychological disorders clearly the impact of this factor needs to be more directly examined a measure of acculturative stress was utilized in a portion of the cpes combined dataset but could not be included as a covariate in the analyses because of its omission from the ncsr portion of the data from which the white american group was being assessed an array of other variables were considered as potential proxies for this measure but none of these were systematically assessed across all three datasets for all racial groups this raises important considerations for future methodological designs and underscores the urgency in obtaining data in a more crossracially sensitive fashion conclusions in order to examine raceethnic differences in the lifetime prevalence rates of common anxiety disorders we examined prevalence data for social anxiety disorder generalized anxiety disorder panic disorder and posttraumatic stress disorder from the collaborative psychiatric epidemiology studies for four raceethnic groups white americans african americans hispanic americans and asian americans statistical analyses revealed that white americans were more likely that the minority groups to be diagnosed with all the disorders examined with the exception of posttraumatic stress disorder which was most prevalent in african americans asian americans were also generally less likely to meet diagnosis for all disorders examined than the other racial groups the results suggest that race and ethnicity need to be considered when assigning an anxiety disorder diagnosis future studies should examine rates of disorders across ethnic groups in datasets that allow the individual to respond in their native language some of the data sets included in our analysis did not do so otherwise the sample will be slanted to acculturated groups and potentially important cultural influence on psychopathology will be reduced furthermore even though the assessments were at least conducted in five different languages to participants in the nlaas survey the members within each racial group are not homogenous african americans in the south versus african americans in the north versus african americans of caribbean origin mexicanamericans versus puerto ricans and three asian groups in the data sets thus future studies should further examine the rate of disorders taking into consideration degree of acculturation in addition future studies should examine rates of anxiety disorders across specific subgroups such as puerto ricans versus mexicanamericans or japanese americans versus filipino americans percentage of dsmiv diagnoses across racial groups significant after a bonferroni correction of 00524 0002 ns not significant at p 05 sad social anxiety disorder gad generalized anxiety disorder pd panic disorder ptsd posttraumatic stress disorder

in order to examine raceethnic differences in the lifetime prevalence rates of common anxiety disorders we examined data from the collaborative psychiatric epidemiology studies cpes the

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introduction excessive rates of college alcohol consumption continue to pose a public health challenge despite the development of efficacious interventions the rate of students who reported at least one heavy drinking episode in past month rose from 417 in 1999 to 447 in 2005 heavy drinking episodes are related to academic relational and legal problems as well as injury driving under the influence and unprotected sex the persistence of heavy drinking suggests the need to understand better the social context of college drinking the peer network is a key factor in the initiation escalation and deescalation of alcohol use among adolescents the college environment characterized by prevalent alcohol use and permissive attitudes about drinking acceptability is unlike any environment emerging adults have previously encountered adolescents entering college may be particularly vulnerable to peer influence because of their need to make new friendships in a context with reduced conventional social controls college students may increase drinking to facilitate peer interactions peer drinking is a strong predictor of how young adults consume alcohol a prospective study of young adults found that peer alcohol use predicted binge drinking but not total drinks per week among young adults who met problem drinking criteria a larger social network of heavy drinkers was associated with higher levels of binge drinking level of close friends drinking predicts increased drinking in the first semester of college peer alcohol use is an important contributor to young adult heavy drinking research from adult and treatment samples indicates that it is not merely the presence of peer drinking in a social network that influences consumption alcoholspecific social support may have a more direct impact friends who are supportive of drinking can encourage alcohol misuse findings from the combining medications and behavioral interventions trial provide further evidence of the specific impact of having heavy drinkers innetwork alcoholspecific support measured by network drinking and level of opposition to patient drinking was predictive of percent days abstinent though the percentage of heavy drinkers in network did not predict the pda latent growth trajectory the number of daily and frequent drinkers innetwork did the number of frequent drinkers was negatively related to pda for within treatment and posttreatment outcomes therefore whereas the proportion of heavy drinkers was unrelated to outcome the total number of heavy drinkers innetwork may have a unique impact on personal alcohol consumption personal consumption is also related network composition in a crosssectional study of 471 couples prior to marriage heavy drinkers social networks had a different composition than the networks of regular and lighter drinkers heavy drinkers networks contained more drinking buddies defined as a person who you got together with on a regular basis to do activities centered around drinking these drinking buddies are comparable to the heavy drinkers identified in combine and further highlight the importance of the number of heavy drinkers innetwork in contrast reifman and colleagues used percentage of heavy drinkers innetwork to recursively predict alcohol misuse higher percentages of drinking buddies innetwork were associated with college students drinking longitudinally the authors note however that other literature has demonstrated that key individuals in a network rather than the entire network are most influential overall most research has identified the number of heavyfrequent drinkers as the most important predictor of an individuals alcohol use trajectory the proportion of heavy drinkers is a useful predictor specifically of autoregressive associations between network composition and alcohol misuse but was unrelated to combine treatment outcome heavy drinkers innetwork may be uniquely predictive of personal alcohol consumption despite the clear association between network composition and alcohol consumption little is known about the evolution of social networks over time one study examined whether changes in college students drinking were the result of fluctuations in current members drinking or of participants dropping and adding network members with different drinking levels changes in network drinking resulted from adding new members and dropping others thus it is important to consider how many heavy drinkers are innetwork and to consider whether members are being incorporated over time this study sought to determine whether different trajectories could be identified that represent how college students include heavy drinkers in their social networks trajectory analysis using social network data has not been used to explain the longitudinal impact of peers on alcohol consumption given the significant temporal variability in drinking over the academic year it is important to consider how students network composition and alcohol consumption concurrently change first we sought to explore patterns in the composition of college students social networks over one year specifically we examined whether different trajectories could be identified by how many heavy drinkers were included in networks if different trajectories could be identified we sought to determine whether they were associated with different levels of alcohol consumption and drinking norms descriptive drinking norms are a key factor in understanding how social context influences personal alcohol consumption norms are defined as selfinstructions to do what is perceived to be correct by members of a culture descriptive norms are perceptions of what others do including estimates of others alcohol consumption college students often overestimate drinking norms this overestimation predicts current and future drinking descriptive norms therefore are important to consider when examining network composition and network effects students who incorporate more heavy drinkers are likely to concurrently increase their descriptive norms research has not investigated the relationship between network composition and drinking norms second we sought to determine whether trajectory classes had different levels of alcohol consumption and norms over one year to accomplish these goals we measured alcohol consumption norms and social network composition during the baseline 6month and 12month followup appointments of a randomized controlled trial of alcohol prevention interventions for mandated college student drinkers after identifying trajectory groups we compared groups on alcohol consumption and descriptive norms at baseline 6m and 12m method measures 221 demographicsparticipants provided information about age gender year in college and racial and ethnic background brief important people interview the bipi is a shortened form of the important people and activities interview which was administered in project match and the combine trial and measured social support for drinking the bipi retained the components of the original interview that best predicted treatment response in combine administration followed the bipi manual with slight adaptations to tailor the assessment to college drinkers as in combine participants identified up to 10 network members at baseline 6m and 12m participants listed up to 10 important friends defined in the current study as friends oncampus that have been important to you and with whom you have had regular facetoface contact during the past six months in their current social network for each person listed the participant specified the nature of the relationship frequency of contact and drinking status the total number of heavy drinkers identified by each participant was used in these analyses alcohol use a standard drink was defined as a 12 oz can or bottle of beer a 5 oz glass of wine or a 15 oz shot of hard liquor either straight or in a mixed drink the baseline assessment covered the month prior to and including the sanction violation event subsequent assessments covered the 30 days prior to the assessment the daily drinking questionnaire used a 7day grid to assess typical week drinking 224 drinking normsperceived drinking norms of typical oncampus student drinking in the past 30 days were assessed with the drinking norms rating form participants estimated the number of drinks they think the typical college student consumes on each day of the week perceived weekly descriptive drinking was calculated by summing the daily estimates to create a total perceived weekly drinking variable analysis plan a series of five growth mixture models was conducted to discern distinct groups of individuals with similar levels of heavy drinkers innetwork from baseline through 12m analyses were conducted using mplus version 5 models with 15 growth classes were fit missing data was handled using the maximum likelihood method which is a best practice strategy for managing missing data gender and intervention condition were controlled gender was controlled because it is a known college drinking correlate and we wanted to model overall change patterns intervention condition was controlled to remove the potential influence of changes in drinking related to intervention condition we chose model fit statistics based on recommendations from a monte carlo study that determined the most appropriate fit indices for gmm and four recommended criteria the first criterion was the bootstrapped parametric likelihood ratio test the blrt extrapolates data to represent better the true distribution it tests for model improvement in each successive model over a model with one fewer class the second criterion was the sample size adjusted bayesian information criterion the sabic maximizes the likelihood ratio statistic while rewarding parsimony low values indicate better model fit and the model with the lowest sabic is generally preferred third entropy values provided an index of model classification quality values range from 0 to 1 higher values indicate better classification quality values greater than 080 are generally considered to have adequate classification quality the fourth criterion was the average latent class probabilities for the most likely latent class membership by latent class discrimination values close to 1 in the primary diagonal and values close to 0 in offdiagonal represent good fit values close to 050 indicate that individuals in a particular group would fit equally well in another group these values provide an index of how likely the individuals within a latent class belong in that class the usefulness of the gmm classes to differentiate participants on variables of interest was also considered we were interested in a model that could be used to differentiate levels of drinking and norms at 6m and 12m final model selection was based on goodness of model fit indices parsimony and substantive interpretability of the model wald tests of mean equality determined whether classes had different levels of alcohol consumption and norms at baseline 6m and 12m wald tests use chisquare to compare latent groups with a posterior probabilitybased multiple imputation strategy these analyses are conducted simultaneously with gmms and allow consideration of the probabilistic class membership of participants to control error finally we examined baseline to followup differences in drinking and norms within each latent class by calculating withinclass change scores and then conducting onesample ttests to compare the change within each class to zero results sample characteristics participants reported an average of 1355 drinks per week and 467 drinks per drinking day at baseline participants believed their peers drank an average of 1927 drinks per week participants reported an average of 730 total friends in their social networks at baseline female participants reported an average of 753 friends and male participants reported 719 friends participants reported an average of 152 heavy drinking friends female participants reported an average of 141 heavy drinkers and males reported 149 heavy drinkers there were no significant differences in the number of friends 185 p 006 or heavy drinkers reported by males and females 060 p 055 growth mixture model results trajectory identification a series of 1through 5class gmms were compared based on model fit and interpretability the 4class model was the best fitting model compared to the 5class model the 4class model had similar sabic and entropy values although the blrt suggests that the 5class model is an improvement over the 4class model the 5class model included a class with only 4 participants which is not substantively interpretable the 4class model showed near perfect average latent class probability for the most likely latent class membership by latent class discrimination indicating that the 4class model was a good representation of participant reports the 4class model created the following groups a small group that reported a severely increasing drinking network mean heavy drinkers at baseline 200 6m 290 12m 660 a group that reported a moderately increasing drinking network mean heavy drinkers at baseline 240 6m 201 12m 437 a large group that reported a stable drinking network mean heavy drinkers at baseline 148 6m 146 12m 239 and a larger group that reported a decreasing drinking network mean heavy drinkers at baseline 135 6m 055 12m 017 class comparison of drinking and drinking norms mean drinks per week and mean perceived drinks per week at baseline 6m and 12m are presented in table 2 for each group table 3 presents wald test results for group differences in dpw and dn one group difference emerged in the comparisons of baseline dpw and dn midn and ddn differed on baseline dn with the midn group reporting higher dn m 2323 than the ddn group m 1875 overall the groups reported similar consumption and norms at baseline in contrast at 6m there were group differences in dpw 1899 p 0001 and dn 2267 p 0001 at 6m most groups differed significantly on dpw and dn all pairwise differences were significant on dpw with two exceptions sidn did not differ from midn or sdn at 6m all pairwise differences were significant on dn with two exceptions midn did not differ from sidn or sdn similarly at 12m there were overall group differences in dpw 1898 p 0001 and dn 2451 p 0001 at 12m most groups differed significantly from one another on both dpw and dn all pairwise differences were significant on 12m dpw with two exceptions sdn did not significantly differ from either midn or ddn similarly all pairwise differences were significant on 12m dn with two exceptions sdn did not differ from ddn and sidn did not differ from midn despite similar dpw and dn among the groups at baseline by 6m and 12m participants with networks that grew more rapidly and contained more heavy drinkers consumed more drinks in a typical week and had higher norms all latent classes demonstrated changes from baseline to 12m on dn and dpw again the two groups that incorporated the most heavy drinkers had the largest increases on dn and dpw whereas the ddn group reported decreases in drinking and norms discussion the results of this study suggest statistically and clinically significant heterogeneity in changes in the number of heavy drinkers in college students social networks trajectories were identified by differential incorporation of heavy drinkers into networks and were related to alcohol consumption and descriptive norms at baseline there were minimal group differences on alcohol consumption or norms at 12m the groups that had incorporated more heavy drinkers reported higher consumption and norms this study represents the first attempt to identify trajectories in how heavy drinkers are incorporated into college drinkers social networks most students demonstrated the ddn trajectory these students reported fewer heavy drinking friends at each followup the next largest group demonstrated the sdn trajectory they maintained similar numbers of heavy drinkers from baseline to 6m and slightly increased at 12m a minority of students were in two trajectories that dramatically increased the number of heavy drinkers a total of 32 participants were in the midn trajectory and 10 participants were in the sidn trajectory these groups differentiated themselves by the number of heavy drinkers at 12m representing 13 to 12 of the maximum of 10 friends innetwork approximately 8 of our sample reported marked increases in the number of heavy drinkers in their networks our finding that most students had social networks that were stable or decreased in heavy drinkers is consistent with college alcohol intervention research meta analysis results indicate that individuallevel alcohol interventions reduce consumption therefore while the natural course of alcohol consumption increases during college those who receive interventions are more likely to reduce or keep their drinking stable consistent with this the ddn class reported a slight decrease in alcohol consumption from baseline to 12m some students increased the number of heavy drinkers in their networks this is consistent with research indicating that alcohol consumption increases during college some students consistently increase their binge drinking after age 18 and coping drinking motives are associated with increased binge drinking after high school our results may provide some explanation for these findings students who increase drinking during college may affiliate with more students perceived to be heavy drinkers or may identify more innetwork members as heavy drinkers selection effects have been shown across studies own drinking predicts innetwork drinking social influence effects could also play a role social learning theory would suggest that exposure to heavier drinkers influences own attitudes and behaviors about drinking thus exposure to heavy drinkers could impact ones perception about what a heavy drinker is and cause a relabeling of others innetwork it is known that elevated drinking norms predict consumption elevated norms may also impact who is labeled as an innetwork heavy drinker this study also sought to determine whether network composition changes were related to alcohol consumption and norms by 12m the latent groups had different levels of consumption and norms the sidn reported more alcohol consumption than all other groups and higher perceived norms than the sdn and ddn groups therefore the group that incorporated the most heavy drinkers also had the largest increase in drinking and norms at 12m there were no differences between the sdn and ddn groups when the number of heavy drinkers in ones network remained stable or decreased students either decreased consumption or increased to a much smaller degree normative perceptions also decreased or remained lower providing some protection against increases in drinking utilizing count data has several advantages over the use of other social network variables including proportion of heavy drinkers first it is the influence of key individuals that impacts drinking rather than the entire network second the count of heavy drinkers is easier to collect and use in timelimited clinical settings than calculating proportions third the count of heavy drinkers is less ambiguous than the proportion for example a person whose network changed from 2 heavy drinkers out of 2 total individuals to 6 heavy drinkers out 6 total individuals would remain at 100 though the count increased by 4 drinkers the same is true of someone who changes from 2 out of 3 to 6 out of 8 there is an overall loss of information compared to the count our findings should be considered in light of study limitations first results rely on selfreports of alcohol consumption norms and network composition studies have supported the validity of drinking selfreport data but studies do not exist on the accuracy of reporting on network composition despite confidentiality assurances some students may have underreported their friends drinking habits the bipi relied on subjective classification of friends into drinking categories students criteria for heavy drinking may vary and may be elevated given the exaggerated descriptive norms observed in college samples students estimates of who is a heavy drinker may be underestimates relative to an objective assessment emerging adults definitions of heavy drinker may change if so the shape of the trajectories may have been impacted these potential biases could have impacted the latent class composition and should be replicated to verify the number and shape of the classes second this was a sample of mandated students replication using a larger sample of students who are not mandated would enhance the generalizability of these findings replication using a sample of noncollege attending peers would also help determine how these trajectories differ by student status lastly because this study is the first to examine these relationships these results should be replicated particularly because one class was small and as such could be unstable despite this potential limitation there are no recommendations for the number of participants that should be in a class to ensure stability and our model fit indices were good and indicated that the 4class model represented the best fit in summary college students exhibit markedly different trajectories in the way heavy drinking peers are incorporated into their social networks trajectories are related to subsequent group differences in alcohol consumption and descriptive norms students with increasing trajectories report more alcohol consumption and higher norms than students with stable or decreasing trajectories these findings suggest that a key risk factor for increasing alcohol involvement during college could be the number of heavy drinkers in a students social network the inclusion of social network assessments into harm reduction interventions could provide important insight into the trajectory of a students alcohol consumption comparison of overall model fit indices for 1through 5class growth mixture 4class growth mixture model of number of heavy drinking friends across study conflict of interest all authors declare that they have no conflicts of interest

backgroundcollege drinking is embedded in a social context drawing attention to the effects of social network composition on consumption the presence of heavy drinking friends in social networks predicts later alcohol misuse but little is known about how the composition of ones social network composition changes over time this study identified changes in social network composition in a sample of atrisk students and examined the relationship among network trajectories alcohol consumption and descriptive norms methodsparticipants were 503 students 64 male mandated to participate in an alcohol prevention intervention for residence hall alcohol policy violations at baseline students provided selfreport data about alcohol consumption perceived peer drinking norms and peer alcohol involvement parallel assessments were completed at 6and 12months postbaselinegrowthmixture models identified four groups of individuals with similar levels of heavy drinkers in their social networks the majority of students had stable or decreasing numbers of heavy drinkers in their networks across the study whereas two groups reported relatively stable densities of heavy drinkers from baseline to 6months and increasing densities from 6to 12months at baseline the four groups were generally equivalent on consumption and normative perceptions at 6and 12months however the groups differed significantly on consumption and norms

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introduction the south african higher education system is in a crisis this crisis manifests itself through ongoing calls for structural reform and reconfiguration of the public higher education system it was the students collins further argued that there are four distinct yet interconnected domains of power that we should think about when theorising intersectionality 1 the structural domain 2 the cultural domain 3 the disciplinary domain and 4 the interpersonal domain the structural domain includes the fundamental structures of social institutions such as organisations companies academies departments and others which vincent suggested have the new materialism agency to includeexclude legitimatedelegitimate and recognisemisrecognise in this paper the structural domain largely speaks to the untransformed public university in south africa and its colonising institutional cultures for black academics through racism sexism ageism and the deeply entrenched coloniality that render black academics the pariahs of higher education system in the country the cultural domain focuses on the values norms beliefs and ideologies in the organisation of power relations here it is the power of ideas images and influences that hide marginality inequality and oppression the disciplinary domain largely focuses on rules and regulations and the extent to which they can be applied to people based on race age gender sexuality ethnicity and other categories according to collins the disciplinary domain focuses on the manner in which individuals and groups are disciplined to fit into society the final domain of intersectional power the interpersonal domain refers to the complex manner in which individuals experience the convergence of structural cultural and disciplinary powerthereby making people vulnerable to many levels of oppressions ranging across race class gender sexuality and ethnicity often simultaneously thus intersectionality is a useful theoretical tool to explore and to theorise the complex positionalities that black women have to grapple with as they navigate their access being and belonging in the university we now turn to discussing the emergent literature on black women academics experiences in higher education on black women academics in higher education the emergent literature on black women academics experiences in higher education largely reveals the complex and intersectional environment that black women have to navigate and negotiate in terms of race racism sexual harassment misrecognition and deeply entrenched patriarchal structures in higher education dominant in this literature are the absence and erasure that black women academics have had to navigate including being deliberately and politically unseen misrecognised and unvalued in their paper titled strange faces in the academy experiences of racialized and indigenous faculty in canadian universities mohamed and beagan wrote about the experiences of racialised and indigenous academics in canadian universities and how they grappled with the culture of whiteness lack of representation tokenism and existential nonbelonging for those two women academics it was the power of everyday racism that lies in its repetition the accumulation of messages of not belonging that socially constructed this marginality this is what ngcobozi called the very methodology of racism that is the operational functioning that seeks to racially includeexclude and to demarcate the abyssal line for us regarding those who live in the zone of being and those who belong in the zone of nonbeing dominated by words such as burdened hidden unnamed presence and resistance women academics experiences in higher education remain complex contested and precarious in the south african context education white paper 3 a programme for the transformation of higher education was clear in its ambitious attempt to restructure the higher education sector away from the racist logic of the apartheid regime and to ensure that institutions of higher learning became inclusive democratic and tolerant spaces part of this bigger agenda was to tackle the challenge of demographic composition of staff in higher education so that it truly reflected the demographic realities of the country white paper 3 conceded that black people and women are severely underrepresented especially in senior academic and management positions between 2000 and 2018 african academic staff members in south african higher education increased from 6291 in 2000 to 25252 in 2018 overall women academics numbered 15123 in 2000and increased to 28729 in 2018 and of these black women academics numbered 2310 in 2000 increasing to 11421 in 2018 although the demographic numbers for women academics in general and black women in particular appear to be increasing and showing a demographic revolution in the staffing of higher education we ought to treat these numbers with suspicion because they do not reveal the complex social experiences that black women academics are still navigating in the sector reading these numbers by rank and gender there were 641 women employed at either associate or full professor level in 2000 and in 2018 that number had increased to 2027 the interesting story in these numbers is how the majority of women academics remain within the lowest level rankings of lecturer junior lecturer and below junior lecturer in 2000 there were 12536 women academics at lecturer or below in the system and by 2018 this number had increased to 23661 of women academics being stuck at the bottom of higher education rankings an increase of some 89 in 18 yearscompared to an only 49 increase in total higher education academics in the same period as mentioned earlier the above numbers appear to show a system that is changing for the better for women because more women academics are accessing the sector and changing the demographic profile what remain prevalent are the racist sexist and patriarchal narratives for women academics that shine a spotlight on the coloniality that remains in higher education in their book black academic voices the south african experience grace khunou edith phaswana katijah khozashangase and hugo canham detailed the anguish and brutalities of navigating institutional racism whiteness and oppression in researchintensive universities and the personal cost to ones mental health and psychological wellbeing more recently literature on black women academics experiences at university has looked at the invisible labour that black women academics often take on and that is often unrecognised unseen and undervalued in the academy the literature has explored the resilience shown by black women academics in senior leadership the racism sexism and disconnection experienced by black women in stem fields black womens efforts at challenging and confronting antiblackness and white supremacy in academia and more in this paper we contribute to this emerging body of research that looks at and theorises black women academics experiences in navigating their being and belonging in a south african university we now turn to the methodological decisions of this paper research methods the tools in this paper we adopted a qualitative interpretivist case study to explore and theorise black women academics experiences in negotiating their being belonging and becoming at university the interpretivist paradigm suggests that our reality is socially constructed unstable malleable subjective and is experienced differently by each of us this aligns with our focus of recentring the voices narratives and experiences of black women academics and their complex experiences in navigating a researchintensive university we purposively selected 10 black women academics from one research university in south africa as per alharahsheh and pius suggestion that interpretivist research focuses largely on achieving indepth understanding of the complex and subjective realities of the research participants 10 participants were chosen to gain some insight into how black women negotiate their being belonging and becoming in a south african university to give a sense of who the research participants were all 10 were black women academics and all of them held doctoral qualifications furthermore the participants were at different stages of their academic careers with some being contract lecturers and others being associate professors we used semistructured interviews as a main data generation tool for this paper in light of the then covid19 regulations and social distancing guidelines all interviews with the research participants were held through various online platforms such as the microsoft teams zoom and whatsapps video call the interviews ranged between 45 minutes to around 90 minutes in length we strongly believe that semistructured interviews were a powerful methodological tool to access the stories narratives and voices of women academics as they navigated and negotiated their belonging in the university this paper forms part of a larger project on higher education transformation and decolonisation that was a research hub for academics and postgraduate students in a researchintensive university in south africa in this project we explored different aspects of institutional cultures in a south african higher education institution ranging from black early career academics experiences black women academics negotiation of entry and success at university the growing massification in higher education decolonising the curricula and the complex studentstaff challenges of the emergency remote teaching and its implication for transforming the higher education sector we obtained the necessary ethical clearance as well as gatekeeper permissions we also provided both in writing and in digitalaudio recordings informed consent from the research participants who took part in this paper all names used below are pseudonyms it is also important to be selfreflexive about our own positionality in the research as well as the research power dynamics that may be involved the first author was a former staff member in the data generation site this made it convenient to access not only the research site but also willing research participants who did not decline when invited to take part in the study because of the prior relationships access trust and collegiality between them and one of the authors this meant that the positionality of one of the two authors of this paper played an instrumental role in aiding us to generate data more easily than it would have been for outsiders in an earlier research article the first author of this paper proposed two types of positionalities that we should contend with when it comes to educational research namely 1 physical positionality in relation to locationgeographyphysical standing of the researchers and 2 epistemic positionality in relation to ones scholarly or intellectual standing in relation to what is being researched in this paper the epistemic positionality largely speaks to our interests as decolonial scholars who see and read higher education in south africa as an imperial colonial apartheid and heteropatriarchal institution therefore exploring and theorising black women academics experiences fundamentally helps the pursuit of the transformation agenda in the sector in this paper data were analysed in two ways firstly we adopted a thematic analysis in an effort to transcribe the data ourselves reread the transcripts to gain familiarity and indepth understanding code it and create themes secondly we relied on intersectionality to theorise the data and to see to what extent the findings could be broadly reflective of the issues of power marginality and intersectional forms of oppression for women academics we now turn to the findings and discussions of the paper the findings and discussions the findings in this paper are divided into two sets of themes that emerged from the data that is 1 the idea of being an accidental academic for black women academics and 2 the crucial role played by formal and informal mentoring in the success of black women academics the accidental academics in her paper the theatrical and the accidental academic an autoethnographic case study jo franklin wrote about herself as an accidental academic who had not originally intended to become an academic she was only interested in theatre and the performance arts through the use of autoethnographic research she theorised her own existential insecurities and academic imposter syndrome as largely emanating from feeling that she was a perpetual outsider forever dislocated and dispossessed from the academy a large number of our research participants expressed similar thoughtsthat they had not originally intended to become academics for most of them their frustration with basic education had forced them to apply for jobs outside of schooling with most of them landing in university accidentally and ultimately deciding to stay thembi and mandlakazi narrated i would be very honest with you i didnt choose to be an academic i just applied for a job it was not my intention to become an academic or what i just saw a job and wanted a change of scenario from the department of education with its frustrations to a different environment so i didnt aspire to be an academic whatsoever i just find my way im learning to be an academic and i am still adapting let me say i just happen to land in the academia by chance or by default i was in basic education for several years but the thing is i was studying so you know when i dont know if you have taught in basic education with basic education there is nothing much about studying you know they are not really interested in you studying in terms of career growth so at some stage when i submitted one of my completed degree certificates you know for cash back and then they told me that you see this is the last time we are giving you cash for any qualification that you will do now you wont get anything so i was like okay and at that time i was studying again thembi and mandlakazi commented on how their entry and access to higher education in a south african institution was largely accidental in that they did not purposively plan to be academics this is largely reflective of the broader literature on black academicshow they either changed jobs to head on into higher education or alternatively stayed in university through various student and parttime employment contract posts thembi above who was still learning to be an academic reflected franklins deliberative term of emerging academic to denote the struggles that women academics have to navigate and negotiate in order to find themselves and their places in the university for mbali another research participant what inspired her to become an academic was seeing a red doctoral gown during the graduation ceremonies that triggered mbali to stay in the academy and to pursue a career in higher education i came into higher education as a student and the plan was to just get a degree and go but in my first year i heard that people who sing at a choir boom into graduation ceremonies then i said although i cant sing but i need to be in a choir now so that i will be able to see what happens there so i joined the choir because of that while i was there there were a lot of black gowns i think there was only one red and i was like how come we have so many black and only one red so i fell in love with that gown i said oh okay so black is for everyone so now i just need to have the red one mmmmh but i didnt know that by pursuing the red gown now it will lead me into higher education in becoming an academic one can deduce that mbalis experience of being inspired by the choir the singing and the beautiful red grown was symbolic of vincents new materialism argument that objects pictures floors and buildings among otherstogether with our bodieshave agency and collectively shape and affect us taking this idea further the choir buildings graduation ceremony the beautiful bright red grown all had a material effect on mbalis decision to stay on and become an academic decolonial scholars often see and recognise these as imperial and colonial architectures and for mbali it was the very same materiality that made her decide to stay in the academy and pursue a career in higher education another important theme that came from the data was around the importance of formal and informal networks and connections of mentoring in the academy and the role they played in helping black women academics navigate their belonging and success in university we now turn to this theme formal and informal mentoring for the black women academics who took part in this study mentoring played a significant role in helping them access and to some extent succeed at university mentors who are often black academics themselves are instrumental in the growth and progress of black women ecas who are often new to academia and overwhelmed by the challenges such as an intensive teaching load the neoliberal demands of publishing starting a community engagement project or being able to supervise postgraduate students effectively and successfully for nandipha her eca journey was relatively enjoyable and productive because of how her mentor helped her with teaching research and even conference presentations when i completed my masters and i was going to start my phd my supervisor was my mentor right she has been like even when it comes to teaching she was my mentor there she was there she let me observe her lectures she showed me the channels where i can get help how to assess how to teach in a university so to navigate even in research you know how like a student you are not sure about something i could always go to her and ask i am always curious i had questions related to research and she was willing to answer me my goto person even in my first conference she was there like how to write an abstract presenting and progression of the presentation because she had been to conferences for nandipha her mentor became her social capital network and connection that allowed her to navigate the challenges of teaching and learning how to cope with the demands of masters doctorate as well as delivering a conference presentation pithousemorgan et al remind us that ecas are often left to sink or swim in the university and miller conceded that senior academics who themselves may have been left alone to navigate the difficult terrains of academia could very well be testing ecas ability to survive the challenges of higher education it was hollywood et al and bosanquet et al who revealed how ecas workload is often disturbingly too high resulting in them feeling shattered stressed swamped and constantly feeling under pressure to performand yet so unable to for nandipha the support mentoring and care she received from her mentor enabled her to avoid such pitfalls and challenges in her academic life for another research participant sinenhlanhla it was the recognition and being seen by one of the academic staff members in the department that made a difference for her academic career and gave her an opportunity to tutor and to teach at university i remember it was dr x who said you have a potential so you should come and teach here in education studies i went to teach in ed studies and i have been lecturing since 2013 till up until today ive never stopped because i was called in by dr x i stuck to him so i wanted to understand how he taught in class because everybody was raving about this man he is such a human being he understands us as students he is passionate and he understands where each person is coming from in ubuntu philosophy and the gender crisis within south africas higher education sector nyoni and agbaje wrote about women academics experiences grappling with the deeply entrenched prejudicial hegemonic patriarchal practices in higher education often insidious implicit assumed and taken for granted these sexist heteronormative and patriarchal tendencies often present themselves through inside jokes departmental traditions doubting the competencecalibreperformance of the women academics and other forms of gender harassment and discrimination these concerns were also reflected on and theorised by feminist intellectual donaldson in her chapter titled what about the queers the institutional culture of heteronormativity and its implications for queer staff and students there donaldson argued that universities are heteronormative spaces that tend to marginalise and ostracise nonnormative genders and sexualities with this exclusion presenting itself through various institutional policies curricula practices and traditions that continue to show that those who do not conform to hegemonic gender and sexual identities end up being excluded for the black women academics who took part in this study the implicit and insidious genderbased harassment and patriarchal practices were also apparent through mentoring and support from a large number of mentors who were male colleagues who often make them feel uncomfortable mbali comments below on how she was often made to feel uncomfortable by male academic mentors especially in the manner in which they spoke to her touched her and monitored her behaviour on campus this was similar to how she was treated by the male security staff on campus as well as her male students those things would be making you feel uncomfortable because sometimes like okay i do need the help but i dont like the way that you are touching me am i supposed to speak up or if i do speak up what is going to happen to our working relationship so i need to tread carefully to say that i dont upset you at the same time i am feeling uncomfortable and then you get the same vibe from the security guards as you are entering campus they are friendly others are even at some point like your car is dirty can we wash your car so you wonder if your male colleagues are getting the same treatment others would be delivering fruits to your office but then you wonder how you know that im in my office now for you to be able to deliver fruits so now am i under surveillance when im on campus then you get students too who as especially as a young academic who are behaving in a strange manner you cant tell for real to put your hand on it to put your feet down asking myself is he hitting on me or its just me mbalis comments on existential tensions in grappling with and responding to the sexual harassment surveillance and mentoring that she was subjected to talks to the intersectional complexities of mentoring for women academics and how that is often a site for power harassment discrimination and abuse for mbali this became an existential crisis because she did not know whether she was overthinking things whether she was really feeling that discomfort and what the possibilities might be if she articulated her frustrations and reported them to the university in a paper titled mentoring sexual harassment and black women academics brown wrote about male colleagues asking her if she wanted to be mentored this often resulted in the following invitations to talk were often located at offcampus bars in hindsight these black male wouldbe mentors wanted to be as far away from the watchful eye of the university personnel and used the guise that they could only be free to speak their minds and offer sage advice off campus these mentoring sessions become sexual sites for predators to hunt isolate and prey on black women academics often under the operational discourse of sistahs understand the culture and the plight of being a black man on a majoritywhite campus these male colleagues use the progressive language of black radical solidarity to recruit pursue hunt and prey on black women academics knowing that black solidarity could potentially save and shield them from scrutiny blame and accountability there are a number of implications for this gender harassment exclusion and oppression firstly it corrupts and undermines the very purpose of mentoring especially for black ecas struggling to negotiate their entry access and success at university secondly it creates a perpetual system of selfdoubt selfpolicing and selfmonitoring for black women academics who eventually become the typical angry black women in academia who do not have the needed support and protection thirdly it maintains and reinforces higher education as donaldson correctly diagnosed it as a heteronormative and patriarchal space that protects sexual predators who prey on the vulnerable without accountability we now turn to a theoretical discussion of the findings returning to intersectionality as mentioned earlier collins suggested that there are at least four overlapping intersectional and interconnected domains of power that operate in our lives that is the structural domain the cultural domain disciplinary domain and the interpersonal domain in this paper the structural domain includes the university departments offices and other institutions in higher education that serve as imperialcolonialapartheid inventions that continue to render black women academics as nonbeings who do not possess the right kind of ontological and epistemic orientation to be recognised as human beings in the academy heletas ndlovugatshenis and kumalos argument remains valid that the university in south africa is a colonial outpost reflecting nothing of the local indigenous communities who live breathe and walk the land in the cultural domains and in relation to this paper we see two things firstly we see the growing communities of practice amongst both senior and junior academics through formal and informal networks that are meant to help ecas negotiate their entry access and success in higher education these networks are instrumental to the growth development and progress of black women academics because they help them manage teaching and learning research and conference presentations although six tonts and huschke cautioned against informal networks and connections as being fragile unstable unreliable and unsustainable in that they tend not to provide the right kind of information protection and safety our participants revealed that they largely benefited from these informal networks because they allowed them to choose their own mentors who knew saw and understood them furthermore the cultural domains together with the disciplinary and interpersonal domains seem to align to produce new forms of marginality for black women academics in relation to the everprevailing and deeply ingrained or institutionalised heteronormative and patriarchal structures in higher education that continue to oppress alienate and colonise them failure to tackle these heteronormative patriarchal and predatory practices through the disciplinary domains will render any meaningful attempts at decolonial and transformative interventions in higher education void in lieu of a conclusion the public university in south africa continues to struggle to respond adequately and systematically to the growing calls for transformation and decolonisation in the sector largely shaped and impacted by two movements that is the feesmustfall and rhodesmustfall protests of 20152016 as well as the emergent covid19 pandemic in march 2020 the university in south africa remains an untransformed colonial outpost in this paper we have explored and theorised black women academics experiences at university through the use of a qualitative interpretivist case study the findings of the paper reveal that black women academics tend to be accidental academics whose journey into academia has been characterised by career breaks resulting in later return to a career in higher education the second finding reveals the important role played by both formal and informal networks in the growth development and success of black women academics in higher education with senior academics often mentoring black ecas to cope with their teaching and learning research and conference presentation commitments perhaps more troubling for us black women academics have to navigate and negotiate the patriarchal sexist and genderbased harassment that often presents itself through mentoring and support this predatory behaviour is often designed to hunt prey upon and take advantage of black ecas the behaviour results in black ecas constantly and existentially questioning themselves and wondering to whether they can report such behaviour and the implications that might have for their employment safety and working conditions thus based on the above discussions we recommend that higher education institutions enact formalised mentoring support systems for black ecas to ensure that such forums have monitoring and accountability mechanisms these could be built into promotions policies to incentivise senior academics into playing an active role in such institutional programmes furthermore genderbased discrimination harassment and predatory behaviour are real for ecas universities should put better systems in place to make sure that academics can anonymously and confidently report such incidences without repercussions for them or their wellbeing finally higher education institutions remain heteronormative spaces that exist on the racial gender and sexual differences this is indicative of the racist sexist patriarchal and classist forms of abuse that black academics continue to experience in higher education decolonial scholars who are rethinking reimagining and reconsidering the public university in the global south can help us to consider what an inclusive socially just democratic and nonheteronormative university might look like for us many of these decolonial conversations often have the gender question missing from them future research could help us think through how the decolonial university or what mbembe called the pluriversity might look and feel like for all the different modes of being seeing and living in the academy

in this paper we adopt an intersectional lens to explore and theorise the complex experiences of black women academics in a researchintensive university in south africa we purposively recruited 10 black women academics ranging from early career academics lecturers to senior professors in the field we relied on intersectionality to theorise black women academics challenges in navigating and negotiating their being and belonging in the university we used semistructured interviews as a data generation method to elicit the narratives storiesexperiences of the black women academics the findings revealed two things firstly they revealed that a large number of the research participants were accidental academics in higher education due to the nature of their entry and access to the university secondly the findings also showed the important role that formal and informal mentoring plays in higher education as a catalyst for helping black women academics access negotiate and succeed at university we conclude this paper with some thoughts on the need for formalised and wellstructured mentoring systems in higher education to support black women academics access being and belonging in the university

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urbanizationone of several factors associated with the adoption of diets high in fat and refined sugar and sedentary behaviours underpins the obesity epidemic in latin america and the caribbean this pattern characterizes the fourth stage of the nutrition transition whereby increasingly urban populations consume diets high in fat sugar and processed foods these lifestyle factors drive higher morbidity and mortality from degenerative diseases migration from rural areas to citiesthe largest contributor to urbanization within the global south † provides a context for examining emerging dietary patterns associated with urbanization urban haiti like many cities in the global south has experienced a rise in obesity and associated noncommunicable chronic diseases including hypertension and diabetes although the obesity prevalence in haiti is low relative to other latin american and caribbean countries the national prevalence among women aged 15 to 49 years has more than doubled from 2•6 in 19941995 to 6•3 in 20052006 and 7•8 in 2012 in 2006 among the adult population of portauprince 48•7 of men and 46•5 of women were hypertensive and the agestandardized prevalence of glucose intolerance was 11•2 among men and 16•9 among women higher than the average among urban latin american and caribbean inhabitants these changes occur even as underweight and stunting in the countrys rural areas remain primary concerns ruraltourban migrants encounter new built and social environments and labour arrangements that may alter diets and activity levels in urban food environments sugary fatty prepackaged and processed foods are available in greater variety and closer proximity although haiti itself has low manufacturing capacity processed foods are imported and declining tariffs between the usa and the caribbean have increased the availability of highly processed foods and further fuelled the nutrition transition furthermore new urbanites come to rely on purchased foods and favour convenient products as employment opportunities pull primary food preparers from the home research examining dietary behaviours among adult migrants in the global south concludes that ruraltourban migrants have diets higher in fat from oils and animalsource foods sugar and sweeteners and energy which contributes to rising obesity and cardiovascular health conditions ruraltourban adult migrants in india consume western foods more frequently than nonmigrant family members in guatemala both sweetened beverages and red meat were consumed more frequently among ruraltourban migrants however no such study examines related outcomes among younger migrants even though youththose aged 12 to 24 years compose a substantial proportion of migrants in haiti more than half the youth population has migrated at least once and ruraltourban migration is the primary pattern focusing on youths dietary behaviours as they adapt to an urban context is merited because early life course health has a cumulative impact on degenerative disease development moreover dietary behaviours when acquired young are difficult to modify youth migrants encounter greater food variety and a new social context in urban destinations at a time when exposure to novel experiences may alter their behaviours youth experience rapid physical social and psychological development and the amount of time spent with peers and peers relative importance increase migrant youths new peer groups in urban areas may transmit dietary ideals and practices and social engagement with peers generates exposure to these ideals and practices among haitian adolescents food and beverages are commonly shared to build and reinforce social alliances and youth migrants may seek cues about how to act from urban peers as a way of integrating into their new environment and attaining status peers may also convey ideals about food choice and encourage particular products which may be experienced as peer pressure among new migrant youth building on previous literature we aim to examine how migration facilitates the consumption of highsugar beverages and fried snacks among ruraltourban youth migrants we focus specifically on differences in the diversity of hsbfs products consumedone mechanism that may influence youths eating behaviours and promote increased consumption to our knowledge no study to date specifically examines the diversity of hsbfs consumption among youth migrants therefore we first assess this association based on previous findings among ruraltourban adult migrants we hypothesize that migrant youth will consume a greater diversity of hsbfs products we further test whether consuming a greater diversity of hsbfs products among migrant youth is conditional on having high peer social engagement we hypothesize that joint exposure to an urban environmentwhere hsbfs products are more readily availableand a high level of social interaction with peerswho may encourage consumption of hsbfswill account for the diversity of hsbfs products consumed methods design and participants these data were collected as part of the haitian youth transitions study the study recruited a cohort of youth who had recently completed primary school in the rural section of a commune in southeast haiti primaryschool directors provided lists of students who completed their 6th grade exams in the summer of 2011 all students were invited to participate recruitment youth baseline interviews and parent or guardian interviews occurred in august and september 2011 followup interviews occurred in february and march 2012 after approximately onefifth of participants had migrated to an urban area interviews lasted approximately an hour and participants were interviewed in haitian creole their native language by trained interviewers questions were posed orally and interviewers recorded responses the interview began with a lifehistory calendar to record migration information and develop rapport between the interviewer and participant it then included questions on health behaviours and social context ethnographic fieldwork and semistructured interviews conducted prior to and during the survey period informed its design content and question wording in the discussion we inform our quantitative findings with these qualitative data the present study analyses data from the 215 youth who were interviewed at followup in february and march 2012 when hsbfs diversity was measured the study was conducted according to the guidelines of the declaration of helsinki and all procedures involving human subjects were approved by the institutional review board of the pennsylvania state university additionally a local organization dedicated to the preservation of human rights and the communes local government approved the research verbal informed consent was obtained from participants aged 18 years and older for participants younger than 18 years their verbal assent and the verbal consent of a parent or guardian were obtained these were witnessed and recorded before the interview began measures table 1 includes the question wording and variable coding at followup to measure the diversity of hsbfs products consumed participants were asked to recall the previous days food consumption based on a list of common food products accessible to both urban and rural youth the list contained six hsbfs products including sweetened fresh juice bottled juice soda sport shake prepackaged fried snacks and fried street food consumption of each item on the previous day was a binary variable the six hsbfs product categories were summed youth were identified as migrants based on their lifehistory calendar which was completed at baseline and augmented at followup to reflect changes that had occurred since baseline peer social engagement was binary at followup it combined responses to questions on organized and nonorganized social activities youth who participated in organized youth activities during the past three months received a score of 1 regarding nonorganized social activities youth were asked how they spent time with peers of the same sex and opposite sex interviewers recorded up to two responses for each of these openended questions we classified these responses as either social or nonsocial and scored responses separately for samesex and oppositesex peers if either reported activity for each question was a social activity we classified the response as social we summed values for whether youth participated in organized social activities nonorganized social activities with samesex peers and nonorganized social activities with oppositesex peers youth with a score of 3 had high peer social engagement peer social engagement at baseline was again binary but was limited to nonorganized social activities as organized youth activities are less common during school vacations when baseline data were collected youth were asked how they spent time with samesex and oppositesex peers nonorganized social activities were coded the same for baseline and followup and the values of nonorganized social activities with samesex and oppositesex peers were summed those with the maximum score were classified as having high baseline peer social engagement because baseline data were collected during summer vacation when youths social activity patterns differ from the school year and because the baseline and followup peer social engagement variables were constructed differently the values of high peer social engagement at baseline and followup cannot be compared directly with one another however the values can compare migrants and nonmigrants with one another at baseline and followup food security combined responses to two questions adapted from the household hunger scale how often did you eat less and how often did you go without eating because of insufficient money or food responses were combined into a zscore higher scores indicate higher food security at baseline a parent or guardian answered questions on durable goods ownership land ownership livestock ownership housing quality and remittance receipt the responses were combined to form an asset index using principal components analysis the asset index reflects the overall wealth of the household where the youth lived at baseline baseline variables are used because asset index values are not comparable between rural and urban households and migrant youths access to resources corresponds closely to their home of origin school day refers to whether the reference day for food consumption was a school day gender refers to the youth and youths age was measured at followup analyses we first calculated descriptive characteristics for all variables and used t tests to compare migrants and nonmigrants on these characteristics we then used ordinary least squares regression to examine how each independent variable is associated with diversity of hsbfs consumption at followup we then used multivariate ordinary least squares regression to predict the diversity of hsbfs products consumed at followup using covariates from both the baseline and followup surveys model 1 includes only migration and high peer social engagement model 2 includes an interaction between migration and social engagement to test whether the association between the diversity of hsbfs consumption and migration varies across high and low peer social engagement model 3 builds on model 2 and controls for followup food security baseline peer social engagement baseline family assets gender age and whether the day for which consumption was measured was a school day all analyses were conducted using the statistical software package stata 12•0 and used multiple imputation procedures to avoid the loss of the eighteen respondents for whom at least one response was missing in this approach multiple data sets were generated in which missing values were replaced with plausible ones using imputation by chained equations using the mi estimateprefix estimates were calculated separately for each data set and the results were combined reported point estimates are the average values across the ten data sets and standard errors were calculated according to rubins rules results descriptive and bivariate characteristics table 2 describes the characteristics of respondents in the hyts information is reported for the complete sample and separately for migrants and nonmigrants the final column indicates whether values for migrants and nonmigrants differed significantly on these values at baseline migrant youth came from wealthier and more foodsecure households they were also on average 1•1 years younger than nonmigrant youth migrant and nonmigrant youth did not differ significantly at baseline in their levels of peer social engagement gender or whether they were the child of the household head turning to characteristics at followup 21•9 of respondents migrated to urban areas and of these 77 migrated to portauprince migrants reported consuming a wider diversity of hsbfs products during the previous day than nonmigrant peers who remained in rural areas approximately onequarter of migrants compared with onehalf of nonmigrants reported high peer social engagement at followup migrants likely engage with peers less frequently because they are still adapting to new social environments migrants reported higher food security than nonmigrants and fewer migrant youth referenced a school day for food recall table 3 describes how each independent variable that would be included in the multivariate models is associated with the diversity of hsbfs products consumed as was found in table 2 migration was positively and significantly associated with the consumption of a wider diversity of hsbfs products there was also a marginally significant positive association between high peer social engagement at followup and wider diversity of hsbfs consumption similarly baseline peer social engagement was positively associated with increased diversity of hsbfs consumption food security at followup was positively associated with wider diversity of hsbfs consumption and wealthier youth consumed somewhat more hsbfs products gender school day and age were not significantly associated with diversity of hsbfs consumption multivariate models multivariate models examined if the number of different hsbfs products consumed on the previous day varied by whether youth interacted frequently with their peers and if the findings were robust to control variables model 1 included migration and peer social engagement when included together the effect for migration was positive and significant as was the effect for peer social engagement the increase in the magnitudes of both variables when they are jointly included in the model fulfils the standard definition of positive cooperative suppression which occurs when the third variable is negatively associated with the primary independent variable as is the case herein this suggests thatalthough migrant youth have lower peer social engagementengagement with peers in the urban environment may further foster hsbfs diversity in model 2 with the migration by high peer social engagement interaction neither the conditional main effect of migration nor high peer social engagement was significant however the interaction term was significant interpreting these findings in the context of the interaction term the nonsignificant effect of peer social engagement indicates that there is no significant effect for peer social engagement among nonmigrants likewise the nonsignificant effect of migration indicates that among those with low peer social engagement migration is not associated with hsbfs diversity however the positive interaction term suggests that the combination of migration and high peer social engagement is associated with consuming 1•5 more hsbfs products on a daily basis these findings indicate a multiplicative effect moving to urban areas and being socially engaged with ones peers are jointly associated with increased hsbfs diversity in model 3 we examined if the findings hold after controlling for confounding factors the migration by high peer social engagement interaction was minimally attenuated food security is the only control variable that was significant in the multivariate model baseline peer social engagement was moderately and positively associated with hsbfs diversity the remaining variables included in the model were not significant we used the estimates from model 3 to calculate the predicted value of hsbfs diversity for migrants and nonmigrants with low and high peer social engagement while holding the other variables constant at their means as a whole these findings support our hypothesis that joint exposure to both the urban environment and interactions with peers contributes to consuming a wider diversity of hsbfs products we tested the sensitivity of our finding using alternative specifications of the peer social engagement variable our findings did not change substantively 0•08 1•11 food security 0•45 0•13 0•77 family assets 0•13 0•11 0•36 male 0•09 0•68 0•49 intake day is a school day 0•20 0•30 0•69 age 0•07 0•03 0•17 constant 1• discussion our findings reveal that ruraltourban migrant youth consume a greater diversity of hsbfs products on a daily basis than their peers who remain in rural areas previous studies observe higher intake of sugary fatty and processed foods among ruraltourban migrants compared with rural nonmigrants consistent with the nutrition transition these provide examples of how urban environments contribute to the increased consumption of processed foods the current findings build on these previous studies and suggest that one mechanism underlying increased intake found in previous studies may be that ruraltourban migrant youth consume a wider diversity of hsbfs products furthermore because we control for food security and family assets it is suggestive that migrant youth consume these products in addition to regular meals not as a replacement for them this is consistent with a pattern of food consumption in urban environments where these foods are readily accessible particularly in portauprince where the availability of these products has expanded in recent decades turning to the second component of our study our findings support the expectation that the association between migration and hsbfs diversity varies by level of peer social engagement migrants with high peer social engagement consume on average 4•3 products daily and nonmigrants with low peer social engagement consume an average of 2•1 products moreover because this finding persists after controlling for peer social engagement at baseline it is unlikely that the effect of peer social engagement measured at followup reflects innate personality characteristics and likely that it reflects the migrationadaptation process the findings raise an important question why is peer social engagement associated with consuming a greater diversity of hsbfs products among migrant youth we propose two potential explanations first young migrants aim to fit in and adapt to their new environments a wide range of studies from western countries and the global south demonstrate the importance of peer influences and peer approval on youth behaviour hsbfs consumption may have a strong social component when purchasing and sharing soda or a bag of chips youth also forge friendships as food sharing builds social alliances in haitian culture in haiti these products are widely sold and consumed in public spaces where youth congregate such as school yards and social gathering spaces thus consuming hsbfs coincides with peer interactions food choices particularly popular snack products may also result from peer pressure which has been demonstrated by evidence from western countries and the global south as a whole as migrant youth adapt to new urban environments peers may be important models of behaviour food choices and consumption may be one way that young migrants adapt to new environments develop social bonds and fit in with their peers a second complementary explanation is that spending time with peers may facilitate access to and the consumption of these products ruraltourban migrants may learn how where and what to purchase from their urbansavvy peers moreover peers may educate migrants about their new environments indirectly as they discuss preferred products thus alerting migrants to these items and encouraging their consumption other examples of how social networks encourage new health behaviours exist novel contraceptive ideals may be transmitted during mundane activities within informal social networks overall our findings provide evidence connecting urbanization to the consumption of a greater diversity of sugary and fatty foods declines in physical activity also contribute to the nutrition transition and complementary qualitative findings provide evidence for the decline in physical activity and the increase in body fat as part of the hyts the first author conducted semistructured interviews with selected respondents although they were not asked specifically about changes in activity levels their responses support other aspects of the nutrition transition when migrant youth were asked to describe how life in their new urban location differed from life in the countryside responses describing reduced physical activity were common some examples included transportation changes i dont walk far to go to school anymore and people dont walk they take vehicles they also highlighted the reduction in physical labour now we get water from a pipe nonmigrant youth observed similar changes among their migrant peers during interviews nonmigrants were asked to describe the changes they observed among migrants who had returned home for vacation one 12yearold girl explained how her older migrant siblings no longer walked anywhere interviewer when your brothers and sisters went to portauprince to live and then came back on vacation do you think they changed respondent yes interviewer how so respondent yes it isnt like its everyone but there are a lot of people who get fat bodies they live without things that cause their hearts to jump out of their chests they are at ease they get fat but it isnt everyone these complementary qualitative findings suggest that the nutrition transition may also operate through an increase in sedentary lifestyles among ruraltourban migrants and the consequences are observed through increases in body fat limitations and future research despite the contributions of the current study it suffers from limitations migrants and nonmigrants may differ from one another on unobserved characteristics related to migration itself and hsbfs consumption that we are unable to control for in our study such differences may mean that migrants consumed a wider diversity of hsbfs products at baseline however the lack of baseline food consumption data prevents the analysis of these differences importantly the design of the study reduces heterogeneity among respondents by selecting a relatively homogeneous population of youth from the same rural villages who completed primary school together additionally food categories were limited to popularly consumed food and dichotomous responses without assessing the quantity consumed this limited our ability to distinguish among individuals who consumed either large or small amounts of hsbfs however we judged this method to be most effective given that respondents were unfamiliar with food recall surveys and would likely be unable to respond to more detailed recall methods our findings may also suffer from respondents bias towards socially favourable yes responses although this may lead to incorrect conclusions about the overall consumption levels it is less of a threat to the ability to differentiate between the eating habits of migrants and nonmigrants moreover any bias towards yes responses likely reflects favourable attitudes towards the product and a desire to consume it if given the opportunity the study is also limited by its short time horizon the vast majority migrated to start the school year in october five months prior to when food diversity was measured thus we are unable to draw conclusions about the lasting effects of these dietary changes future studies should consider whether the observed changes in dietary consumption lead to changes in weight status or the development of other related health conditions the present study opens the door for future work that unravels how peer social engagement encourages higher hsbfs diversity and consumption we propose two potential mechanisms by which peer social engagement and consumption are related that youth migrants adapt new patterns to fit into their new environment and that peers indirectly encourage diversity of hsbfs consumption the role of each factor could be examined by questions that ask about how youth access these items and examine their attitudes towards peers who consume these specific items further work to unravel these processes may reveal strategies for promoting healthier food choices among youth conclusion by comparing ruraltourban youth migrants with rural nonmigrants the present study offers a unique contribution to the current literature on the nutrition transition whereas previous research has concluded that ruraltourban migrants within the global south consume more fatty and sugary foods we conclude that adolescent migrants eat a wider diversity of these foods than their nonmigrant peers we also expand previous literature by highlighting how migrant youths engagement with their new peers may facilitate hsbfs consumption as they adapt to the urban environment our findings should be considered with respect to migrant youths individual health trajectories high hsbfs consumption is associated with overweight and developing morbidities that include hypertension diabetes and cvd our findings imply that migrant youth in urban areas consume a wider diversity of hsbfs and may develop strong preferences for these products in turn they may also increase the quantity of hsbfs they consume and eventually be at risk of developing degenerative health conditions

objective the present study examines whether ruraltourban migrant youth consume a greater diversity of highsugar beverages and fried snacks hsbfs compared with their peers who remain in rural areas it also tests whether the association between migration and hsbfs diversity is moderated by migrant youths social engagement with their peers design participants were recruited in august and september 2011 following the completion of primary school 6th grade and shortly before many rural youth migrate to urban areas participants were reinterviewed six months later hsbfs diversity was assessed at followup analyses control for baseline and followup characteristics setting baseline interviews occurred in rural southeast haiti followup interviews of migrants occurred at urban destinations in haiti subjects the sample includes 215 youth mean age 15•9 years 43•3 female 21•9 ruraltourban migrants who were interviewed at baseline and followup results ruraltourban migrant youth consumed a greater diversity of hsbfs products at followup than their rural counterparts b 0•70 p ≤ 0•05 moreover we found that this relationship varied by level of peer social engagement youth who migrated and had a high degree of peer social engagement consumed 2•2 additional types of hsbfs products daily than their counterparts who remained in rural areas and had low peer social engagement conclusions higher hsbfs diversity among migrant youth is consistent with the patterns proposed by the nutrition transition interactions with peers may have an important influence as migrant youth adopt new dietary preferences emerging dietary patterns among youth migrants have important implications for health trajectories and the development of degenerative diseases

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introduction and background worklife balance of women employees is an integral issue in the employment world globally there is ample evidence in the academic literature which shows the issues benefits and need for policies to help women in their work environment however although these factors are well known little has been researched with the recent disruption due to the covid19 pandemic on the effects on female academics this study aims to compare the opportunities and challenges of female academics in australia and africa during this period of disruption so as to understand the female academics workloads and related issues when the world of higher education was forced to deliver programs digitally mainly from their homes research by lunyolo et al reports that sociocultural barriers hinder women not only in academia but also in other areas further morley explains that the culture in academia is frequently viewed as unfriendly and unaccommodating to women in africa nomadolos work shows that the gender stereotypes and prejudices are exhibited by a number of organizations with males classed as privileged although gender equality in africa and australia are at different stages some countries in africa have policies in place to ensure gender equality eg south africa although women remain marginalized however australia is much advanced for example with the australian equal opportunity law promoting women in the workplace literature review working from home the balancing act the rapid transition almost overnight for many from working at a desk in an office to working from home has been reported to have many positive benefits these include increased flexibility which may have led to the reported decreased burnout increased worklife balance satisfaction and where many stated they could sustain wfh indefinitely the remote work has shown to strengthen employee and employer relationships through its support of employee wellbeing the nature of work and womens roles in the pandemic period has shown that women have adapted in numerous ways such as sacrificing work and nonwork roles and boundaries have been managed through structural support such as flexibility and social support such as empathy the term boundarywork has been used by wethal et al to describe the changes that have been made to recalibrate work and home duties and can also be referred to as boundary traffic as a congestion between home and work the shift to wfh has shown many benefits and positive outcomes many issues in worklife balance have also been reported these include increased work in traditional gendered role responsibilities blurred delineation between home and work lives and increased depression exhaustion and burnout female academics in particular are managing multiple and demanding roles in their home environment preand during covid19 it is reported that in the middle east and in north africa it is as high as 8090 gendered issues females have been impacted during covid19 with increased care roles increased household responsibilities being able to manage home schooling while managing their own workloads highpowered women balance professional and home lives spectacularly ethnicity and cultural context play a role in barriers to how well female academics have been able to manage work and life balance where those of africanblack females stated greater issues in cost of communication connectivity social isolation and a high burden of care responsibilities with external family members greater gender gaps have now been reported since covid19 with perceived job satisfaction and distractions and disturbance from family and decreased motivation toward career progression the current pandemic has deepened the inequalities among genders and is an issue that needs attention and adequate response by higher education institutions madgavkar et al are pushing the key message that the sooner the policy makers and leaders act on gender equality as covid continues the greater the benefits for economic growth academic transition to online teaching and learning online teaching and learning have now become the new norm the way academics and heis have had to adapt in a short space regardless of their academic preparedness digital technologies have taken the interest of heis due to its ability to manage the high volumes of inperson teaching the most commonly used mode of teaching prior to the impact of covid19 academics have certainly transformed themselves in their understanding of online pedagogy and have been thrust into learning about digital technologies academic online integrity and managing online engagement with their students in both synchronous and asynchronous modes evidence since the start of covid19 supports the need for academics to create an engaging online environment to encourage student interaction communication motivation and learner achievement all of these require a great amount of effort to accomplish especially if it is a new mode of teaching the support mechanisms for academic staff thus have become a critical element of hei importance during this pandemic adequate support and resourcing are critical at classroom level for pedagogical support quality professional development academic integrity of teaching and assessment practices and at institutional level including adequate resourcing technological infrastructure numerous online tools and technologies have been applied with the learning management system being one of the most common platforms across heis for information management communication and assessment upload regardless of the digital technologies if academics are not properly supported through their online methods then the students can be passive learners who are disengaged with academic staff their peers and with content online engagement just as in facetoface engagement remains a key component of maintaining quality pedagogy and assessment practices methodology the research was led through australia where the ethics approval was received through the university of western australia due to covid19 social distancing and with the intention to capture a broad scope of global responses an online survey was developed to collect data from the female academics across the world using a mixedmethod approach with both open and closed questions there were 33 questions in total with 24 being closed questions including demographics and 9 openended questions asking specific perceptions about the academic workload career progression support motivation and academic leadership the specific questions being reported from the larger online survey are s follows 1 what are some of the changes to the academic role being experienced during covid19 2 what are some of the opportunities being perceived by female academics as a result of the changing roles during covid19 the key method used to gather responses came from email invitations from each of the researchers email lists from their universities social media including linkedin twitter facebook and whatsapp and the researchers own academic networks the data were collected from july 2021 to october 2021 with the participants spanning across the globe to seek participation this study explores a comparison between the australian and african respondents as this is where the researchers are based the data were analyzed by applying thematic analysis for the openended questions and descriptive statistical analysis for all closed questions thematic analysis is a commonly used tool in qualitative research adopted to identify analyze describe organize and report themes found within a data set the specific thematic applied was inductive thematic analysis often used in mixedmethod designs as the theoretical flexibility of thematic analysis makes it a more straightforward choice than approaches with specific embedded theoretical assumptions an inductive thematic approach allows research findings to emerge from frequent dominant or significant themes inherent in raw data as used in grounded theory results there were 260 responses from female academics across the globe a total of 171 respondents were included in this study from the larger global study gathering data about female academics experiences during covid19 role changes as listed in table 1 the majority of respondents claimed their workload had increased since the start of covid19 in varying degrees the australian cohort was agreement and the african respondents were most respondents claimed that their workload had increased a great deal australia and africa followed by increased somewhat a smaller of the australian respondents stated that the workload had stayed approximately the same and from the african respondents the lowest response was in relation to the workload decreasing in overall responses with the australian cohort and african cohort in response to having to work remotely the responses were 100 for both cohorts of respondents australia 144 and africa 27 managing working from home with others as reported in table 2 the majority of respondents in both cohorts stated it was easy managing working from home with others which could have included children partners parents friends or coresidents in the australian cohort of academics most found it more difficult managing their workload followed by no difference in the pandemic period with the lowest response that it was easier to manage workload a large majority of the african cohort found it more difficult to manage their workload since the start of the pandemic especially with balancing both work and home duties challenges faced as a female academic since the onset of the pandemic an openended question in the survey asked respondents to comment on what they perceived were the greatest challenges they faced with their workload as a female academic since the pandemic started as reported in table 3 the australian female cohort rated worklife balance as the number one theme followed by health and wellbeing challenges and a perceived lack of support by their higher education institution leadership other lower rated themes included research related challenges gender disparities and managing online teaching from the top theme comments such as the following were reported highlighting the challenges of worklife balance trying to work from home with a 2yr was an absolute disaster had to work while he napped and at night after he went to bed managing family and care needs of family whilst juggling never ending virtual online meetings at all hours a worklife balance is really important for health and wellbeing but we are pushed and pushed to do more this is not okay especially when we are women and also raising children and looking after household duties we are not superwomen although we are expected to be health issues were also stated as follows health is in an issue and i prefer to work at home also have elderly parents in the home and do not want to expose themthis is seen as weak and not committed perhaps a male with similar problems would be given greater slack in females health and home and carer issues are minimised my children have struggled with mental health lack of support was stated as follows coping with initial heavy workload no support and subsequent job loss due to redundancy after 21 years research has been impacted due to the pandemic and this has also caused challenges for female academics as stated as follows inability to conduct fieldwork overseas which is a major part of my research needs and gender issues were also raised in perceived inequities in research opportunities males used lockdowns and online teaching to write papers while females took on extra adminengagement domestic and carer roles in the gender theme there were many statements about perceived lack of care for female academics no one cares about what is happening to women academics females identify challenges of procedures and process and are identified as posturing for power the rhetoric in online zoom meetings are generally male voices in meetings and in the decision making process another major challenge has been identified as the theme of online teaching lack of resourcestight budgetary constraints and no adequate training in online education are my main concernsne teaching and zoom fatigue being more exhausted as i am doing household work and work at the same time while 14 themes emerged from the openended question on personal challenges which the african cohort faced since the onset of the pandemic as summarized in table 4 the top3 personal challenges faced by the african cohort of female academics were wlb extended working hours and access to a private workspace four respondents indicated that they faced no personal challenges since the onset of the pandemic a complete list of emerging themes on personal challenges faced are presented in table 4 worklife balance was difficult to maintain as some academics did not have access to a domestic assistant respondent 143 stated i no longer have domestic help so i am doing more domestic work i have a capable husband who shares the load though he does all the cooking so all in all it is an equal load with extra work for both of us respondents 9 and 143 added that both family responsibilities and employment duties increased this was was cited by a number of respondents knowing when it was time to stop working and end meetings and discussions was difficult respondent 145 stated that she found that work responsibilities take longer in an online way forcing you to work beyond normal hours of duty i cannot work around the clock and yet the university management seems to expect it added respondent 161 not all academics were blessed with a home office setup as the forced transition to work from home was made in the early stages of the pandemic comments related to the absence of a conducive physical workspace highlighted this issue eg working from home with a new baby around respondent 258 added the consciousness of the four walls of the workspace with distractions becomes more difficult when it is difficult to ignore family members when they want to talk especially as i do not have a separate office space to use access to institutional resources also posed a challenge as respondent 258 outlined inability to physically access reading materials from the library respondent 161 shared how this impacted on her own research stating that a research project had to be put on hold as it required students to engage in laboratorybased practical activities throughout 2020 and 2021 and these were completely suspended due to the move to online teaching initially and then the practical difficulties with implementing covid protocols with limited spaceequipment and large classes respondent 260 shared her challenge of accessing students work on all platforms the lack of facetoface contact with colleagues has resulted in me feeling isolated their isnt anyone to share experiences and concerns with or engage in regular discussions with my colleagues around issues pertaining to teachinglearningresearch respondent 161 highlighted the social isolation academics faced respondent 261 supported experiences in managing workload this adding i miss the stimulation and encouragement of work colleagues i feel isolated and not sure what is happening in the academic world even nonworkrelated social isolation was cited the ongoing lockdowns and being unable to see family have been challenging health deterioration and covid sickness contributed to health issues faced respondent 45 indicated that finding supportmentors in particular finding the right support for where i am at was challenging in africa in particular the lack of mentorship for females is more prevalent hard to get men or women to really mentor other women she further highlighted that in africa there are less opportunities for women to get real practical is skills most organisations want men culturally women have other duties to do housework childcare etc respondent 161 indicated that she was uncomfortable with online teaching as she found it alien and disconnected significant increase of cost of living was highlighted by respondent 63 in addition respondent 161 added she was gripped with fear and uncertainty i have felt emotionally stressed and drained by the worry of covid and how it might affect my world which affects my work opportunities created personally and as a female academic since the onset of the pandemic another openended question asked respondents to comment on what they perceived as the top3 workrelated opportunities referring to positive opportunities from the challenges of a pandemic and what academics could take forward beyond the pandemic period slightly more than 50 of respondents stated online opportunities as the top theme followed by teaching and flexibility a complete list of emerging themes on workrelated opportunities perceived by australian academics are presented in table 5 a number of online workrelated opportunities were realized during the pandemic such as ease of remote work and meetings ability to develop new relationships and increased online education and related skills as reported by respondents virtual consultations relationship building up skilling in online education opportunities to upskill in delivery of online content the online theme extended into the teaching themelearning how to use different technologies ability to develop online teaching practices and learning how to manage the transition of in person teaching mode to fully online flexibility was mentioned as a key opportunity allowing the academics to manage work and home giving them a greater wlb easier to manage family care responsibilities greater worklife balance more flexibility in working hours no commuting an interesting response by just over 20 percent of respondents was that they could see no opportunities coming from the pandemic if asking for opportunities for positive change in some waynone i was drowning before and am drowning much more now none the university has less need for my skills my workload as a sessional tutor has decreased by 75 do you mean good things that have come of this none as presented in table 6 not all was gloomy in africa during the pandemic respondent 47 shared that in the more relaxed atmosphere she felt more content no stress of needing to present an appearance of being together respondent 143 stated that she was engaged in selfreflection during the pandemic and ongoing lockdowns given me a lot more time and reflective thinking opportunities respondent 146 noticed that there was an opportunity for new student types during the pandemic stating a growth in student number and diversity for postgraduate degrees mostly working students who enjoy the flexibility of online learning while many academics battled with student engagement in the fully online environment respondent 260 enjoyed better engagement citing that class discussions are great notably the greatest opportunity came from the flexibility which the new work setup brought with it respondent 33 enjoyed teaching from home which as respondent 258 added allowed for increased flexible tutoring the flexibility also allowed some academics to dedicate additional time to students respondent 9 with uninterrupted chunks of time respondent 27 as well as flexibility to attend to family duties respondent 9 the ability to reach a wider spectrum of students was highlighted by respondent 31 more teaching opportunities not controlled by geographic proximityonline flexibility with personal time was also indicated some flexibility with time am able to attend webinars at all hours respondent 161 increased virtual networking and virtual collaboration were highlighted by a number of respondents one of the ironic and unexpected consequences of the pandemic is that fellow academics and researchers all over the world are now much more comfortable communicating in online formats this has made international collaboration much easier i have also been able to participate in global events without physically traveling which is a real blessing on the whole i have met and worked with fellow researchers we have developed such strong connections that i completely forget that we have never actually met facetoface stated respondent 143 this was supported by respondent 188 who stated i feel that i have had more opportunity to pursue my research career i feel this is due to the ability to attend global conferences virtually respondent 31 added that she experienced an increase interaction with academics across borders thus creating more research opportunities with people from all over the world an increase in faculty research collaboration was noted by respondent 8 with more opportunities for sharing and peer discussions opportunities for professional development were created in online learning teaching assessment being able to attend free webinarsconferences online that are presented all over the world that either did not exist previously or i was not able to access previously due to lack of funds to travel this was supported by respondents 182 260 and 261 attending online conferences i would not be able to attend easily as a single parent respondent 35 spoke about the ability to experiment with new technologies like rpa in online teaching respondent 146 highlighted the growth in innovative approaches to teaching using online tools like mural mentimeter kahoot etc even in the arts there was the introduction of new technologies in online programmes for teaching music education respondent 149 respondent 63 alluded to having more time for research when working from home this was supported by respondents 79 and 148 respondent 35 supported the notion of working from home stating lets stay at home it is better to be a good parent as you can multitask funding for online research and research grants increased during the pandemic respondent 9 indicated that working at home gave her the flexibility to attend family duties and allowed her to give quality time to children this was supported by respondent 28 who stated that she appreciated spending more time with family and i actually got time to see my daughter grow and was there for each milestone working online is more economical according to respondent 9 respondent 15 felt that she had access to more online journals during this period supervisor responsiveness to the needs of a female academic worklife balance as can be seen in table 7 the highest selected response for both the australian and african respondents was that they felt their immediate supervisor was responsive to their needs as female academics the lowest response was to the not at all category overall of australian based academics and of the african based academics stated that their supervisor was responsive to their worklife balance needs discussion the result from this research supports the previous work that the female academics face challenges which need to be considered by policy makers in institutions however this comparative study clearly demonstrates that although challenges are present geographic locations have brought different challenges within the context of teaching in a hei the result clearly demonstrates the work from home was perceived very positively by female academics both in australian and africa with both cohorts reporting the ease of managing working from home with others children partners parents friends or coresidents although this was a positive outcome further analysis on managing workload show the need for support for the female academics supporting this premise is that seven out of 10 african female academics found it more difficult to manage their workload since the start of the pandemic especially with balancing both work and home duties compared to just 6 out 10 australian female academics in terms of challenges faced by the cohort there were distinct differences between the cohort the australian female cohort reported the top3 challenges to be worklife balance health and wellbeing and the perceived lack of support by their higher education institution leadership the african cohorts top3 challenges were wlb extended working hours and access to a private workspace this finding also supports the research work of ravi and anulakshmi and mani that worklife balance of women employees is an integral issue in employment but is specific to regional settings this study further shows that both the australian and african respondents felt their immediate supervisor was responsive to their needs as female academics the study suggests that there has been development of support mechanisms during the pandemic for female academics during the pandemic environment however even with this advancement of support for their institutions the study suggests that during the pandemic workloads were an issue and impinged on the worklife balance suggesting that the leadership in higher education institutions develop policies and procedures to support this balance an approach would include female academics in the process for change at the institutional level though challenges were prevalent this study also showed that during the pandemic setting there were also workrelated opportunities the australian cohort listed their three top opportunities as online opportunities which included remote work and meetings ability to develop new relationships and increased online education and related skills teaching and flexibility the african cohort on the other hand listed flexibility virtual collaboration and virtual networking as the top3 opportunities both cohorts had similar perceptions that the online opportunities and flexibility was critical positives in the pandemic setting limitations there were a number of limitations to this current study including this being a small sample of a large cohort of female academics experiences during covid19 across the globe in particular the african cohort was much smaller than the australian sample despite numerous attempts to reach out to female academics in africa to participate in the study there were differences in the australian and african isolation and lockdown times rules and freedoms afforded in both locations which is acknowledged as a limitation of the study another limitation due to covid was the inability to run any focus groups in person and the organization of online formats would have been difficult to arrange within given timelines at the time of preparing research articles the future research looking at policies and practices within australia and africa will shed further light on female academics experiences during this period conclusion this study adds to the academic literature of female academics on their worklife balance during the covid19 pandemic effects such as increased workloads additional domestic work and extended works have impacted on the health and wellbeing among female academics this research compares the opportunities and challenges faced as well as the support received by female academics in australia and africa the study shows that the geographic locations of the female cohort results is differing support needs suggesting that policy makers have to be aware of the specificity of the cohort interestingly this comparative study also highlighted that notwithstanding the geographic locations female academics were on the same page in terms of workrelated opportunities primarily the online learning opportunities and flexibility in the pandemic setting data availability statement the original contributions presented in this study are included in the articlesupplementary material further inquiries can be directed to the corresponding author ethics statement the studies involving human participants were reviewed and approved by university of western australia the patientsparticipants provided their written informed consent to participate in this study publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

the covid19 pandemic has taken a heavy toll on women globally and female academics were no exception to the unprecedented forced shift to working from home increased workloads additional domestic responsibilities and extended working hours have led to high levels of dissatisfaction among this group of academics this disruption has also impacted mental and physical wellbeing there has been limited research on the experiences of female academics during the transition to the new work environment in the early stages of the pandemic this research compares the opportunities and challenges faced as well as the support received by female academics in australia and africa specifically this study reports on the changing roles demands of increased workloads challenges and opportunities faced both personally and in general an exploratory qualitative approach was adopted in this study an online questionnaire was developed and distributed through mailing lists in africa and australia linkedin as well as a personal invitation by the researchers on whatsapp and email purposeful and snowballing sampling female academics in australia and africa were targeted inclusion criteria for this study were female academics employed at any higher education institution hei private or public in contract and parttime and fulltime employment in australia and africa since the start of the pandemic february 2020 a total of 171 respondents 144 from australia and 27 from africa were received from a larger global study with 260 responses gathering data about female academics experiences during covid19 the data were analyzed using thematic and inductive analyses the study sheds light on workload motivation perceptions about career progression and work status the research contributes to the body of knowledge of femaleacademic work gender disparity and higher education impact during frontiers in psychology 01 frontiersinorg singh et al 103389fpsyg2022944384 covid19 the research aims to add value to the literature that supports the growing feminism in academia to ensure heis support this cohort of academics

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background the global aging problem is prominent and the aging trend is particularly serious in china where the seventh population census shows that the number of people aged over 60 reached 264 million accounting for 187 of the total population and the proportion of people aged over 60 is expected to exceed 30 in 2050 1 more seriously the prevalence of chronic diseases among the elderly in china is gradually increasing and is as high as 758 2 thus increasing the demand for safe effective convenient primary health care services for the elderly which has a positive role in safeguarding and improving their health 3 4 5 family doctor contracting service is a key initiative to improve the quality of primary health care services and its development varies from country to country the united kingdom required residents to contract with general practitioners when the national health care system was established in 1948 and the united states established fdcs systems in the 1960s 6 chinese residents tend to go to highlevel hospitals and in order to promote a system of hierarchical diagnosis and treatment and to promote the residents first to visit primary care facilities china began to emphasize fdcss in 2009 and is currently in the developmental stage chinas fdcs is based on the team of family doctors in primary care facilities and based on the principle of voluntary choice by residents family doctors establish a health record for the residents and provide services such as diagnosis and treatment of common illnesses health management preventive vaccination and referrals by appointment the fdcss have a positive effect on residents health yuan et al showed that family doctors can provide highquality comprehensive care services for the elderly 7 the study of yu et al and wang et al showed that contracted residents strengthened the monitoring of chronic diseases and increased the utilization of primary care facilities 89 lai et al showed that the healthrelated quality of life of contracted residents was significantly higher than that of uncontracted residents 10 in 2016 the government proposed to promote key populations such as chronic disease patients and the elderly to contract with family doctors and the contracting rate should reach 60 by 2020 however the results of yangs study showed that the contracting rate of family doctors among the elderly in china was only 282 11 which was still some way from the goal therefore it is necessary to further study the factors that influence the elderly to sign up with family doctors there were few articles examining the factors that influence the elderly to sign up with family doctors but some studies show that the probability of residents signing up with family doctors increases with the increase of age 1213 the number of elderly with chronic diseases is gradually increasing and if they suffer from two or more chronic diseases at the same time they are referred to as having multiple chronic conditions 1415 several survey results have shown that the prevalence of mccs in the elderly in china has exceeded 50 16 17 18 mccs increase the risk of disability and reduce the quality of life in the elderly causing more adverse health outcomes than having a single chronic disease which has a serious negative impact on physical and mental health 19 20 21 thus the elderly with mccs have a higher demand for health services and may be more likely to contract with family doctors wangs study showed that the elderly want family doctors to provide more chronic disease management services 22 yangs study found that the elderly with cardiovascularmetabolic multimorbidity were more willing to contract with family doctors however the authors also state in the limitations of the article that this study included only three chronic diseases and did not examine the effect of the degree of mccs on contracting 11 socioeconomic status is a comprehensive concept and studies have been conducted to predict socioeconomic status through educational level income and occupation 23 it has been shown that residents of high socioeconomic status were more likely to suffer from mccs 2425 feketes study showed that residents with higher socioeconomic status were more likely to use the services provided by general practitioners 26 however it has also been suggested that the prevalence of mccs may be lower in residents with high socioeconomic status 2728 the elderly with high education and high income may also be more inclined to seek treatment in highlevel medical institutions reduce the use of primary health care services and are reluctant to sign up with family doctors 29 30 31 there are still contradictions in the above research results and it is worth further investigating whether socioeconomic status has a positive influence on the elderlys contract with family doctors being of different socioeconomic status there may be differences in the contracting of the elderly with mccs with family doctors in summary this study aimed to explore the influence of mccs on the elderly contracting with family doctors and to further investigate whether socioeconomic status plays a moderating role methods study design and questionnaire survey a crosssectional survey was conducted from july to august 2021 in beijing china using a wholegroup sampling method a questionnaire survey was conducted among the elderly aged ≥ 60 years in a community this community is located in the f district of beijing which is a combination of urban and suburban areas and also has a relatively large elderly population so it is representative to select the elderly in this community to carry out the survey according to the sample size calculation formula n u 2 a p δ 2 where p 282 δ 0025 α 005 μα 196 and the required sample size was calculated as 1245 people the questionnaire was selfdesigned according to the literature review and the purpose of the study and consisted of two parts the first part was demographic information and the second part was exposure factors and disease outcomes the cronbachs α coefficient was 0927 indicating that the reliability of the questionnaire was good a questionnaire survey was conducted among the elderly through uniformly trained investigators a total of 2052 elderly people were investigated in this study after excluding the questionnaires with logical errors and those with missing values 1814 valid questionnaires were recovered meeting the minimum sample size requirement and the effective recovery rate of the questionnaires was 8840 measurements dependent variable this study was based on the question are you currently contracting with family doctors to determine the contracting status between the elderly and the family doctors and answering yes meant that the elderly had contracted with family doctors and answering no meant that the elderly had not contracted with family doctors independent variables in this study 12 common chronic diseases in the elderly were selected through literature review 1832 according to the number of chronic diseases there were four levels of suffering from less than one chronic disease two chronic diseases three chronic diseases and greater than four chronic diseases socioeconomic status is generally a comprehensive indicator including educational level income and occupation and some studies used single or multiple indicators for measurement 233334 however the classification of occupation is essentially based on educational level and income and the criteria are more subjective 35 at the same time chinese elderly people over 60 years old have retired the proportion of reemployment is very low and the heterogeneity of indicators is not high so measuring the socioeconomic status of elderly people by occupation has limitations income can reflect the guarantee of daily necessities and educational level means the ability of individuals to obtain resources to meet their needs 3637 therefore this study referred to the study of jiao et al and combined income and educational level after standardized processing to represent socioeconomic status 38 control variables based on the literature review combined with the study purpose and population characteristics of this study gender age marital status smoking status drinking status physical activity intensity selfrated health and the willingness to first visit primary care facilities were selected as control variables data analysis spss 260 was used for data analysis in this study frequency and percentage were used to describe the demographic characteristics and healthrelated characteristics of the elderly the chisquare test to compare differences in basic demographic characteristics and healthrelated characteristics between contracted and uncontracted older adults logistic regression analysis was used to explore the factors influencing the contract between the elderly and family doctors model 1 adds control variables mccs and socioeconomic status and model 2 adds an interaction term for mccs and socioeconomic status variable assignments are shown in table 1 results basic characteristics of the elderly among the surveyed elderly 391 people were contracted with family doctors and 1423 people were not contracted with family doctors there were 979 males and 835 females the largest number of people aged 6069 was 679 and most of the elderly were married the educational level of the elderly was concentrated in junior high school and high school with 689 people and 637 people respectively the monthly income of 815 people and 733 people was 40005999 yuan and 60007999 yuan respectively z i1 standard deviation e z i2 standard deviation i ses i 2 health status of the elderly among all the respondents 259 of the elderly now smoke 402 of the elderly now drink and most of the elderly had high intensity of physical activity about half of the elderly suffer from two or more chronic diseases with the highest number of elderly suffering from two chronic diseases there were 699 people and 257 people who were relatively willing or very willing to first visit primary care facilities respectively 713 of the elderly had good selfrated health there were statistically significant differences in physical activity intensity mccs and willingness to first visit primary care facilities between contracted and uncontracted elderly people analysis of factors influencing the elderly to sign up with family doctors model 1 results showed that age at 8089 years now smoking physical activity intensity willingness to first visit primary care facilities and mccs influenced the elderly to sign up with family doctors the higher the degree of mccs the higher the likelihood of signing up but socioeconomic status had no significant effect on the elderly to sign up with family doctors model 2 added an interaction term for mccs and socioeconomic status and the interaction term had a significant positive effect on the elderly signing up with family doctors suggesting a possible moderating effect of socioeconomic status a further simple slope test showed that the slope of the high socioeconomic status straight line was greater than the slope of the low socioeconomic status straight line indicating that socioeconomic status has a positive moderating effect in the process of mccs influencing contracting discussion the results of this study indicated that the contracting rate of family doctors among the elderly was 2172 which was similar to the results of yangs study in china 11 there was still a gap from the goal that the contracting rate of family doctors for key populations should reach 60 and the fdcss should be further promoted the mccs were an important factor in influencing the elderly to sign up with family doctors and as the degree of mccs increases elderly were more likely to sign up with family doctors meanwhile the elderly with mccs table 1 variable assignment variables assignment family doctor contracting status 0 uncontracted 1 contracted multiple chronic conditions less than one chronic disease 1 two chronic diseases 2 three chronic diseases 3 greater than four chronic diseases 4 socioeconomic status continuous variable gender of high socioeconomic status may be more willing to sign up with family doctors the results of this study were similar to those of yangs study in which mccs influenced the elderly to contract with family doctors 11 the mccs can harm the physical and mental health of the elderly with the impact increasing as the degree of mccs increases 3940 fdcss were helpful to improve the treatment effect of chronic diseases improve the quality of comprehensive care and improve the healthrelated quality of life 794142 patients with chronic diseases may also be more willing to use health services to meet their health needs 4344 thus the elderly with mccs were more likely to sign up with family doctors to improve their health at the same time some studies have shown that patients with chronic diseases tend to use the continuous medical services provided by general practitioners 4546 due to the increasing demand for medical services for the elderly with mccs family doctors can provide continuous and effective chronic disease management and basic medical services for them the elderly with mccs were more likely to sign up with family doctors and the willingness to sign contracts increased with the increase in the degree of mccs socioeconomic status is associated with health inequalities and the results of this study were similar to yins study in which socioeconomic status was able to play a moderating role 47 the elderly with higher socioeconomic status may have more resources and opportunities to obtain health information and can learn about chronic disease management and regular followup services provided by family doctors through various channels 48 when these elderly people suffer from chronic diseases they may be more likely to accept and use fdcss chronic diseases affect the health level of the elderly and residents with higher socioeconomic status may be more proactive in utilizing healthcare services to improve their health 49 therefore high socioeconomic status may promotes the elderly with chronic diseases to sign up with family doctors compared to the elderly of high socioeconomic status the elderly of low socioeconomic status may have access to fewer health information resources have slightly lower health literacy and may have insufficient awareness of fdcss 50 at the same time the elderly with lower socioeconomic status may pay relatively less attention to their health status have a low percentage of visits to medical institutions and may tend to alleviate adverse health effects of chronic diseases through selfmedication 5152 thus low socioeconomic status may discourage the elderly with chronic diseases to sign up with family doctors the elderly who were willing to receive the first treatment in the primary care facilities may have a better understanding of the hierarchical treatment system and fdcs policies 53 they may have more trust in the doctors in the primary care facilities and have higher satisfaction and be willing to sign up with family doctors 5455 although family doctors in primary care facilities may not be able to completely solve the health problems of patients twoway referral channels are currently smooth and family doctors can transfer patients to highlevel hospitals for convenient medical treatment 56 some studies showed that residents with high activity intensity generally have better physical fitness and health and also make more use of public health services and fewer visits to hospitals 57 58 59 similar to the findings of nie et al and li et al physical activity was the factor that influenced the elderly contracts with family doctors 6061 the elderly who are physically active may be more healthconscious and want to improve their health by signing up with family doctors limitations first this study was a crosssectional study and the relationships of the variables in the results were more likely to be interpreted as correlations and causal inferences are somewhat limited second the number of chronic diseases in the elderly was calculated by selfreporting whether they had 12 common chronic diseases and recall bias may exist finally our study was conducted only in beijing china where economic conditions are better and fdcss are developing rapidly so the generalization of the findings of this study is limited and sampling can be conducted in wider areas in a followup study conclusion this study provides further evidence that mccs were a factor that influenced the elderly to sign up with family doctors also as the degree of mccs increased the willingness of the elderly to sign up increased this study found that socioeconomic status was not a factor that directly influenced the elderly to sign up with family doctors but socioeconomic status positively moderates the influence of mccs on contracting meanwhile this study found that the elderly with high physical activity intensity and willingness to first visit primary care facilities were more likely to sign up with family doctors on the one hand it suggests that the elderly who may be more concerned about their physical health may make more use of primary health care services on the other hand it suggests that maybe the capacity of primary care facilities influences the elderly to sign up it is recommended to strengthen the promotion of the fdcs policies for the elderly with lower socioeconomic status improve the construction of hierarchical diagnosis and treatment systems enhance the service capacity of primary care facilities to meet the needs of the elderly and promote the elderly to contract with family doctors abbreviations fdcss family doctor contract services mccs multiple chronic conditions sess socioeconomic status competing interests the authors declare no competing interests

background chinas family doctor contracting service is an important part of deepening the reform of the healthcare systems aiming to further develop chronic disease management services enhance the capacity of primary health care services and improve the health of residents the purpose of this study was to explore the influence of multiple chronic conditions in the elderly on family doctor contracting and whether socioeconomic status played a moderating role methods a crosssectional survey was conducted in beijing china a total of 1814 elderly people over 60 years old were included in this study using a wholegroup sampling method the univariate analysis and logistic regression analysis was used to analyze the data results 2172 of the elderly signed up with family doctors the multiple chronic conditions was a factor influencing the elderly to sign up with family doctors or 144 95 ci 128161 and the higher the degree of multiple chronic conditions the stronger willingness to sign up socioeconomic status positively moderates the effect of multiple chronic conditions on signing also physical activity intensity or 125 95 ci 103154 and willingness to first visit primary care facilities or 138 95 ci 125154 influenced the elderly to sign up with family doctorsthe elderly with a high degree of multiple chronic conditions high activity intensity and a strong willingness to first visit primary care facilities were more likely to sign up with family doctors the health literacy of the elderly should be further improved and publicity on the family doctor contracting service policies for the elderly with lower socioeconomic status should be strengthened to guide them to sign up with family doctors at the same time the service capacity of primary care facilities should be further improved to meet the health needs of the elderly

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background syringe services programs also commonly referred to as syringe service sites syringe exchange syringe access or needle exchange programs aim to prevent the transmission of infectious diseases by providing sterile injection supplies and a range of other services to people who use drugs and have shown to be effective in reducing the spread of viral hepatitis and hiv 1 2 3 4 5 ssps take a harmreduction public health approach which aims to reduce the negative health effects of substance use 6 in this context ssps focus on prevention of the primary sources of morbidity and mortality associated with injection drug use including preventing infections transmission of infectious diseases and overdose deaths rather than abstinence from drug use despite the evidence for successful prevention of infectious diseases and other positive public health outcomes the harm reduction approach is not universally adopted in public policies 2 there is a growing prescence of ssps in the us currently operating in 39 states and dc 7 yet there remains variation in state laws restricting the purchase and possession of sterile syringes 8 for instance some states have decriminalized syringe possession or purchase while others have allowed exemptions from drug paraphernalia charges 9 some ssps started with controversial beginnings in defiance of state laws banning the distribution of clean needles for example in colorado the setting of our study the first syringe exchange program began in 1989 as a nonstate sanctioned initiative to address the spread of hiv in one county 10 unlawful distribution of syringes continued until 2010 when the colorado governor signed a law legalizing these programs statewide 11 given these beginnings it is not surprising that there could be discordance between ssp activities and law enforcement practices prior studies have described how law enforcement actions can have a negative influence on the ability of a ssp to provide services 12 13 14 this could be by direct interference with operations and access to ssps or through other practices such as charging pwud with paraphenalia in contradiction to the law 14 15 16 17 negative interactions with law enforcement can deter pwud from using ssp services 18 one reason for law enforcement practices that undermine harm reduction programs operated by ssps could be lack of awareness on the part of law enforcement and perception that the harm reduction approaches are counterproductive 19 20 21 however the public health principles of harm reduction can be applied to law enforcement and policing 2223 identifying effective means of communication including having tailored inservice training with police officers have proven effective in obtaining buyin from law enforcement 20 23 24 25 there is evidence that law enforcement when supportive of public health efforts can facilitate participation by referring pwud into the program 26 there are harm reduction policing iniativies being adopted across the usa such as law enforcement assisted diversion programs in which police officers forgo the normal response of engaging a pwud in the criminal justice system in favor of referring people into support systems and treatment programs 27 in seattle washington this approach has been found to be successful in reducing recidivism and other positive outcomes 28 given the importance of the role of law enforcement professionals in the implementation of successful ssps we sought to better understand the nature of current relationships between ssp and law enforcement agencies in colorado and learn about factors that facilitate and hinder a collaborative relationship and adoption of a harm reduction approach by law enforcement this study builds on the existing literature in the context of a us state with exemptions for drug paraphernalia charges methods study design and population in our qualitative study we used a phenomenological approach to examine the relationships between ssps and local law enforcement agencies and personnel this approach allowed us to explore the phenomenon of interactions engagement and personal experiences between law enforcement and ssp staff we conducted semistructured interviews with key program staff at all legislated syringe service sites in the state of colorado ssp staff included executive directors program managers and program staff members as of 2019 there were 11 ssps operating in eight counties across the state the interviews were part of a broader needs assessment of currently operating programs the goal of the syringe services programs which can then lead them to other resources such as housing wound care and substance use treatment programs keywords syringe service programs needle exchange law enforcement harm reduction qualitative research needs assessment was to report on current activities of legislated ssps currently operating in the state of colorado to identify the needs for operating and barriers to effectively serving ssp clients we developed a semistructured interview guide to understand how ssps define determine andor measure their impact on the service population ssps knowledge of community perceptions of their program and services they provide ssps communication andor collaboration with boards of health county commissionerscity council district attorneys and law enforcement we conducted interviews using broad lines of questioning and introduced additional questions during the interview process as relevant information was revealed by the interviewee we asked participants in what ways do you engage with law enforcement and do you have a sense of how they view your program and the services you provide these broad lines of questioning allowed us to further probe on ssps staffs interactions and relationships with law enforcement and how these relationships impact their ability to serve ssp clients it also allowed ssp staff to share experiences between ssp clients and law enforcement during contact at a ssp agency recruitment and data collection we received contact information for the primary contact for each ssp from the colorado department of public health and environment primary contacts included program coordinators directors and health educators interviews were conducted either inperson or by videoconference depending on availability of the interviewee and their location participants were read a consent form by the interviewer and participants provided a verbal consent inperson interviews were recorded using a digital voice recorder and videoconference interviews were recorded using the zoom application interviews lasted between 37 min to 1 h and 54 min the interviews were led by members of the research team with experience in collective qualitative data interview recordings were professionally transcribed via a thirdparty validated by members of the research team and analyzed with qualitative analysis software nvivo11 two independent study team members conducted thematic analysis using datadriven iterative process which allowed us to develop a coding scheme coding consistency checks were done between coders and resolved discrepancies through discussion after coding memos were written to synthesize and categorize data into broader themes found among all participants this process revealed two major themes the value of relationships between ssp and enforcement and factors that influence the quality of relationships we identified four subthemes of factors that influence relationships between ssp and law enforcement including law enforcement culture support from law enforcement leadership law enforcement participation in the lead program and law enforcements implementation of local laws related to ssps and syringe users data collection analysis and reporting followed guidelines established by consolidated criteria for reporting qualitative research 30 we present supporting quotes from ssps staff indented and in italics the data collection procedures were reviewed by the colorado multiple institutional review board and determined to be a quality improvement project and reviewed by the institutional review board at the cdphe results overview of variation in relationships with law enforcement participants were asked about their interactions with law enforcement agencies and all ssp staff members discussed at length the relationship with law enforcement all ssp staff viewed having a positive relationship with law enforcement as important to the success of their program and having a negative or nonexistent relationship with law enforcement as a barrier to the program and potentially having a negative impact on ssp clients the degree of engagement and the type of collaboration with law enforcement varied by site relationships ranged from having a partnership with a high degree of interactions from both parties having no relationship to having a hostile or confrontational relationship value of relationships programs that described having a positive relationship shared that the partnership had positive implications for ssps and clients including facilitating referrals of clients into social services working with ssps to reduce syringe litter and reducing reoffenses in the criminal justice system likewise ssp staff stated that law enforcement agencies viewed ssps as a resource for pwud that provided critical services for this population in their community and thus valued ssps and supported their mission many of the ssp staff described the implications on ssp clients and the broader community when ssps and law enforcement viewed each other positively and as a valuable resource such as getting community members into social services a ssp director detailed the positive and collaborative nature of their relationship with law enforcement stating we have had very longstanding good relationships with law enforcement agencies… we work very closely with them on trying to do a comprehensive approach to substance use and so when we span the full spectrum from prevention early intervention treatment harmreduction… were trying to have a collective impact approach where were reducing the negative impact of substance use in general a few ssps staff described collaborating with law enforcement in community efforts such as holding syringe litter pickup days in which ssps and law enforcement partnered to clean up local areas with used syringes several ssps staff also reported that local law enforcement who view ssps positively will refer pwud they encounter while performing their normal duties to ssp programs or other local resources instead of criminalizing them ssp staff that reported a lack of collaboration with law enforcement expressed a desire to do so and acknowledged the potential benefits of having a positive relationship with agencies including being able to learn from each other and working together to best serve substance users in their community this lack of collaboration stemmed from law enforcement personnels lack of valuing ssp programs and a lack of understanding of the services provided including services to the broader community such as hiv testing and referrals to services a shared understanding and implementation of a harm reduction approach were described as factors influencing mutual respect and their perception of value to community members factors that influence quality of relationships several themes emerged as factors that influence the quality of relationships between ssps and law enforcement these include alignment in agency cultures in adopting a harm reduction model support from law enforcement leadership police officers participation and compliance with the law enforcement assisted diversion program and variation in the implementation of laws including the needlestick prevention law ongoing communication between ssps and law enforcement was a critical factor in all aspects of maintaining a positive relationship with law enforcement agencies alignment in agency culture almost all ssp staff suggested that law enforcement agency culture beliefs or attitudes toward harm reduction approaches influenced law enforcement perception of ssp services the relationship between ssps and law enforcement and had implications for ssp clients some ssp staff expressed that law enforcements positive endorsement of the harm reduction model and an agency culture marked by reduced biases toward people with substance use dependence supported a positive relationship between ssps and law enforcement agencies the partnership then led to law enforcement providing more support and resources for ssp clients specifically pwud alignment in attitudes and beliefs consisted of law enforcement officers viewing ssps as a resource for pwud to reduce the spread of disease access treatment and reduce the likelihood of needlestick injuries for law enforcement those who did not share this belief viewed ssps as a means to enable substance use and accelerate syringe litter in their community through a shared philosophy of harm reduction either through a collective agency culture or by individual police officers ssps and law enforcement were able to have a positive working relationship there were several examples of how ssp and law enforcement could work together for example some ssps conducted trainings for law enforcement and educated them on the benefits of using a harm reduction model to address substance use and the spread of disease these trainings led to a change in perspective among law enforcement officers and assisted in positive collaboration andor engagement one ssp has representation of law enforcement on their board of directors and as a result has police officers regularly visit the site for tours and law enforcement refer potential pwud clients to the ssp when on duty another ssp staff observed that law enforcement representatives attend opioid prevention coalition meetings many ssp staff noted that having an established positive relationship and the use of a harm reduction model with law enforcement leads to better communication including identifying ways to better serve the community a ssp staff member from one site recalled they law enforcement worked really closely with us in learning about the law enforcementassisted diversion program and they are now harmreduction advocates themselves and i am sometimes in a meeting and its the law enforcement staff who are correcting people about harm reduction laughter … bringing to peoples attention like oh the only end goal is not treatment we also need to think about harm reduction and keeping people safe when theyre not actively using… law enforcement who did not agree with a harm reduction approach labeled ssps as enablers according to several ssp program staff they reported that this was a common and problematic perception that can have negative consequences for ssp clients and pwud a few ssp staff mentioned that law enforcements preexisting negative perceptions toward pwud and ssps often lead law enforcement to ignore the statewide law to protect ssp clients they attributed such negative law enforcement culture to misunderstanding of ssps role in the community the belief that ssps are enablers of continued drug use or directly providing illegal substances such as fentanyl were common misperceptions one program manager stated for example i think they view what we do as enabling and giving people the tools to do things illegally while another staff member from a different program advised i dont think that they view us as a spectrum of treatment or a spectrum of care i think that a lot of it really boils down to the perception of the people who use drugs and that anybody who tries to help them is also bad ssp staff suggested this is more common in law enforcement agencies having a conservative agency culture one ssp staff member for example mentioned how one district attorney brought false and misleading evidence against the ssp to highlight how ssps enable more drug use among their clients these shared beliefs among law enforcement agencies have negative implications for ssp clients as described by several ssp whereby having a conservative agency culture was believed to have contributed to the charges placed on ssp clients having syringes on their person reluctance of clients to seek help from police or other emergency personnel when their or someone elses safety is endangered one ssp manager described how clients are afraid to contact emergency services because police officers would arrest them instead of providing help demonstrating an agency culture of criminalization of substanceusing people instead of viewing them as people who need help or resources stating all of our people feel terrified… they dont feel comfortable to call emergency services because they know that the cops are going to come support from law enforcement leadership most sites discussing the role of law enforcement leadership discussed having positive relationships and that these relationships had implications for their program and the clients they are serving some ssp staff mentioned that positive endorsement andor a positive relationship with law enforcement leadership was often a result of ongoing communications between ssp and law enforcement leaders such as the chief of police who would serve as a champion for ssp and their mission in reducing the spread of disease ssps were able to receive support from leadership by communicating the goals of ssps with leadership educating leaders of the role of ssps on a spectrum of care and their efforts to reduce syringe litter law enforcement leaders who advocated for ssps were perceived as influencing the overall law enforcement agency culture and influencing the attitudes beliefs and behaviors of individual officers partnerships between law enforcement leadership and ssp staff also led to additional training for officers including laws surrounding harm reduction and paraphernalia charges to ssp clients a program manager from one ssp described communication with law enforcement leadership and the need to educate officers on current laws surrounding syringes when we mentioned to them that were seeing an uptick in people getting paraphernalia charges they actually had in one of their chiefs meeting where all the chiefs of police come they went and did a review of all the harm reduction laws that the officers need to be aware of and how they need to not be filing paraphernalia charges for participants ssp client of our program and they are making sure that our local law enforcement are abiding to harm reduction laws lead program participation the law enforcement assisted diversion is a program that provides intensive case management for lowlevel drug offenders established in seattle wa previous studies have shown how the lead results in a reduction in recidivism by diverting people to social services instead of incarceration 28 the lead program offers an alternative route for lowlevel drug offenses that provides case management and connection with resources rather than jail and prosecution the lead programs are operating in four counties in colorado that also have ssps 31 and nearly all these ssp staff noted this in their interviews that lead is a positive program in their community some ssp staff noted that lead is part of a changing culture in law enforcement around responding to drug use one ssp staff member expressed the helpfulness of the program in giving law enforcement more options than arresting and putting individuals in jail when what they often need is services and treatment stating … but i think the officers here are more feeling like oh theres options we have besides just throwing someone in jail they get back out throwing them back in jail they get back out and so i think that has helped giving law enforcement options i mean its still their decision whether they take someone to jail or not but just to know that there are some options and support that they have another ssp staff from a different site mentioned that the lead program is an opportunity to work in partnership with law enforcement and that lead officers presence in the community provides a feeling of safety among pwud and trust toward law enforcement she said theyve got folks that will come in here and volunteer fairly regularly again thats an opportunity for them to make that facetoface contact with the participants ssp clients within the program they will wear their lead shirts and stuff in here so that way participants know that hey these guys are our reductionists these guys arent out to get you these guys want to help you not all ssp staff however were successful at gaining buyin from law enforcement to implement the lead program in their communities a few ssp staff acknowledged challenges of successfully implementing and disseminating the lead program in their communities including less systemic adoption of the lead program strict criteria to implement the program and unknown reasons for lack of buyin from law enforcement leadership a program manager from one site discussed the challenges in getting support for the implementation of lead in their community saying they wanted to do lead but the tops of law enforcement have set the exclusion criteria so strict that no one can really get into the program through them at that point varying implementation of laws many sites shared that officers do not adhere to laws that relate to ticketing of people for drug paraphernalia according to state statute titled the drug paraphernalia law exemption 32 syringe exchange program clients are exempt from drug paraphernalia charges a state needlestick prevention law 32 also allows for an exception to drug paraphernalia charges if someone informs a law enforcement officer prior to search that they have a sharp object ssps provide cards to clients to show they are exempt from drug paraphernalia charges however ssp clients are still sometimes ticketed either due to an apparent lack of familiarity of the law or in some cases in apparent defiance of the law several ssp staff shared that law enforcement do not adhere to the needle stick law due to their personal beliefs toward pwud or misunderstanding about the benefits of the law to officers one ssp staff member implied the general lack of understanding of the needle stick law among some officers suggesting so that law is meant toits meant to protect them a couple of sites noted the importance of framing the state statutes to protect law enforcement from being pricked by a used syringe while patting someone down these staff shared that by presenting the law in a way that demonstrates its benefits to law enforcement officers they would have more buyin and adherence to the law by officers who have direct contact with ssp clients among site staff who characterized their relationship with law enforcement as problematic the key concern was around police officers ticketing their clients with paraphernalia charges despite having these regulations in place to protect ssp clients from being charged program staff from several sites reported that clients had shown law enforcement their ssp identification card and were still ticketed or charged for having paraphernalia for example one ssp staff member shared interactions involving clients producing a ssp card for officers weve had officers tear up our participants ssp client syringe exchange cards saying that harm reduction is not a real thing this isnt legal… its like once they see a syringe card then theyre like okay well we want to search your car a drug paraphernalia charge creates a cascade of events for ssp clients that can lead to negative outcomes such as potential jail time ssp staff often conduct outreach to law enforcement and district attorneys regarding inappropriate ticketing to dispute charges on behalf of the clients several ssp staff described variation in law enforcements observance of the ssp id cards and a few claimed that law enforcements resistance to abiding by the colorado statute were influenced by the officers personal views surrounding the statute similarly a different site reported that their client also experienced resistance from law enforcement and despite efforts to engage with law enforcement they continue to give out tickets because of their negative views toward substance use and pwud staff recounted an instance when officers were reported to dump out sharps containers to find syringes with residue in them despite a ssp client having a ssp id card on them another site discussed how law enforcement has become more accepting of the law and while many officers still ticket clients it has become less frequent than when their site first opened discussion the goal of our qualitative investigation was to identify challenges and barriers to operating ssps and serving ssp clients this study provides examples of challenges and successes in cooperating with law enforcement and the implications on ssp clients from the perspective of ssp staff this qualitative study adds to existing literature on the relationship between law enforcement agencies and ssps in the context of a us state with legislated ssps exemptions for drug paraphernalia charges as part of this study all study participants were asked about their relationships with law enforcement participants revealed a range of interactions and engagement with law enforcement including positive collaborative relationship to adversarial relationships participants described the implications of the relationship for ssp clients including unnecessary harassment and arrests by law enforcement participants describing a positive relationship with law enforcement discussed how programs and law enforcement shared similar views toward harm reduction initiatives the need to reduce the spread of disease and importance of connecting ssp clients to resources law enforcement training or education in harm reduction communication between ssp staff and law enforcement agencies and having a champion within law enforcement leadership were all factors contributing to a positive relationship this is consistent with prior research that has shown the value of law enforcement training for building a collaborative relationship between law enforcement and ssps 24 lack of a relationship was attributed to a lack of buyin from law enforcement leadership and officers including a conservative political perspective and a lack of interest in establishing a relationship from leadership implications for policy and practice consistent with studies done in other communities in the usa our findings suggest several activities or strategies are important to fostering relationships between police and ssps including ssps to provide trainings or encourage training to law enforcement personnel on harm reduction models findings of prior research show that trainings on occupational safety information are acceptable to police and associated with a reduction in needlestick injuries among law enforcement 121333 future research could examine the trainings and training approaches that are most successful at supporting working relationships between ssp and with law enforcement ssp can further demonstrate their commitment to supporting law enforcement by advocating for socalled needle stick laws this is a discrete opportunity for ssps to demonstrate they have the best interest of law enforcement officers in mind and can be advocates for law enforcement interests a continuing focus on reducing syringerelated risks to law enforcement may be a pathway to demonstrate shared values our findings suggest law enforcement professionals existing attitudes toward pwud may supersede their adherence to the laws on ssp id cards and result in inappropriate ticketing and charges this calls for additional research on law enforcement professionals attitudes and beliefs toward ssps and pwud as well as their current training and understanding of the laws on ssp id cards to expand our knowledge on building a successful working relationship between ssps and law enforcement finally we found the adoption of the lead program is associated with a successful and supportive relationship between ssp and law enforcement 28 the causal direction of this is unclear it seems likely that it is bidirectional in that more supportive police districts choose to adopt the lead program which then reinforces a harm reduction approach thus there remains the challenge of a ssp initiating or improving a relationship with the local enforcement leadership when a positive relationship does not yet exist limitations our findings are limited to existing ssps in the state of colorado having data from one state with its unique community and legislative context may limit generalizability to states with differing policies detailed and nuanced results of our study however can inform practices and policies in other states with existing ssps or are in the process of establishing a ssp in their community further research from the perspectives of law enforcement could also be beneficial as it may vary from our findings from the perspective of ssps conclusion all ssp staff expressed a strong desire to have positive relationships with law enforcement and described how a collaborative working relationship was critical to the success of their programs not all ssp staff however were fortunate in having a positive working relationship with law enforcement our findings suggest effective strategies to foster relationships between ssps and law enforcement as well as key barriers to address our findings support the need for both ssps and law enforcement to devote time and resources to build a strong positive partnership having such positive relationships with law enforcement has implications for ssp clients in that law enforcement will be less likely to ticket persons who get their syringes from ssps encourage pwud to seek services from ssps which can then lead them to other resources such as housing wound care and substance use treatment programs abbreviations declarations ethics approval this study was declared nonhuman subjects research by virtue of being a quality improvement project and all procedures were in accordance with colorado multiple institutional review board ethical standards the authors certify that the study was performed in accordance with the ethical standards as laid down in the 1964 declaration of helsinki and its later amendments or comparable ethical standards all participant and site identifying information was removed for anonymity informed consent participants provided verbal consent to participate in this study competing interest the authors declare no competing interest • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration 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background syringe services programs provide sterile injection supplies and a range of health services eg hiv and hepc testing overdose prevention education provision of naloxone to a hardtoreach population including people who use drugs aiming to prevent the transmission of infectious diseaseswe performed a qualitative needs assessment of existing syringe services programs in the state of colorado in 20182019 to describetheir activities needs and barriers using a phenomenological approach we performed semistructured interviews with key program staff of syringe services programs n 11 all interviews were digitally recorded transcribed and validated a datadriven iterative approach was used by researchers to develop a coding scheme to organize the data into major themes found across interviews memos were written to synthesize main themes results nearly all the syringe program staff discussed their relationships with law enforcement at length all syringe program staff viewed having a positive relationship with law enforcement as critical to the success of their program main factors that influence the quality of relationships between syringe services programs and law enforcement included 1 alignment in agency culture 2 support from law enforcement leadership 3 police officers participation and compliance with the law enforcement assisted diversion lead program which provides intensive case management for lowlevel drug offenders and 4 implementation of the needlestick prevention law and drug paraphernalia law exemption all syringe program staff expressed a strong desire to have positive relationships with law enforcement and described how a collaborative working relationship was critical to the success of their programsour findings reveal effective strategies to foster relationships between syringe services programs and law enforcement as well as key barriers to address the need exists for both syringe services programs and law enforcement to devote time and resources to build a strong positive partnership having such positive relationships with law enforcement has positive implications for syringe services program clients including law enforcement being less likely to ticket persons for having used syringes and encourage people who use drugs to seek services from

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the us social security disability insurance program provides income support to individuals who become unable to work because of a disability ssdi is one of the largest social insurance programs in the united states in 2017 it paid 1443 billion dollars in benefits to 87 million disabled workers and 30 million of their dependent family members ssdi disabled workers as a group equate to 54 percent of the us labor force the central policy tradeoff for the ssdi program is to provide protection against disabilityrelated earnings losses but in a way that does not induce labor force nonparticipation among people who could otherwise work balancing insurance against incentives is exceptionally difficult and the political discourse surrounding ssdi throughout its history of expansion and retrenchment has reflected this deep tension by 2014 the program had expanded in nearly every year since its birth in 1956 and was inching dangerously close to insolvency some of the caseload growth was predictable resulting from deliberate expansions of eligibility rising labor force participation by women or from population aging but much of the growth was due to the eroding labor market prospects of lowerskilled workers who despite significant health problems might have otherwise worked in 2014 the ssdi program began transitioning to a smaller steadystate size due to the natural fading of earlier demographic pressures and administrative changes at the appellate level the program now appears solvent until 2052 with the caseload contracting the case for ssdi reform is no longer primarily a fiscal one i as emphasized by liebman the case for ssdi reform rests on the need to reoptimize the program to account for change in the composition of applicants originally a program for older men with clearcut permanent impairments ssdi now serves men and women of all ages who more often than not have a musculoskeletal or mental impairment and diminished employment opportunities many of these individuals have some degree of residual work capacity the case for reform is bolstered by the fact that the last major reform of the ssdi program was in the 1980s the core structures that define who does and does not have work capacity have not been updated to keep pace with advancements in medicine technology or the functional requirements of jobs ssas listings of automatically qualifying impairments have been updated infrequently despite decades of medical progress similarly there have been no updates to the medicalvocational grid used by disability adjudicators to determine whether an applicant can do any other job in the national economy despite broad structural change in the nature and skill demands of jobs decades of research highlight five highlevel takeaways that should guide reform first ssdi participation is not just a reflection of an individuals underlying health it also reflects their labor market outcomes and prospects for future employment second a significant portion of ssdi entrants have substantial work capacity third they lose further work capacity during the ssdi application process because program rules require them to sit out of the labor market while they wait for a disability determination a process that takes several years for some fourth once people finally enter the ssdi program they are unlikely to return to work even when offered work incentives repeated policy efforts to incentivize work among beneficiaries have largely failed to increase work activity finally ssdi provides immensely valuable social insurance benefits for american workers who experience a disabling health problem it is essential to maintain this protection in light of these findings the goals of reform should be to allow ssdi applicants to stay in the labor force for as long as possible improve identification of what work capacity ssdi applicants have and help them to use and augment their available work capacity before it is too late i propose two major interrelated reforms to the ssdi program that address these goals the first is to improve measurement of work capacity and eliminate the outdated medicalvocational grid the second is to award partial disability benefits for partial disabilities under a system that included partial benefits as well as full benefits applicants could apply while still working and the new system of work capacity measurement would more precisely identify their amount of remaining work capacity the article proceeds as follows i first explain how the ssdi program works and how it has been changed over time i then describe historical and recent trends showing that the caseload has begun to decline after decades of unrelenting growth while concurrently employment among people with disabilities has risen i next review the evidence from the literature that provides the basis for reform i then present my reform proposals i close by commenting on some of the other reforms that have been proposed in recent years overview of ssdi how ssdi works ssdi is a federal social insurance program established in 1956 to protect individuals against loss of earnings due to a disability individuals and their employers pay ssdi insurance premiums in the form of payroll taxes in the same way they contribute to the social security retirement program and to medicare ii once individuals begin making payroll tax contributions they become insured only after accruing sufficient work credits the required number of credits increases with age and at least half must have been earned recently iii although it is necessary to be insured for ssdi to obtain ssdi benefits insured status is not enough to guarantee benefits the social security administration must also determine that an applicant has a medicallydeterminable mental or physical impairment that prevents them from engaging in substantial gainful activity sga is defined as earnings of 1220 per month iv or higher an amount roughly equivalent to a fulltime job at the federal minimum wage individuals are not permitted to even apply for ssdi benefits if they are working at or above sga in addition an applicants impairment must be severe and longlastingexpected to result in death or last for at least 12 months importantly partial disabilities resulting in partial loss of earnings capacity do not meet ssas definition of disability v ssas medical review process is designed to identify and award benefits to two types of applicants 1 those who have one or more especially severe medical impairments on the listing of impairments and 2 those whose functional limitations in combination with ii ssdi payroll taxes are collected under fica the federal insurance contributions act selfemployed individuals are responsible for the entire tax amount while wageandsalary workers split the payments evenly with their employers iii one work credit is earned for every 1360 in earnings and a maximum of 4 credits may be earned each year those who become disabled at ages 3142 are insured for ssdi if they have accrued 5 years worth of work credits and at least half the credits were earned in the most recent 10year period those who become disabled before age 31 need fewer credits to be insured while those disabled after 42 need more the maximum number of credits required is 40 for individuals age 62 or older the minimum number is 6 for individuals younger than 24 the requirement that credits be earned recently does not apply to individuals with statutory blindness iv the sga threshold is higher for statutorily blind individuals v this stands in contrast with state workers compensation systems and disability insurance systems in many other countries that provide partial benefits for partial disabilities vocational backgroundtheir education skills and ageprevent them from performing any job in the national economy at or above the sga level vi the initial disability review is performed by disability examiners in state agencies if an applicant is initially denied ssdi benefits he or she may appeal the decision similar to social security retirement benefits an individuals ssdi benefit is based on their average lifetime earnings except there is no actuarial reduction in benefits for claiming before full retirement age the average monthly benefit for a disabled worker was 1197 in 2018 in addition to cash benefits ssdi beneficiaries automatically qualify for medicare following a 29month waiting period once benefits begin ssdi beneficiaries are allowed to try working again and a small number of beneficiaries are referred for ssafinanced vocational rehabilitation services beneficiaries may reengage in work above sga for up to nine months during what is called the trial work period vii but after that any amount of earnings above sga results in suspension of monthly cash benefits viii this abrupt loss of the entire benefit amount for as little as 1 in additional earnings is often called the cash cliff once cash benefits are stopped because of work activity the beneficiary enters a 36month extended period of eligibility during which time benefits can be restarted whenever earnings fall below sga after that benefits are terminated but can be reinstated on an expedited basis during the next five years the early years of the ssdi program were marked by intentional program expansions benefits that were originally only for disabled workers aged 5064 were quickly extended to disabled workers of all ages as well as their dependent spouses children and disabled widows and disabilities no longer had to be permanent just long lasting which was defined as lasting at least 12 months ssdis first work incentive initiative the trial work period was established in 1960 the caseload growth that followed this period of expansion was met with concerns about fiscal solvency to curb program costs in the late 1970s ssa tightened the medical eligibility criteria and pressured states to reduce initial allowance rates as a result the award rate fell from 45 percent in 1976 to 32 percent in 1980 adding to this effort congress passed the 1980 social security amendments which placed a cap on family benefits revised the benefit computation formula and established several work incentive initiatives ix to encourage work the sga earnings test would now be applied to beneficiary earnings net of impairmentrelated work expenses and if benefits were suspended for work activity individuals could keep their medicare coverage for an extended period furthermore cash benefits could be restarted if a former beneficiary vi these medical criteria are the same as those used by the supplemental security income program the meanstested disability insurance program for individuals with low incomes and minimal work history vii the nine months of the trial work period may be nonconsecutive and are followed by a threemonth grace period before benefits are suspended viii although cash benefits are suspended medicare benefits are maintained for 93 months after this period ends medicare benefits may be continued under buyin provisions some states offer premium assistance through medicaid ix the 1980 amendments also included performance standards to improve decisional consistency among adjudicators at the initial and appellate levels became unable to continue working during the new extended period of eligibility more controversially the 1980 amendments added a requirement that beneficiaries be reassessed regularly to ensure continued qualification for benefits the reassessment requirement which resulted in a large number of terminations was met with intense resistance by states administrative law judges the courts and the public this backlash led to further amendments in 1984 that limited benefit terminations to cases of demonstrated medical improvement or error in the initial determination in addition the functional capacity of applicants with multiple impairments was to be assessed taking into account the combined effect of all impairments the list of automatically qualifying mental impairments was to be revised and it was clarified that pain could be a contributing factor in a disability award since the 1980s congress has enacted no major reforms of the ssdi program incremental changes include the elimination of substance abuse disorder as a qualifying disability in 1996 and the creation of the ticket to work and selfsufficiency program in 1999 which provides employment services and supports to ssdi beneficiaries interested in returning to work the most impactful program change has come not from congress but from ssa itself beginning in 2010 ssas appeals council launched a management initiative to improve policy compliance and decisional consistency among administrative law judges who hear appeals of denied claims x the initiative which included case reviews direct feedback to individual judges and a redesigned judge training curriculum was associated with a large decline in the hearinglevel allowance rate from 52 percent in 2010 to 38 percent in 2016 although the causes of the decline are not known with certainty it appears the ssdi program may have recently undergone a major tightening ssdi trends ssdi has long been characterized as a program undergoing unsustainable growth indeed the di trust fund was on course for depletion in 2016 when congress averted benefit cuts of 19 percent by temporarily shifting a larger share of payroll tax revenues to the di trust fund xi since then however two surprising trends have shifted the narrative about the ssdi program the first is that the ssdi caseload is unexpectedly and persistently declining the second is that employment among people with disabilities is steadily rising a surprising reversal of a decadeslong downward trend this section discusses these new facts in greater detail x other notable changes by ssa included a ruling in 2015 that all evidence relating to a disability claim must be submittedincluding unfavorable evidence and in 2017 elimination of the longstanding rule that the treating physicians opinion should carry the most weight xi see fichtner and seligman for further information about the payroll tax reallocation legislated in the bipartisan budget act of 2015 pub l no 11474 129 stat 584 figure 1 shows the ssdi disabled worker caseload from 1960 to 2017 the caseload increases during the 1960s and 1970s reflect the early expansions in eligibility and the sharp decline in the early 1980s reflects the controversial terminations the subsequent backlash restored the caseload to its upward trajectory between 1982 and 2013 the caseload more than more tripledfrom 26 million to 89 million the latter number equivalent to 58 percent of the us civilian labor force correspondingly annual expenditures on cash benefits for disabled workers grew from 138 billion to 1230 billion during this period in 2014 the ssdi caseload plateaued and in 2015 it began decliningfor only the second time ever initially the growth in new ssdi awards was concentrated among people with circulatory system impairments as shown in figure 2 the policy changes that followed the terminations in the 1980s made it easier for people with mental impairments and with pain to qualify which shifted growth to mental impairments followed by musculoskeletal impairments the figure also shows a recent sharp reduction in the number of new awardsprimarily awards due to mental and musculoskeletal impairmentsreflecting the sharp reduction in the hearing allowance rate and suggesting that sharply reduced inflows are at least part of the reason for the recent caseload decline but the recent caseload decline is also in part due to an increase in exits figure 3 plots the annual number of awards and exits against the caseload stock focusing on the period since 2001 the annual number of exits has nearly doubled and beginning in 2014 has exceeded the annual number of new awards figure 4 shows that the vast majority of ssdi exits are accounted for by everlarger numbers of baby boomers aging out of the program at full retirement age in demographically predictable fashion not predicted however was the surprising rise in program exits due to successful return to work as shown in figure 5 although work exits are rare it is nonetheless striking that work exits have nearly doubled since 2013 it is possible that the strong labor market is driving the trend in work exits during this period there has been an unexpected and remarkable increase in employment among people with disabilities figure 6 shows the employment rate for people with and without worklimiting disabilities from 1988 to 2018 in approximately 2014 the employment rate among people with disabilities began to rise after several decades of decline the shaded areas denote the timing of recessions while the employment rate has risen during the long recovery since the great recession there was no such rise during the recovery from the 20012002 recession or prior recessions although speculative this may point to structural changes in employers willingness to hire individuals with disabilities perhaps in response to growing labor demand pressures associated with population aging what the research evidence tells us the research evidence to date points to five highlevel findings that provide a basis for crafting future disability reforms the first finding is that ssdi participation is not just a reflection of an individuals underlying health it also reflects their labor market outcomes and prospects for future employment both of which are affected by cyclical and structural labor demand conditions and which interact with ssdi program features that economic factors should play an important role in ssdi participation is not surprising nonparticipation in the labor market is a precondition for application and ssas decision rules are based on assumptions about the number of jobs for unskilled workers in the national economy nonetheless experts have disagreed about how much of the programs growth has been due to nonhealth factors such as economic incentives on one hand as the program expanded after the mid1980s there was no evidence of a decline in population health but strong evidence of weakening demand for lowskilled workers that occurred just as the 1984 amendments made the program more lenient and rising earnings inequality made the ssdi benefit more generous relative to the earnings of lowskilled workers in contrast others argued that even though the percent of the population in poor health had not increased the number of people insured for disability benefits had risen dramaticallyprimarily women and baby boomers liebman resolved the debate by showing that the sources of program growth differed over time during 1985during 1993 xii women becoming insured and population aging accounted for very little program growth implying that nonhealth factors were the primary drivers but from 1993 to 2007 women becoming insured and population aging accounted for twothirds of the growth thus ascribing a smaller though still important role to nonhealth factors such as economic incentives xiii the second takeaway follows from the first many ssdi beneficiaries retain residual work capacity indicating that for many ssdi participation is an alternative to employment but how much work capacity is retained or recovered has been the subject of considerable debate parsons found the ssdi program was responsible for the entire increase in labor force nonparticipation among men aged 4554 between 1948 and 1976 xiv in other words had the ssdi program not been established all of the additional nonworking men would have been able to work to some degree this xii this is largely the time period examined by autor and duggan xiii it is difficult to precisely identify the relative contribution of economic factors from leibmans analysis for two reasons first the effects of the business cycle on the ssdi program are held constant by the inclusion of the annual unemployment rate as a control variable other research demonstrates the importance of cyclical effects second the effects of economic conditions are not estimated separately but are captured by the portion of the disability incidence rate that is not explained by the demographic factors the disability incidence rate is not the incidence of disability in the workingage population but following ssa convention the incidence of ssdi award in the workingage population xiv labor force nonparticipation by males 4554 rose from 42 percent to 84 percent between 1948and 1976 finding was critiqued for its reliance on nonrandom variation in the ssdi benefit amount which as a function of lifetime earnings was potentially confounded with underlying health and labor force attachment bound countered that the ssdi program was responsible for at most onequarter of the rise in male nonparticipation to obtain this estimate he used denied applicants as a control group for ssdi beneficiaries arguing that since denied applicants were healthier than beneficiaries their postdenial labor supply was an upper bound on the work capacity of ssdi beneficiaries specifically he found that the employment rate among ssdi beneficiaries would have been at most 35 percentage points higher had they not been awarded ssdi benefits xv in response parsons argued that bounds estimate was not an upper bound on the total effect of the ssdi program if denied ssdi applicants had lower labor force attachment than allowed applicants or if the long ssdi application process eroded human capital evidence of both effects has since emerged recent advances have made use of quasiexperimental variation and administrative data to pin down the residual work capacity of ssdi beneficiaries maestas mullen and strand found that approximately 23 percent of applicants were on the margin of an ssdi award meaning that their chances of ssdi receipt depended entirely on the allowance propensity of the disability examiner to which they were randomly assigned xvi using the examiners allowance propensity as an instrumental variable for an applicants chances of receiving an ssdi award maestas mullen and strand found that the employment rate among this subset of ssdi beneficiaries would have been 26 percentage points higher in the absence of ssdi receipt furthermore the employment rate would have been as much as 50 percentage points higher in the absence of ssdi receipt among the least impaired applicants in the group overall their estimates imply that 43 percent of ssdi applicants have residual work capacity of which about 18 percent ultimately qualify for benefits sometimes under the listings but more often under the outdated medicalvocational criteria that said the residual work capacity of these beneficiaries is a partial capacity in the sense that their potential earnings in the absence of ssdi are substantially less than their predisability earnings that is even though many could work they have nonetheless experienced a significant disabilityinduced loss in potential earnings xvii the third highlevel finding relates to the second residual work capacity declines even further the longer people spend out of the labor force although initial ssdi decisions are rendered in a matter of months applicants who are initially denied and file an appeal often wait several years during which time most do not risk disqualification by working even though strictly speaking they could work as long as their earnings were below the sga level during this time out of the labor force waiting for a disability xv von wachter song and manchester corroborated bounds estimate in more recent data xvi french and song obtain a similar estimate using the award propensities of disability judges who hear appeals of initial denials specifically employment among ssdi beneficiaries would be 2648 percentage points higher in the absence of ssdi receipt determination their work capacity declines likely due to skill depreciation or loss of attachment to employers or employment networks if they are ultimately denied they are less likely to work because they applied for ssdi benefits if they are ultimately awarded benefits they are less likely to work because they applied and also because receiving benefits deters employment for some xviii this means the ssdi program reduces the subsequent employment of applicantsboth allowed and deniedby far more than the prior literature suggests furthermore autor et al find that accounting for the effect of processing delays increases the magnitude of the deterrent effect of ssdi receipt on labor supply indeed the employment rate of ssdi beneficiaries on the margin of award would be 48 percentage points higher had they not received ssdi benefits in other words their residual work capacity was also far greater than previously estimated the decay in work capacity that occurs with time out of the labor force may offer an important clue as to why policy efforts to incentivize work among ssdi beneficiaries have repeatedly failed indeed the fourth highlevel finding is that we still do not understand how to increase work effort among ssdi beneficiaries despite decades of research early studies noted low levels of work activity limited awareness of work incentives like the trial work period and extended period of eligibility low rates of benefit termination and a high likelihood of reenrollment among those who did terminate similarly the ticket to work program has suffered from low participation and has had little impact on beneficiary employment and earnings more recently the benefit offset national demonstration project to test the effect of replacing the ssdi cash cliff with a less abrupt benefit offset or partial reduction in benefits found no impact of the weakened work disincentive on employment and earnings what these policies have in common is that they target individuals only after they have enrolled in ssdi having already spent significant time out of the labor force xix last despite longstanding concerns about moral hazard among some beneficiaries and perhaps also among some employers an emerging body of economic research finds that the benefits associated with the ssdi program are substantial and may offset the distortionary costs it is important to note that this in turn suggests that the optimal ssdi program is not no ssdi but rather an ssdi program that retains its protective aspects while at the same time reducing its labormarket efficiency costs reforms to identify and promote work the implication of the major research findings i have reviewed here is that an effective reform strategy must achieve three goals first we should encourage individuals to stay xviii these programinduced losses in employability occur in addition to losses arising from the disability itself xix the same is true for federallyfinanced vocational rehabilitation services individuals become eligible for these services only after they are awarded ssdi benefits engaged in the labor force when reasonably possible while increasing access to vocational rehabilitation and other supports while they still have an employer or they still have skills that employers value second we should identify who has work capacity and specifically what jobs they could do currently we know work capacity exists in the ssdi population but the available evidence does not offer any specificity about who has what capacities and what alternative jobs use those capacities third we should help individuals to use and even augment their available work capacity before it is too late in this section i propose two interrelated reforms to the ssdi program that address these goals 1 improve measurement of work capacity and eliminate the medicalvocational grid and 2 award partial disability benefits for partial disabilities the reforms are interrelated in the sense that payment of partial benefits would be greatly facilitated by replacing ssas current method of determining work capacity with a modernized approach with greater discriminatory power in addition i discuss several reform proposals put forth by others highlighting those that are complementary with those that i have proposed proposed reform 1 improve measurement of work capacity and eliminate the grid the medicalvocational guidelines also known as the grid are used by ssa to determine whether an applicant can perform any other job in the national economy in their recent proposal to eliminate the grid warshawsky and marchand argue that the grid is no longer fair necessary or reflective of current conditions instead disability determinations should be focused solely on remaining earnings capacity combined with an evaluation of potential jobs suitable for the claimant in this spirit my first proposal is to eliminate the medicalvocational grid and replace it with a robust system for measuring earnings capacity estimating applicants remaining earnings capacity is the core objective of the ssdi determination process the current process is sequential ssa first checks whether the applicant has a listed impairment xx applicants with listed impairments are presumed to have no earnings capacity and therefore they qualify on medical grounds alone if the applicants impairment is not listed but it nonetheless prevents them from performing any of their vocationally relevant past jobs then ssa assesses whether the applicants skills are transferable to other occupations that fall within the applicants functional capacity range ssa makes these skill transferability assessments by first determining the applicants level of residual functional capacity based on medical evidence and then determining whether the applicant is disabled by applying the medicalvocational guidelines the guidelines are a grid of rules specifying whether an applicant is disabled based on combinations of residual functional capacity age education and skills gained from work experience table 1 shows how ssa defines these factors residual functional capacity has just four categories that describe the applicants maximum exertional capability sedentary work light work xx ssas listing of impairments includes over 100 impairments such as serious and persistent depressive disorders major dysfunction of a joint inflammatory bowel disease with obstructions epilepsy chronic kidney disease with impairment of kidney function metastatic cancers for the complete list see medium work and heavy work age is divided into closely approaching retirement age advanced age closely approaching advanced age and younger individual education has three categories illiterate or unable to communicate in english limited and high school graduate or more work experience also has three categories unskilled or none skilled or semiskilledskills not transferable and skilled or semiskilledskills transferable xxi to illustrate how the grid rules work table 2 shows several segments of the grid for someone with sedentary functional capacity limited education and skills that are not transferable the disability decision hinges on age if the applicant is 4549 they are not disabled but if 5054 they are disabled if the applicant with sedentary capacity is illiterate and unskilledthe disabilityage cutoff is 45 instead of 50 if the individual has capacity for light work but limited education and nontransferable skills they are not disabled if 5054 but they are disabled if 5559 for someone who can handle light work but is illiterate and unskilled the disabilityage cutoff is 50 instead of 55 while the grid is a convenient heuristic that enables adjudicators without medical or vocational training to render disability decisions it has major limitations xxii the first is that the grid has not been updated to reflect changes in the functional demands of jobs the regulations indicate that if a particular grid rule directs a decision of not disabled it is to be assumed that a reasonable number of unskilled jobs xxiii are available to an applicant with that medicalvocational profile across the national economy but this assessment of job availability is based on the dictionary of occupational titles which saw its final publication in the 1990s the ensuing decades have seen a dramatic shift in the nature of work most relevantly the rise in industrial automation has eliminated many physically demanding tasks and made others less demanding furthermore advances in medical care and assistive technologies have likely altered the set of tasks that can be performed in a given range of functional capacity although ssa has a decadelong initiative to create an updated occupational information system disability decisions today continue to use grid rules based on the obsolete dot xxiv the second limitation of the grid is that the medicalvocational combinations it delineates are coarsely defined and lack consideration of individual variability the grids reliance on fixed age thresholds to distinguish the disabled from the nondisabled is particularly problematic given the individual variation in health at any given chronological age dramatic gains in life expectancy the same or a lesser degree of skill is required the same or similar tools and machines are used and the same or similar raw materials products processes or services are involved xxii see also warshawsky and marchand for a detailed review of the grids many limitations xxiii the grid is calibrated to the number of unskilled jobs in the national economy because it is used when the applicant can no longer perform vocationally relevant occupations unskilled jobs require no particular skills training or education xxiv the dot was replaced by the occupational information network o net collects occupational information through national surveys of workers who selfreport about their job requirements o net has less occupational coverage than the dot and vaupel 2002 and secular improvements in many dimensions of health a third limitation of the grid is that residual functional capacity is conceptualized in terms of a single ability domainthe ability to exert physical strength xxv in determining an applicants maximum exertional level adjudicators are instructed to consider whether the applicant can also perform the nonexertional requirements of unskilled occupations at that level xxvi but this is a secondary consideration and the grid otherwise provides little direct guidance for disability cases that are primarily nonexertionalcases involving mental impairments sensory disorders skin disorders or pain symptoms perhaps not suprisingly mental impairments and those associated with pain have been a major driver of program growth i propose ssa modernize its method of assessing skill transferability several principles should guide this effort first the assessment should be individualized second it should measure the full range of remaining work abilities possessed by the individual third the assessment should use validated data collection methods and evidencebased guidelines for assessing function the more systematic and comprehensive the measurement system the greater will be the potential gains in efficiency and equity as standardization enhances consistency across adjudicators and provides decision support to enhance application processing speed in practice the system would measure the applicants functional capacity across a full range of ability domains use that information to query a database of job requirements identify the set of jobs the applicant has the functional capacity to perform and then assess whether the applicants education and skills are transferable to any of those jobs with only a limited amount of onthejob retraining xxvii the key to the approach is to measure individual function in the same terms as the functional demands of occupations the disability assessment system in the netherlands offers an informative model first an applicants functional capacity across a range of domains is assessed by a social security physician using a specially designed survey instrument the applicants information is then compared to a database of occupations that exist in all regions of the country and which have been rated along the same functional dimensions as the survey instrument an algorithm combines the applicant information and the occupational information to identify a list of feasible occupations for the applicant a social security labor expert reviews the list of feasible occupations pruning the list to take into account any extenuating information not captured by the algorithm the feasible occupations are then ranked by average earnings and the average earnings of the secondranked xxv specifically the grid takes account of strength available for sitting standing walking lifting carrying pushing and pulling xxvi the nonexertional capacities consist of postural and manipulative abilities vision hearing or speaking abilities tolerance for environmental exposures and the mental requirements of unskilled work xxvii ssas disability criteria does not take account of local job availability that said the grid rules are based on the notion that a given alternative job should be reasonably prevalent across the national economy occupation become the applicants estimated residual earnings capacity the percent difference between the applicants prior earnings and their estimated earnings capacity is the applicants estimated percent earnings loss which then determines their benefit amount there are at least two promising efforts underway in the united states that could be integrated to create a modern system of work capacity measurement based on the principles above first ssa has already invested in development and testing of an instrument for measuring individual work capacity the instrument known as the work disability functional assessment battery was developed over a 10year period by experts at the national institutes of health and boston university under an interagency agreement with ssa the wdfab has many advantages it is broad measuring function across eight physical and behavioral domains xxviii it provides coverage across the continuum of function within each domain by using computerized adaptive testing to iteratively select relevant items from a bank of more than 300 hierarchical items precisely because it is adaptive it can be administered in just 1520 minutes in different modes in extensive testing in samples of ssdi applicants and the general adult population wdfab displayed good testretest reliability measurement accuracy and convergent validity with legacy instruments last the wdfab was designed to evolve over time with ongoing research and development items can be added and removed measurement precision can be adjusted and scoring algorithms can be modified the drawback of the wdfab is that its items reference functional tasks performed in the home domain rather than in work settings this was intentional because people who apply for disability benefits are not working and might not be able to reference their functioning against workrelated tasks but this feature makes it difficult to identify which specific work tasksand thus which occupationsan applicant can perform nonetheless the wdfab could be adapted to this purpose if a team of occupational analysts created a crosswalk between wdfab items and specific job demands a second promising effort is the occupational requirements survey being developed by ssa and the bureau of labor statistics ors is an establishment survey designed to elicit detailed information about job requirements from the employer perspective ors is part of the occupational information system ssa is building to replace the dot the dot was maintained by a team of analysts who visited workplaces around the country to observe and record the requirements of jobs in contrast ors collects data by interviewing employers and establishment representatives an approach that yields similar measurements as direct observation while being less costly and timeconsuming further by randomly sampling establishments ors is nationally representative as of 2018 ors represents about 90 percent of civilian employed workers to fulfill its potential the ors should be synchronized with a functional measurement system like the wdfab so that it can be used to produce realistic individualized and multidimensional assessments of work capacity and a complete list of feasible jobs in addition to enhancing equity and efficiency across the ssdi system the use of a modern integrated work capacity measurement system would open the door to new types of interventions to improve outcomes for people with disabilities for example such data would facilitate targeting of returntowork interventions to precisely those individuals with residual work capacity the data generated by the system could be used to identify retraining opportunities for individuals who have the functional capacities for other occupations but who lack the necessary vocational skills or certifications it would also make possible other types of ssdi reforms such as my second proposal to allow for partial disability benefits proposed reform 2 allow partial disability benefits the ssdi program uses an allornothing definition of disability when in reality medical conditions reduce some abilities but not others and the reductions may be full or partial although there is no definitive estimate it is possible that 20 percent of ssdi beneficiaries are only partially disabled for those who have experienced partial loss of work capacity the optimal arrangement would be to combine partial earnings with partial disability benefits without a partial option these individuals must either forego disability benefits or attempt to qualify as fully disabled typically such applicants stop working altogether further weakening their labor force prospects should they be denied or subsequently attempt to return to work i propose the ssdi program add partial disability benefits for individuals with partial disabilities there are many ways to structure partial benefits with examples from the us workers compensation system the veterans affairs disability compensation system and the disability systems in several other countries xxix the core component is estimation of the applicants residual earnings capacitythat is the amount they could be expected to earn given their remaining functional abilities anyone with residual earnings capacity below the sga floor would receive a disability rating of 100 percent as under the current system those with residual earnings capacity above the sga floor would receive a disability rating equal to × 100 percent a ceiling could be placed on predisability earnings to restrict insurable earnings to a desired multiple of the sga level xxx under this structure an applicant with residual earnings capacity of 30000 and predisability earnings of 50000 would receive a disability rating of 40 percent if instead her residual earnings capacity were 10000 the disability rating would be 100 percent because 10000 is below sga if her predisability earnings were 100000 then her disability rating would be 70 percent if there were no ceiling on predisability earnings but 60 percent if a ceiling on predisability earnings were set at for instance 5 × sga the estimation of xxix countries with partial benefit provisions include sweden netherlands finland norway germany switzerland czech republic greece hungary korea france poland portugal spain japan andslovenia xxx with a ceiling on insurable earnings set at 5 × sga the disability rating would be × 100 percent residual earnings capacity would be greatly facilitated by a modernized system for measuring work capacity disability ratings could correspond to exact percentage reductions in an individuals full ssdi benefit amount or they could be grouped into ranges defining discrete benefit levels say 25 percent 50 percent 75 percent and 100 percent the choice of benefit schedule should depend on the precision with which work capacity can be measured the more precise the measurement instrument the more articulated the benefit schedule can be such a system would have several advantages most importantly people could apply while still working and receive a partial disability rating this would preserve unique employer accommodations and attachment to the labor force while providing replacement of lost earnings beneficiaries would maintain their ssdi entitlement until their full retirement age as long as they continued to be medically eligible regular continuing disability reviews would be used to ensure ongoing medical eligibility at the initially determined level or to revise the initial disability rating up or down as needed xxxi work cdrs would be eliminated xxxii eligibility for medicare benefits would be extended indefinitely even for those whose employers offer health insurance coverage xxxiii allowing employers to be the secondary insurer would create an incentive for employers to retain and hire people with disabilities xxxiv partial benefits could be usefully paired with a generalized benefit offset to provide beneficiaries with a strong incentive to increase work effort beyond their partial rating if they can unlike a standard benefit offset that imposes a tax on earnings the generalized benefit offset taxes earnings only when earnings are low and subsidizes earnings when earnings are higher the earnings subsidies act as a strong work incentive with the possibility of entitlement to partial benefits and postentitlement incentives to increase work levels above the initial rating leveland without risk of entitlement terminationthere would be no need for a trial work period the extended period of eligibility or provisions for expedited reinstatement xxxv the biggest drawback of partial benefits is the possibility that they would increase ssdi expenditures by inducing program entry by people who currently choose work instead of ssdi participation to see the issue consider the hypothetical individual above who had predisability earnings of 50000 and residual earnings capacity of 30000 under current rules if she works and earns 30000 she does not qualify for ssdi benefits if she does not work she may qualify depending on her impairments age and vocational background if xxxi as fichtner and seligman put it beneficiaries would have a right to due process that guarantees a timely cdr xxxii elimination of work cdrs will be tested under ssas planned work incentive simplification pilot xxxiii indefinite continuation of medicare coverage will be tested by wisp current law already provides for extended medicare eligibility for at least 93 months after ssdi benefits are suspended for work activity xxxiv requiring employers to be the primary insurer would tend to disincentivize hiring because individuals with disabilities have relatively high medical expenditures xxxv research is currently under way that may shed light on the value of such simplifications the promoting opportunity demonstration which is testing a 1 for 2 benefit offset without a trial work period or extended period of eligibility includes one treatment arm in which beneficiaries maintain entitlement indefinitely no matter how long their benefits are suspended due to work the other treatment arm terminates entitlement after 12 consecutive months of fully suspended benefits successful she would receive full ssdi benefits or approximately 15000 on average but if she were awarded partial benefits of 40 percent she would receive 6000 in ssdi benefits in addition to 30000 from employment the individual is financially better off under partial benefits which allow her to combine employment with ssdi receipt for a total income of 36000 but the ssdi system saves money only if she would have received full benefits under current rules it loses money if she would have worked xxxvi nonetheless this risk could be managed with careful analysis to determine optimal program parameters indeed recent research finds that a system of partial benefits would reduce disability expenditures on net on one hand more people would apply for benefit support when partial benefits are available than when only full benefits are available but these increases in caseload and costs are more than offset by two factors first some new beneficiaries who would receive full benefits under the current system would receive partial benefits instead xxxvii second even though the ssdi caseload would increase the expected program duration at full benefits would shorten since transitions to full benefits are postponed to later in life and the total years spent receiving full benefits decreases on average other important concerns are administrative complexity and the need to process more applicants than under the current system while these are real concerns partial benefits implemented along with several of the administrative simplifications noted above would help to offset the added complexity xxxviii because partial benefits allow beneficiaries to work they complement and even enhance other proposed ssdi reforms for example partial benefits and the generalized benefit offset both provide for reduced benefits with employment but partial benefits are established at entitlement while the generalized benefit offset allows further flexibility during the postentitlement period together they deliver incentivecompatible programmatic flexibility they combine formal disability assessment with an incentive for individuals to reveal their true work capacity at a given point in time by allowing them to selfselect into higher work activity but because ssdi eligibility is maintained at the last established level beneficiaries are not penalized if they are no longer able to sustain employment at higher levels or if they are laid off individuals whose conditions worsen would have a right to be reassessed for a higher disability rating through a medical cdr another example would be a pairing of partial benefits with an early intervention system of integrated employment and eligibility services which would emphasize rehabilitation and supported work attempts with the goal of increasing employment to the degree possible while maintaining access to the ssdi safety net xxxvi although she would earn more from employment than ssdi participation under current rules other factors influence claiming decisions such as whether her employer would allow her to work parttime whether she would qualify for employersponsored health insurance the probability of future layoff and her disutility of work xxxvii for humanitarian reasons partial benefits should be considered for new beneficiaries with current beneficiaries grandfathered in this would extend the period of transition to the programs new steadystate size xxxviii wisp will test similar simplifications of work incentive rules like this partial benefits proposal the promoting opportunity demonstration is testing elimination of the trial work period and extended period of eligibility other possible reforms making employers put skin in the gamessdis work incentives are misaligned not only for disabled workers but also for employers although employers are required by law to provide reasonable accommodation to employees with disabilities accommodation can be costly and firms pay no penalty should their employees enter the ssdi program instead several reforms have been proposed to make employers internalize the costs of not accommodating their employees these include requiring employers to cover the cost of ssdi benefit payments during the first two years as is currently done in the netherlands requiring employers to provide temporary disability insurance to their workers and introducing experience rating through the payroll tax system all these proposals would make employers internalize costs they do not currently bear but there are at least three reasons for caution first by making employers cover costs associated with a worker becoming disabled firms may avoid hiring workers with disabilities or those who might plausibly become disabled xxxix detrimental effects on hiring have been attributed to the employerresponsibility policy in the netherlands although not to antidiscrimination laws in the united states that have required employers to provide reasonable accommodations to employees with disabilities second the idea of experience rating is rooted in an economic theory that implies employers whose former employees enter ssdi at a relatively high rate should pay higher ssdi payroll taxes than those who send employees at relatively low rates experience rating is used in insurance settings and in state workers compensation systems for experience rating to work there needs to be enough pooling of individuals with high and low disability risks within firms to promote a stable system the system breaks down if the highrisk types cluster in the same firms while the lowrisk types cluster in different firms as firms have evolved in recent years workplaces have become more fissured with support occupations clustered in subcontractor firms further research is needed to assess whether the structure of occupations within firms would support adequate riskpooling last ssdi is not the same as workers compensation where employers can control injury rates to some degree by improving workplace safety it seems unlikely that employers could prevent disability onsets that arise from genetic predisposition or environmental factors beyond the workplace and accommodation may be unreasonably costly for some kinds of disabilities in some work settings early interventions to promote returntoworkcurrently people with disabilities do not have access to federally financed vocational rehabilitation services until after they are awarded ssdi benefits people who are denied benefits never receive such federal support intervention after the long ssdi application process comes too late for many and misses xxxix one way to offset a negative hiring effect of payroll tax penalties would be to include payroll tax discounts to employers who hire disabled workers earlier opportunities to restore work capacity develop transferable skills or identify potential accommodations while the individual may still be attached to an employer several have proposed reforms designed to take advantage of opportunities for early intervention in the hopes of avoiding ssdi entry in general early intervention would complement partial benefits since efforts would be made to restore as much work capacity as possible while the individual was still partially employed in addition the new work capacity assessment system could be used to identify specific areas where work capacity could be generated or restored stapleton benshalom and mann propose an integrated employmenteligibility services system where once a worker experiences a serious medical condition she would undergo triage and be fasttracked to either ssdi benefits employment supports or neither benefits or supports the triage decision would be based on the severity of the condition and the individuals work history if the individual is assigned supports she would only be awarded ssdi benefits if she attempted to return to work but was unable to do so even with the work supports the ees system differs from the current system by providing individuals with work supports quickly after the onset of their medical condition before an ssdi determination is made similarly christian wickizer and burton propose a health and work service that would coordinate various resources and supportssuch as referrals for specialized services and creation of a stayatwork and returntowork planfor individuals who experience a serious medical condition the goal is to provide these supports as soon as a week after the onset of the work disability additionally there is empirical evidence for the effectiveness of the hws the hws is partly modeled on the centers of occupational health and education in washington state which reduced longterm work disability for workers with musculoskeletal injuries by 30 percent moreover early intervention efforts might also be particularly effective for mental health disorders in part compensating for the wide variation in mental health service availability across states yet another way to keep individuals connected to the labor force after onset of a work disability is to offer transitional jobs as kerksick riemer and williams propose under this system both ssdi applicants and current beneficiaries would have an opportunity to work in subsidized wagepaying jobs tailored to their work capacity these jobs would pay an amount greater than the benefit amount to encourage uptake the authors further propose modifying the earned income tax credit to increase the credit for workers without children and who are unmarrieda subpopulation that makes up a large portion of individuals with disabilities both proposals would increase the incentive to work and keep applicants more connected to the labor force to prevent deterioration of skills temporary benefitsmaking ssdi benefits temporary for all new beneficiaries has been proposed as a way to limit longterm dependence by those who might benefit from returntowork interventions under a temporary benefits scheme all new beneficiaries would receive ssdi benefits for a timelimited period during which time they would receive rehabilitation and other returntowork interventions such as the early interventions described above at the end of the temporary benefit period all beneficiaries would be reassessed to determine their eligibility for longterm benefits longterm benefits would not be timelimited temporary benefits would complement a system of partial longterm benefits so that those who recover partial work capacity can transition to partial benefit support and partial work temporary benefits can also be paired with employer responsibility requirements such as a requirement that employers finance the temporary benefit period however in this case the same cautions apply about the risks of creating hiring disincentives or destabilizing employers with many highrisk workers 1for 2 benefit offsetthe benefit offset proposal is less creation of a work incentive than it is weakening of an existing work disincentive instead of losing their entire benefit when their earnings exceed the sga level beneficiaries would lose 1 in benefits for every 2 in earnings above an earnings disregard amount xl although this implicit 50 percent marginal tax rate on earnings is much less than the astronomically high implicit tax rate associated with the current cash cliff it nonetheless represents a substantial tax on earnings of all the disability reforms that have been proposed the 1for 2 benefit offset has been studied the most first during the decadelong bond project and currently through the promoting opportunity demonstration as noted above a weakness of the standard benefit offset policy is that applicants still have to demonstrate that they are fully disabled by not working during their long application period the inducement to reengage in work comes after benefits are awarded which is too late for many perhaps not surprisingly the bond showed no positive employment effects a generalized benefit offset is an appealing alternative but it should be paired with a partial benefit scheme that would allow applicants to continue working during the application process otherwise it too is likely to target individuals too long after they have left the labor market conclusion the reforms proposed here are not about requiring ssdi beneficiaries to work rather their intention is to encourage people who retain work capacity to work while they maintain complementary ssdi support in the amount needed for as long as it is needed and with the flexibility to adjust to changes in beneficiary health and employment prospects over time in this article i have proposed two interrelated reforms first i propose ssdi eliminate the outdated and incomplete grid framework for assessing disability in its place would be a new system that would measure residual functional capacity across an array of multidimensional abilities and would make use of this information to identify potential new jobs and estimate potential earnings xl the disregard amount can be the sga level or another level the promoting opportunity demonstration is testing a disregard amount that is less than sga second i propose that partial benefits be offered to applicants who have partial disabilities residual earnings capacity would be assessed during the application process using my proposed work capacity measurement system those with partial earnings capacity would receive a partial benefit proportional to their lost earnings capacity applicants who have lost their entire earnings capacity would continue to receive full benefits as they would currently importantly any applicant could apply for ssdi benefits while still working to whatever degree they are able beneficiaries would be reassessed regularly to ensure continuing medical eligibility for ssdi and to adjust their disability rating up or down as needed ssdi entitlement would continue until beneficiaries age out of the program or are found to no longer be medically eligible a generalized benefit offsetwhich features a true work incentive unlike the standard benefit offsetwould further enhance the proposed partial benefits scheme by providing all beneficiaries with postentitlement flexibility to further increase work effort when employment opportunities arise source annual statistical report on the social security disability insurance program 2001 table 392002 table 4520032004 table 46 table 4620052017 table table 50 2001 table 392002 table 4520032004 table 46 table 4620052017 table table 50 source current population survey annual social and economic supplement 19882018 retrieved using ipums note work disability is defined as a disability or health problem which limits or prevents work beginning in 2016 the wording of this question in the annual social and economic supplement of the current population survey changed by covering the entire previous year and including issues that affected work even for short periods of time maestas page 31

the social security disability insurance ssdi program which provides income support to individuals who become unable to work because of a disability has not been substantially reformed since the 1980s despite sweeping changes in health medical technology and the functional requirements of jobs i review how the ssdi program works its history in terms of caseloads and reforms and findings from the research evidence that offer lessons for the future i then propose two interlocking reforms that would modernize the core functions of the program the first is to improve ssdis process for determining whether an applicant has remaining capacity to work by replacing the outdated medicalvocational grid with a new system of individual work capacity measurement second i propose the introduction of partial disability benefits which would make use of the new system for measuring work capacity and allow beneficiaries to combine benefit receipt with work partial benefits could be paired with a generalized benefit offset to further encourage work by beneficiaries and the social security administrations complex array of workrelated rules could be eliminated

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the spatiality of geography teaching and cultures of alternative education the intuitive geographies of the anarchist school in cempuis cultural geographies vol 23 2016 615633 page 3 following an established literature that archives are not only bulks of sources but research objects in themselves 18 my main argument is that early anarchist education had its own spatiality largely based on outdoor practices and in unconstrained openair activities and inspired by the idea that the best way to help free individuals in their growing is to encourage their direct approach to both social and natural environments this owed on the one hand to the tradition of pestalozzi and fröbel which was introduced into frenchspeaking countries by james guillaume ferdinand buisson and others 19 and on the other to the works by the anarchist geographers charles perron elisée reclus and pyotr kropotkin who called for the implementation of freer methods in geographical teaching and proposed a different approach to maps and textbooks the present paper also aims to contribute to the recent international literature which has rediscovered the historical and epistemological links between anarchism and geography by stressing the central role that education played in the development of this relation 20 in the first part of my paper i address the historical educational context in which the cempuis school was founded in the second part i analyse the spaces of learning at the cempuis school based on external activities and pedagogical walks and trips in the third part i explore the specific teaching of intuitive geography at cempuis considering as well the examples of its closest avatars namely the barcelona modern school and lausannes ferrer school i conclude by arguing for the importance of this case to present debates on cultural and educational geographies geography intuitive method and integral education the first educational ideas of european anarchists were inspired by pierrejoseph proudhon the first person to even declare himself an anarchist 21 these anarchist ideas sprang from proudhons proposal of a polytechnic education a concept that was meant to build a specific form of knowledge for the working class one which was not limited to high culture but which integrated technical and intellectual capacities to improve the process of social emancipation proudhons set of ideas on education was then reinterpreted by paul robin under the spatiality of geography teaching and cultures of alternative education the intuitive geographies of the anarchist school in cempuis cultural geographies vol 23 2016 615633 page 4 the label of integral education 22 a teacher and political exile under the second empire paul robin was later part of the networks of internationalists in frenchspeaking switzerland together with charles perron the future anarchist geographer who was to work alongside elisée reclus 23 perron and robin were the first within the first international to emphasise education as a priority field in the struggle for social emancipation 24 in subsequent years robin participated in the network of another french exile he met in switzerland ferdinand buisson close to the leftlibertarian wing of the 1871 paris commune 25 who later assumed institutional responsibilities under the third republic and became director of the department of public instruction in collaboration with the republican minister jules ferry in this role he served as the editor of the mammoth dictionary of primary education 26 considered the symbol of the secularisation and democratisation of the french school system which was realised in the follow decades by leftrepublican governments 27 buisson involved in his enterprise anarchists like robin and the swiss polymath james guillaume who saw the idea of working to build the french system of public education in the name of the shared principles of popular and secular education as consistent with their political background 28 one of the conceptual frameworks of guillaumes commitment was provided by his ideas about the french revolution of 1789 which he envisaged as the origin of the debates for public and secular education guillaume was involved in drafting the materials of the public education committee of the revolutionary convention of 1792 29 some historians have observed that guillaume in dealing with the revolution of the previous century acted in a classic way historians tend to act by building a history which was inseparable from his present concerns 30 guillaumes trajectory is a typical example of the dialectical and occasionally contradictory relationship between anarchism and republicanism among french anarchists the idea of the republic was either rejected or proclaimed as a fundamental principle which had been betrayed by official republicans 31 an interest in the french revolution was also shared by the anarchist geographer pyotr kropotkin who worked closely with both guillaume and the spatiality of geography teaching and cultures of alternative education the intuitive geographies of the anarchist school in cempuis cultural geographies vol 23 2016 615633 page 5 reclus 32 and who carried on a scientific correspondence with guillaume on these topics 33 we find this contrast recalling anarchisms connection with the original republican idea of freedom as nondomination 34 in the conflictual relationship the cempuis educators had with the symbols of the french republic they were officially asked to represent guillaumes work was also important in the spread to france of ideas emanating from educators like the swiss johann heinrich pestalozzi and the german friedrich fröbel these ideas were universally endorsed during the buisson moment 35 as the inspiration of a pedagogical method based on childrens direct experience known in the frenchspeaking world as the leçon de choses or intuitive method this kind of approach shows several unmistakable links with the idea of integral or polytechnic education clearly grounded in experience proudhon for example was endorsed in the dictionary of primary education as a point of reference for professional teaching… allowing all citizens to have equal access to knowledge 36 pestalozzis approach was strongly spatial and directly addressed the teaching of geography in his writings on pestalozzi guillaume stressed his natural method as well as his links with important geographers of the day like carl ritter who defined himself as pestalozzis disciple according to guillaume pestalozzi came twice to yverdon in september 1807 and january 1809 and then during his stay in geneva between 1811 and 1812 he visited the orphanage managed by pestalozzi several times forty years after his stays in yverdon ritter said to the historian louis vuillemin pestalozzi didnt know what a child in primary school knows about geography yet it was no less in talking with him that i felt awakening in me the instinct of natural methods it was he who led the way for me and what i managed to do i must ruefully assign to him as his 37 guillaume also stressed vuillemins own eyewitness accounts of the natural methods employed by pestalozzi in teaching geography to primary school pupils the first elements of geography were taught to us in the field they began by pointing our walk towards a narrow valley near yverdon where the buron stream flows they made us observe it as a whole and in its details until we had a complete and accurate sense of it then they invited each of us to collect his own supply of a clay found there in layers in one of the small valleys sides and we filled large baskets we had brought along for that purpose once back at the château they the spatiality of geography teaching and cultures of alternative education the intuitive geographies of the anarchist school in cempuis cultural geographies vol 23 2016 615633 page 6 distributed long tables to us and left us to reproduce in relief the valley we had just studied each of us for the part he was assigned the following days new walks new explorations carried out from an everyhigher point of view and each time a new extension given to our work we continued in this way until we had completed the study of the yverdon basin until from atop the mountain that utterly dominates it we had taken it in wholly we had completed our relief model then and only then did we go from the relief model to the geographic map which we arrived at only after having acquired an understanding of it 38 ritters frequent references to the earth as home for the education of humankind his antipathy for the uncritical use of maps for lists and pedagogical dogmatism as well as his commitment to building the german system of instruction owed a great deal to pestalozzi ritters importance to the formation of european geography in the 19 th century is universally acknowledged and the influence of his ideas on several geographers who worked for public education is well known in both the frenchspeaking world 39 and great britain 40 it is clear that the socalled natural methods were immediately endorsed by anarchist geographers like kropotkin and reclus and some of their collaborators like patrick geddes 41 as an alternative to an ideological state education 42 guillaume also dedicated to pestalozzi a chapter of his book études révolutionnaires dealing with topical figures in the construction of the idea of secular education during the french revolution in that chapter guillaume offers a rather original interpretation of pestalozzi investigating his littleknown participation in the revolutionary movement at the end of the 18 th century as well as his contribution to the spread of enlightenment ideas in switzerland pestalozzi was acknowledged in 1792 as a french citizen by the paris national assembly which endorsed him as one of the men who contributed the most by both their writings and their bravery to the cause of freedom and the liberation of peoples 43 according to guillaume pestalozzi was the most original and the bravest among all the thinkers and writers in germanspeaking switzerland in the 18 th century 44 the spatiality of geography teaching and cultures of alternative education the intuitive geographies of the anarchist school in cempuis cultural geographies vol 23 2016 615633 page 7 it is worth stressing that in the same years according to teresa ploszajska the introduction of fieldwork practices in british schools is often assumed either to have seeped down from educational practices in university practices or to be the result of pestalozzian theories 45 the posterity of these practices in the following decades is clearly stated by this author as well as the geddess influence on the idea that doing fieldwork in the countryside involved defining citizenship in strict counteropposition to anticitizenship 46 geddes is equally evoked by pyrs gruffudd as one of the inspirers of fieldwork practices in the welsh schools in order to build a national identity thus initiatives in wales followed on from the resurrection of nature study in scotland and england at the turn of the century inspired and led by the scottish polymath patrick geddes 47 as geddess influence on all british geography and planning in the 20 th century is undeniable 48 and his closeness to anarchist geographers like kropotkin and reclus is clear 49 it is possible to hypothesise that the posterity of the pedagogical movement which i am addressing in the anglophone world transited indirectly through geddes works which played a not negligible role in the shaping of later fieldwork and teaching practices openair spaces and natural methods at cempuis bulletins which the cempuis school produced from 1882 and 1894 form an exceptional source documenting almost day by day the schools activities reading them today we can appreciate the heavy use of tutelary figures like pestalozzi fröbel and elisée reclus by the cempuis educators founded thanks to the legacy of the philanthropist jean prévost to shelter orphans from four to sixteen years of age the school was run from 1880 to 1894 by robin who had been invited there by buisson buisson was the executor of prévosts will for example and his wife had managed the school over the last two years 50 the school belonged officially to the local administration called the conseil général de la seine where the councillor responsible for the cempuis school was aristide rey a former member of the paris international workingmens association and friend of reclus and benoît malon 51 it was rey who laid the foundation for a wide programme of integral education 52 there was also a constant exchange taking place between the orphanage and buissons dictionnary as can be seen by its inclusion of several of robins essays that had originally been published in the bulletin the spatiality of geography teaching and cultures of alternative education the intuitive geographies of the anarchist school in cempuis cultural geographies vol 23 2016 615633 page 8 in cempuis it was first established that as many activities as possible were to be done in the open air for reasons of hygiene and to put the leçon de choses into practice 53 which included both unhampered gymnastics and exercises inspired by the fröbel method and manual work in the garden or the workshop 54 in this first issue of their bulletin the cempuis educators explained their programme of school walks and excursions frequently the whole community leaves in the early morning for long excursions a wagon follows behind us to carry our food for the outward leg of the trip and to carry those who are too tired or the littlest ones on the way back 55 shorter walks were made generally twice a week on thursdays and sundays following pestalozzis principle of starting by exploring ones surroundings walks set off from the schools surroundings plains hills uplands valleys pupils learn to model reliefs with clay indicating streams springs tributaries and branches after which they understand streams rivers and estuaries walk after walk they indicate the districts the cantons the departments the rest comes by intuition 56 according to gabriel giroud a former pupil and later robins soninlaw and the first historian of cempuis these walks were never organised randomly but with a precise aim which had both a naturalist and a social interest walks always had an aim visiting the factory of a workshop seeing a natural spectacle like a spring or a valley or looking at a historical or prehistorical monument here was a living lesson of geography history and ethics 57 as giroud recalls three kinds of excursion were systematically practised at cempuis the first trips in a deserted or unknown field 58 the second trips accompanied by a wagon 59 and the third trips with stays in cities or little towns 60 in this sense the approach of cempuiss educators finds a clear echo in the geddes idea of nature not as evasion but as a good training for both urban and rural citizenship as i argued above the spatiality of geography teaching and cultures of alternative education the intuitive geographies of the anarchist school in cempuis cultural geographies vol 23 2016 615633 fig 1 rest during a cempuis excursion these walks especially the longer ones involving overnighting outside the school walls also had a strong social dimension targeting the contact between the orphanage members and the inhabitants of the surrounding communes because the educational debates in those years were the central issue of a political and cultural conflict 61 and secular education needed to gain supporters especially among the lowest classes of the countryside traditionally the portion of the population most exposed to clerical propaganda in those pioneering years the secular teachers who worked in the most peripheral villages were often isolated and subject to the diffidence of catholic peasants thus local teachers and progressive mayors were both the first targets of the cempuis visits and often those who allowed the cempuis pupils and teachers to be sheltered in their villages where the latter offered in the evening celebrations and entertainment for the inhabitants vocal and instrumental music gymnastics diction plays etc 62 music had great importance in teaching at cempuis it was for all these reasons that his school formed a brass band which did its first public performance on 13 march 1884 63 one of the aims expressed by giroud was that everywhere the spatiality of geography teaching and cultures of alternative education the intuitive geographies of the anarchist school in cempuis cultural geographies vol 23 2016 615633 page 10 school pupils should be welcome and all pupils should travel 64 in any case sleeping on the straw 65 was considered a formative experience these according to nathalie brémand 66 anticipated some aspects of baden powells scouts movement recently addressed by research in historical geographies of youth and citizenship 67 music also involved the dialectical relationship between anarchism and the republic in many of the villages visited people asked the cempuis band to play the national anthem la marseillaise originally the rallying song of the french revolutionaries of 1792 whose music was played with a last hurrah for the republic nevertheless according to giroud in more discreet occasions the patriotic song was not only played but also sung and at such times in a different version called it is clear that these performances offered to exterior people were also part of a diplomatic necessity for legitimating the cempuis experiment as a republican one in order to safeguard the schools public funding which was often questioned by the conservative press but as i have argued above the links between anarchism and republicanism rendered republican slogans acceptable to the leftlibertarians of the first decades of the third republic an historical experience welcomed by reclus who said i set my hopes not on the republic which does not exist but for its name because a name is always something 69 thus while waiting for the creation of the true republic anarchists like robin strengthened their alliances with leftrepublicans and offered themselves as the republican vanguard in this sense then the bulletin evinces cempuiss concern with helping the secular teachers of the countryside often isolated and faulted by local priests and conservative people one of the the spatiality of geography teaching and cultures of alternative education the intuitive geographies of the anarchist school in cempuis cultural geographies vol 23 2016 615633 page 12 declared aims of these trips as in the case of an 1888 excursion to the northern towns of tréport and dieppe was to show these peasants what the republic can obtain through education hoping that their children will later become loyal and intelligent republicans 70 in this regard it is important to stress that the cempuis schools visits were not necessarily well received everywhere the welcome depended on the political tendencies of local governments conservative governments like dieppe for instance often refused to shelter the group and the adults and children were sometimes obliged to sleep in tents or in schoolrooms opened to them by sympathetic teachers in other districts the bulletin recorded a fine welcome by republican councillors 71 that is to say leftist or nonconservative ones a feature of cempuiss organisation was thus a discipline without obligation 72 which is still a theme not only of anarchist literature but also for the philosophers of republicanism 73 and recalls the alexander neills definition of freedom without licence the politicisation of these expeditions is seen in a range of anecdotes from the different trips the author of the account of the 1891 school summer trip relates with amusement that one night the cempuis group discovered they had set up camp in the surroundings of a convent and the appearance of a nuns headgear sparked the laughter 74 it is worth pointing out that later experiences of alternative and radical education will be characterized by a similar rebuttal of religious teaching from the summerhill school to the cambridge malting house garden school studied by laura cameron where the schools head geoffrey pyke advertising an available teaching position specified that interested people should not hold any form or religious belief 75 in cempuis other occasions to socialise with neighbours families and other educators were the fêtes pédagogiques school festivals of one or more days with demonstrations of music performances theatre gymnastics and different sorts of manual labor along with talks and lectures which had an evergreater presence in the life of the community as stated in 1883 like school walks and excursions festivals occupy and will continue to occupy an increasingly important place in our familys life 76 the spatiality of geography teaching and cultures of alternative education the intuitive geographies of the anarchist school in cempuis cultural geographies vol 23 2016 615633 page 13 what characterised the cempuis excursions was a rigorous preparation that included equipment for orienteering and for climatic and morphological studies from the beginning of their experience the cempuis children were trained to make regular meteorological observations which they did three times a day according to the standards of the central office of meteorology to which observations were periodically transmitted 77 a deliberate awareness of geography and space affected both internal and external activities including those that had the pupils working with their hands for instance the project and spatial arrangement of school typography was made over into a social activity the printing laboratory was thought to be able to employ up to twenty children 78 and became the centre for printing the cempuis bulletin as well as propaganda pamphlets which increasingly put to work older pupils besides the educators other productive activities involved the school vegetable gardens and animal farm which were regarded as resources for basic alimentation the latter also represented a field for trying out a range of ideas according to the bulletin some pupils encouraged by robin experimented with vegetarianism whereas the majority consumed the meat of the schools animals including pigs raised by the orphanage one of which is killed every month 79 it is worth stressing that in their writings both buisson and guillaume viewed gardening and farming as a central learning activity guillaume stated that it was an essential task for putting children in touch with nature 80 while buisson admired at the 1873 world exposition in vienna the models representing primary schools where the main garden contains at least one little garden for every child who cultivates his plot in hisher own way 81 the surroundings were firstly perceived in their morphological features cempuis is a toponym linked to the presence of numerous wells or pits due to the absence of surface water flows the first itineraries were therefore directed to find the closest streams as we know from the long quote above water flow was a major pedagogical concern for pestalozzi and reclus living on the watershed between the basins of the somme and the seine we love going to visit the running waters which we are deprived of in the village of the hundred wells 82 the spatiality of geography teaching and cultures of alternative education the intuitive geographies of the anarchist school in cempuis cultural geographies vol 23 2016 615633 page 14 a consideration that we find in the same text recalls another feature of the thencurrent debates going on around the buissonguillaume dictionary and teaching through experience when cempuis pupils evoke all the beauties by which our eyes were enchanted 83 during their first long school trip they use the same words and expressions that reclus and his cousin franz schrader employ conjuring up the need to awaken the childs wonderment for the imagination and the gigantic he wants absolutely that he sees a stone he imagines a boulder he sees a molehill he suddenly imagines a mountain 84 a complementary tool for excursions was the formation of a velocipede squad which boasted twelve bicycles and eight tricycles one of which had been made in the orphanage 85 but as i have pointed out social concerns as well as naturalistic ones were important too as the cempuis children grew they increasingly took part in writing articles for the bulletin showing an increasing class consciousness which is on display in numerous remarks like those they made after the school holidays of 1884 they write that these sea baths we have now were once a privilege for very few wealthy people 86 direct participation of children to the bulletins and the propaganda activities was constantly increasing in the 14 years of the schools history as the first classes children grew my sources do not detail individual contributions because in all the schools publications children were anonymised but i can argue that the difficulty in distinguishing their contributions from the adults ones was an effect to the application of a participative school democracy which will characterize the later experiences of summerhill and of radical education in general 87 as i remarked the first historian and defender of the cempuis school was one of its first pupils gabriel giroud i can conclude this section arguing that cempuis and integral education anticipated several features of the presentday alternative experiences studied by kraftl who envisages in their outdoor practices the mobilisation of morethansocial elements of life the interaction and blurring of the natural and the social which defines learning as an ongoing series of collaboration between the natural and the social 88 according to kraftl practices of walking and tasks like farming which characterise today several kinds of home schooling are an the spatiality of geography teaching and cultures of alternative education the intuitive geographies of the anarchist school in cempuis cultural geographies vol 23 2016 615633 page 15 instrument to break down a formal educational relationship between teacher and learner 89 who are no more facetoface but sidebyside one difference with the cases addressed by kraftl to my mind is that in cempuis walks farming and gardening were not distractions from more formal practices but very structural and declared learning activities in this vein their repetition seems to me not the institutionalisation of a routine as in the theory of habit discussed by kraftl but rather the opening of diverse possibilities to make a school republic work considering that the cempuis documented walks were always different planned with the participation of pupils and sometimes constituted by explorations with a didactic explicit aim but without a definite destination the teaching of picturesque and intuitive geography beyond the material reality of excursions the sector of knowledge which is now called geography was constantly practised at cempuis this started from the critical use of one of its more typical and more controversial tools viz the map according to giroud the excursion groups were equipped with topographical military maps whose deficiencies for educational use were regularly stressed by the author even if the planimetry is correct the terrain relief both on the military staff maps and on the local service ones is absurdly represented by an awful daubing which darkens the drawing and indicates nothing 90 this critique of the obscure cartographic symbols immediately brings to mind recluss critique of flat maps which he viewed as an ideological device and a false one which should be avoided in primary education thus according to the anarchist geographer maps ought to be entirely tabooed they must be tabooed because maps are made on different scales and that being so it is quite impossible to compare them and if you cannot compare them it is only waste of time and trouble in all wellconducted schools globes should be used and children ought to be entirely forbidden the use of maps 91 nevertheless at cempuis maps were not entirely outlawed but they were critically analysed in the school printing laboratory advanced pupils produced in 1885 a world map based on a projection which differed from the ones then adopted in education stating that we need a better the spatiality of geography teaching and cultures of alternative education the intuitive geographies of the anarchist school in cempuis cultural geographies vol 23 2016 615633 page 16 system than the mercator cylindrical projection 92 it is well known that the mercator projection deformed the relative dimensions of countries and contributed to the construction of a eurocentrism 93 but its questioning by a french orphanage in the 19 th century is undoubtedly a very early instance of criticising imperial map projections the cempuis people preferred lamberts conic projection unfortunately unknown in primary education which conserves relative surfaces everywhere 94 these activities for the production of geographical models and representations paralleled the introduction of the same practices in english schools analysed by ploszajska who argues that like fieldwork with which it was closely associated both in principle and practice modelling made children active participants in the acquisition of geographical knowledge 95 once more these practices echoed the debates on natural methods promoted by reclus and kropotkin and assumed by geddes maps were also used for practical tasks linked to outdoor activities one idea was the map under glass a military topographic representation of the region was covered with a glass panel on which children could draw and redraw itineraries and check them in the field during an excursion to beauvais the map under glass was attached to our wagon 96 and regularly consulted during the long 1888 trip through bray neufchâtel dieppe and tréport every excursionist had a map with an abstract all chromatographed by one of them they were generally quarts from the military staff 97 but among the characteristic features of the cempuis excursions the most significant was not the use of a map but of the most uptodate equipment for orienteering and measuring robin had returned from his travels in great britain with several topographic devices like the prismatic compass a precious instrument still unknown in france which we used as well as the aneroid barometer the pedometer and sometimes the pocket sextant and the abney level 98 robin made an impressive list of the scientific instruments which the cempuis students and teachers used during the sixteenday trip they made on foot in the summer 1891 to their base for group holidays by the sea in the village of merlesbains notebook for drafts and notes pencil the spatiality of geography teaching and cultures of alternative education the intuitive geographies of the anarchist school in cempuis cultural geographies vol 23 2016 615633 page 17 map of the region and itinerary chronometer compass binoculars magnifying glass pedometer aneroid barometer box to collect plants garden trowel geologists hammer sewing kit pharmacy kit 99 alexis sluys a belgian freemason and freethinker the director of brussels école normale and a great fan of robin was one of the teachers responsible for teaching geography at cempuis his interest in these topics started in the 1870s with the publication of an intuitive geography 100 in 1890 he was host to a cempuis expedition in brussels to promote an international conference against the exploitation of orphans work which was the usual practice in traditional orphanages and to launch a new rationalist orphanage in brussels 101 after the cempuis model sluys wrote in the cempuis journal fêtes pédagogiques on the teaching of geography in primary school laying out arguments very close to those used by kropotkin in his celebrated paper what geography ought to be 102 on childrens delight in nature and travel narratives a sharp contrast with their deep boredom in geography classes based on memorised enumerations sluys quotes another russian inspirer of libertarian pedagogy leo tolstoy endorsing his claims against arid nomenclatures… a jumble of names 103 but unlike tolstoy sluys stressed the opportunity to teach geography from the earliest levels if it was taught according to nature otherwise it is useless 104 in this sense a true intuitive geography should start with the schools surroundings but without abstraction and thus be grounded in the observation method 105 which sprang from an example directly inspired by recluss histoire dun ruisseau 106 namely the observation of the nearest stream 107 at this early stage according to sluys teachers have to avoid erudite details like technical names and definitions but try to stimulate pupils curiosity to investigate and understand causal links between phenomena like rain and water runoff or the source and the river in this way children were allowed to understand greater generalisation until they realise the idea clearly influenced by the 19 thcentury philosophy of nature that the globe is no longer a set of disparate pieces as it appears studying geography by fragments but like a whole whose different parts are intrinsically linked among themselves 108 among the recommended books of his ideal geography programme sluys names several of recluss works like la terre histoire dun ruisseau and histoire dune montagne 109 while also endorsing popular writers on nature and adventure like jules verne and the spatiality of geography teaching and cultures of alternative education the intuitive geographies of the anarchist school in cempuis cultural geographies vol 23 2016 615633 page 18 archibald geikie sluys was the organiser of the sixteenday school field trip of 1891 and relates in his diary several anecdotes like the welcome the cempuis group received in the village of saintemarguerite by the secretary of the paris geographical society charles maunoir 110 and among the authors quoted by sluys we find charles delon one of the other cempuis geographers this maverick figure like other protagonists of secular education at the time had renounced his public appointment as a schoolteacher under the second empire in 1859 by refusing to swear loyalty to napoleon iii 111 working as a peoples teacher and a writer delon was then one of the early cultural channels of the ideas of pestalozzi and fröbel in france in this he collaborated with marie papecarpantier one of the first women involved in the establishment of public nurseries inspiring the work of pauline kergomard reclus under the third republic a cousin of elisée reclus kergomardreclus worked with guillaume and buisson 112 in particular delon was interested in clearing fröbels system of all metaphysics to reform and supplement it scientifically 113 the task of secularising protestant thinkers like ritter pestalozzi and fröbel a clearly political undertaking was often presented as a cultural transfer between the german and french linguistic areas according to delon to make this method a french one it had to be freed it had to be naturalised to be established among us 114 taking his cues from fröbels kindergarten delon was also interested in space remarking that the interior layout of schoolrooms was different from the traditional system still used in france for instance daises are suppressed 115 and the organisation of internal and external spaces thus had to be arranged to allow children freedom of movement in order to develop their integral capacities as at cempuis music and songs were very important in the fröbel system they accompanied every walk and set the pace they sing a great deal in the fröbel school they sing to mark the rhythm in play and walks before and after study during the distribution of work 116 as for activities outside the school walls the other of delons points of reference was clearly pestalozzis valley walks which the french teacher described using the plan of reclus histoire we can thus assume that the cempuis orphanage was the most advanced attempt to put into practice the debates fuelled by buissons dictionary which included arguments that were often too revolutionary to be introduced by the french state moreover the french government was not unanimous in its appreciation of works by buisson and other instituteurs laïques or lay teachers and the changes of ministers and governments implied different practical choices cempuis and robin were targeted for a long time by the french catholic and conservative press which was scandalised by mixedsex education calling such arrangements a pigsty and eventually obtaining robins dismissal in 1894 even though he was hotly defended by buisson and kergomard and all the alleged episodes of immorality were never proved 119 benjamin buisson compared cempuis to the mythic orphanage managed by pestalozzi in switzerland we went to cempuis the way people once went to yverdon to see pestalozzi 120 it is worth stressing the strong commitment of french anarchists and secular educators in what was later called gender parity and in defending the works of female teachers like pauline kergomardreclus often demonized by the conservative press mixedsex education was in this sense a very pioneering effort if we consider for instance that according to elizabeth gagen teaching to both girls and boys in the usa still posed problems in the middle of the 20 th century 121 from that moment on anarchist schools were generally created through selffinancing and selfmanagement in order to be independent of the states politics and policies such was the case of two direct heirs of the cempuis school the barcelona modern school which was run by francisco ferrer y guardia and lausannes ferrer school both these experiments were directly inspired by robin and geographers like reclus and kropotkin i should also stress the internationalism of both anarchism and these experiments witness for instance robins efforts to introduce at cempuis the teaching of several foreign languages 122 the spatiality of geography teaching and cultures of alternative education the intuitive geographies of the anarchist school in cempuis cultural geographies vol 23 2016 615633 page 20 in the case of barcelona francisco ferrer worked directly with elisée reclus whom ferrer had known during his exile in france at the time reclus was settled in brussels as the director of the cartographic institute at the université nouvelle where he experimented with the construction of threedimensional devices like raisedreliefs and globular maps 123 to resolve the aforementioned problem of the inadequacy of flat maps it should be emphasised that part of these devices were intended for use in anarchist schools like the one in barcelona there were for example little cardboard globes meant to be indestructible pupils can drop them 124 cartography was thus adapted to the needs of an active education one which involved not only visual abilities but also the other senses ferrer participated directly in the design of recluss spherical maps by trying them out at the modern school and going over the experience with the geographer our teachers loved the spherical map very much but one made an observation wondering if it is not too small to be seen in the classroom 125 even if based in an urban context the barcelona modern school applied the idea of external fieldwork as an integral part of educational spaces including in this case the industrial environs of barcelona a 1903 visit to the textile factories of sabadell was for children the occasion to become aware of workers conditions 126 a 1904 trip beyond the french border to visit the banyulssurmer research station in maritime biology was also a chance for teachers and pupils to have material contact with the phenomenon of national boundaries discussing the oddity of different flags waving over regions like catalonia and roussillon where local dialects were not that different from each other 127 the modern school was closed in 1906 by the authorities and ferrer began a new exile in france returning to spain in 1909 he was murdered by the spanish state as i have already explained during the campaign of international solidarity to win his release ferdinand buisson declared that ferrer was the representative of the french revolution in spain 128 the spatiality of geography teaching and cultures of alternative education the intuitive geographies of the anarchist school in cempuis cultural geographies vol another of cempuiss heirs lausannes ferrer school was devoted to the memory of ferrer and his work its programme directly recalled robins integral education which is explicitly laid out there to give pupils too early on manuals with definitive phrases that dispense them from turning to the work of their hands eyes and intelligence means as rousseau said to accustom them to always believe and never know 129 reclus was likewise one of the most quoted references not the least because of his direct links with some of the founders and inspirers of the school 130 invoking reclus and geikie the teachers of the ferrer school argued that for children books on natural sciences are useless what is more needed is learning to observe on the spot to do botany in fields and woods to study atmosphere stones insects birds and animals along the way and in the midst of natural surroundings 131 in one of the last issues of the school bulletin we find one of the most expressive definitions for the adoption of a learning space that includes openair practices borrowed from the french historian jules michelet the human flower according to michelet is the one which needs the most sun 132 the spatiality of geography teaching and cultures of alternative education the intuitive geographies of the anarchist school in cempuis cultural geographies vol 23 2016 615633 page 22 conclusion the present paper is but a first attempt to explore and analyse through archive work historical and current spaces of anarchist education a rich field of research that deserves greater scholarly interest historical anarchist education was a pioneering approach in pedagogies that were secular antipatriarchal and based on children activism this research has shown that geographers and geography rather neglected by much of the existing historiography on these schools in fact played a primary role in the foundation and functioning of anarchist schools like the ones in cempuis barcelona and lausanne and established a series of pedagogical practices relevant for the cultural historical geographies of education discussed in the quoted papers by mills and ploszajska beyond geography in a disciplinary sense however my aim was to show that the discussion around and practice of the right places and spaces for secular and liberated teaching and learning were of fundamental importance to anarchist educators for now i can conclude that historical anarchist education possessed its own spatiality which was firstly defined by the deliberate choice of openair spaces and unconstrained openair activities it was not a rigid or unique space but a broad definition of open spaces as a dimension that allows the expression of liberated teaching it was mainly the result of an indepth critique of closed spaces as mechanisms that form subjects not citizens and is best put in recluss statement anticipating some of foucaults own that it will not be in narrow rooms with barred windows that brave and honest people will grow 133 i also argue that the integration of manual physical and intellectual practices consistent with anarchist social theory 134 further stimulated the development of free and openair spatiality providing an early critique of the alienation of work while introducing in the early stages of education something like the concept of attractive work 135 in fact the ironic references to extramural activities as an école buissonnière and the organisation of holidays as school excursions were part of the questioning of the separation of school time and recreation time which was in turn a questioning of the separation of school spaces and external spaces the spatiality of geography teaching and cultures of alternative education the intuitive geographies of the anarchist school in cempuis cultural geographies vol 23 2016 615633 page 23 in this sense i can argue that what is important for anarchist education in these early experiences is the idea of a school which directly engages with society and which can be a tool for social emancipation rather than a naturalistic estrangement current debates on childhood and policy have stressed the political nature of childhood and questioned the commonplace of children as passive victims of great historical dramas arguing that they could have an agency in political struggles 136 early anarchist education should be considered then as a specific childhood and youth policy aiming to help individuals grow and acquire their own critical instruments which should allow them to deal with a future social transformation the question of the influence of this movement and of buissons secular education out of france and southern europe is still open and deserves further research but i argue that an important deal of this posterity transited generally in indirect ways through the works of patrick geddes and pyotr kropotkin who both exercised strong influence on englishspeaking geographers and educators 137 about kraftls questioning of the spaces of alternative education one answer that we can retrieve from the cempuis experience is the idea that the best alternative educational space should be the real world kraftl argues that in home schooling if learning flows from everyday life childrens exposure to the greatest variety of everybody spaces is crucial 138 and this leads to the general idea among alternative educators that learning should be imminent and immanent to everyday life 139 thus early anarchist experiments have something important to add to current debates on these topics for instance by reinforcing the idea equally expressed by kraftl that essays in diverse education are more than a mere alternative to the mainstream because they constitute and provoke refection about alternative visions and versions of lifeitself 140 and should be like in the case of cempuis a public endeavour 141 towards the whole society in this sense they allow to affirm practices that involve some kind of utopian impulse but which too are grounded in realworld practices affording a sense that alternatives are possible and not merely desirable 142 in cempuis this alternative was anarchism

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introduction the global population is ageing with the proportion of adults aged 65 years or older predicted to increase from 6 in 1990 to 16 by 2050 12 healthy ageing entails more than simply being free of disease and disability 3 to age in the healthiest way possible a priority must be to enable older adults to continue to engage fully in life older adults have the right to live in and contribute to their community whatever their physical capacity 3 psychological and social wellbeing plays a significant role in healthy aging 4 in alignment with this vision for health a model of positive epidemiology has recently been proposed 5 as described by vanderweele the study of diseases and risk factors should be supplemented with a positive epidemiology focused on health assets and a broader range of healthrelated states 5 taking a positive epidemiology approach will highlight opportunities to promote wellbeing functional capacity character strengths and quality of life as our population ages by enhancing certain resources an individual possesses including psychosocial characteristics 5 our work reflects the principles of health promotion that were first introduced by aaron antonovsky in his seminal work proposing salutogenesisan assetbased approach to health and wellbeing focused on the factors that support wellness 6 optimism is a psychosocial factor that contributes to promoting health and wellbeing in older age 7 optimism is a facet of personality described as the tendency to expect favourable outcomes and to have a positive outlook 8 higher levels of optimism are associated with lower incidence of agerelated diseases such as cognitive impairment 9 and heart disease 10 additionally optimism has been found to be positively correlated with quality of life 11 pessimism is described as expecting the worst 12 and historically has been considered diametrically opposed to optimism 13 higher levels of pessimism are associated with a greater risk of allcause mortality 14 higher incidence of cardiovascular mortality 15 and with shorter leukocyte telomere length 16 evidence indicates that optimism and pessimism are modifiable 17 it may be possible to identify modifiable factors associated with higher optimism and lower pessimism which can be targeted in healthpromotion interventions studies report that younger age more advantaged socioeconomic position and higher level of education are each associated with higher optimism and lower pessimism 18 19 20 healthrelated behaviours may also play a role for example in young and middleaged women being physically active was associated with being more optimistic 21 while higher optimism is also associated with abstaining from smoking 22 and the probability of engaging in volunteer work 23 though there may be other factors that yet have not been sufficiently examined there is some evidence on the putative association between lower pessimism and the increased likelihood of engaging in healthpromoting behaviours 24 though less is known about whether healthy lifestyle behaviours in turn promote lower pessimism there is a scarcity of evidence for correlates of optimism and pessimism in older adults aged over 70 years this age is of particular interest as research suggests that levels of optimism and pessimism vary across the lifespan levels of optimism may decline at approximately 70 years with a concurrent rise in levels of pessimism 1825 identifying factors associated with low optimism or high pessimism when optimism and pessimism are assessed in later life could enable targeting interventions to help promote healthy ageing although recent evidence reports the association of lifestyle with optimism and longevity is not substantial 26 the unique association of different lifestyle factors and optimism and pessimism in both men and women is not clear to address the abovementioned gaps we aim to determine the association of socioeconomic behavioural and social health factors with optimism and pessimism in men and women aged 70 years or over and to determine whether correlates of optimism and pessimism are distinct acknowledging that the current evidence is unclear regarding the endogenous or exogenousenvironmental origin of personal optimismpessimism we interpret our findings as correlational connections rather than a causeeffect relationship of the socioeconomic behavioural and social health factors and optimismpessimism on healthy ageing materials and methods study population the study population was men and women participating in the aspree longitudinal study of older persons alsop was a substudy of a largescale clinical trial called aspree which was designed to study the effects of a low dose of daily aspirin on health outcomes in older adults living in the united states of america and australia in early 2012 aspree participants who were living in australia and had been recruited by general practitioners to participate in aspree were invited to participate in alsop 2728 the sample were aged 70 years and over lived independently and were free of cardiovascular disease cognitive impairment or major physical disability at baseline 26 findings of the aspree study have previously been published 29 30 31 the aspree study complies with the declaration of helsinki a total of 14892 participants 89 of aspree participants who were living in australia participated in the alsop substudy alsop participants were representative of australian adults who reached the age of 70 years in reasonably good health 28 of these 12896 individuals returned the baseline social questionnaire which contained the revised life orientation test a test to measure optimism and pessimism 13 the final sample used was those participants for whom we had data for all observations assessment of optimism and pessimism the lotr was used to assess optimism and pessimism lotr is a validated tool consisting of six items plus four filler items which were not included in the alsop study to reduce the burden on participants completing the survey as per kim et al 32 of the six items three items are positively worded which are summed to assess dispositional optimism whilst three items are negatively worded and summed to assess pessimism participants respond to questions on a 5point likert scale from strongly disagree to strongly agree with the optimism and pessimism subscale scores ranging from 3 to 15 following recent evidence from scheier et al 33 our study considered optimism and pessimism as separate constructs the lotr has been demonstrated to have good testretest reliability and convergent and discriminant validity 13 the optimism variable was not normally distributed and none of the variable transformations corrected skewedness therefore in line with previous literature 3435 we expressed the optimism and pessimism variables as tertiles t1t3 with higher tertiles representing greater optimism or pessimism independent variables participant characteristics to summarize characteristics of the study population age was considered in three categories 7074 years 7584 years and 85 years and more however in the regression models age was used as a continuous variable binary or categorical variables were created for gender level of education marital status and living situation healthrelated behaviours binary categorical variables were created for physical activity smoking status and unpaid volunteer work alcohol intake was categorized as never consumed alcohol former drinker current drinkerlow risk current drinkerhigh risk low risk was defined according to current australian safedrinking guidelines which specify that safe alcohol consumption is ≤40 g pure ethanol on any one day and ≤100 g pure ethanol in a week 36 socioeconomic factors residential postcode determined the socioeconomic indexes for areas based on the index of relative socioeconomic advantage and disadvantage 37 seifa was categorized in quintiles from least socioeconomically advantaged to most advantaged annual household gross income was classified as 40 g pure ethanol on any one day or 100 g pure ethanol in a week correlates of optimism factors associated with higher optimism for both men and women having more than twelve years of education compared with twelve years or less being more physically active compared to less physically active and doing volunteer work compared to not doing it was associated with higher optimism factors associated with lower optimism being lonely compared with not being lonely and being socially isolated compared with not being socially isolated was associated with lower optimism household income was associated with higher optimism in women only being a current or former smoker compared to those who never smoked drinking alcohol at lowrisk levels or highrisk levels compared to those who never drank alcohol or reporting low social support compared to being well socially supported were associated with lower optimism footnote horizontal bars present 95 cis seifa socioeconomic indexes for areas referent categories in order of variable appearance in the figure 12 years education aud 20000year least advantaged lives with others less physically active never drinks figure 1 the association of socioeconomic behavioural and social health factors with optimism in 10146 men and women aged ≥70 years the results of multivariable ordinal logistic regression footnote horizontal bars present 95 cis seifa socioeconomic indexes for areas referent categories in order of variable appearance in the figure 12 years education aud 20000year least advantaged lives with others less physically active never drinks alcohol never smoked no volunteer work not lonely not socially isolated and socially supported as figure 1 indicates higher level of education being more physically active doing volunteer work and not being lonely were associated with higher optimism compared to the referent categories for both men and women drinking alcohol at high risk levels was associated with lower optimism compared to the referent categories for men and women for women being older and earning aud 2000099999 compared with aud 20000 was associated with higher optimism figure 1 also indicates that for women being a currentformer smoker drinking alcohol at lowrisk levels and having low social support were associated with lower optimism compared with the referent categories gender differences for correlates of optimism some associations with optimism were different for men and women in women only being older compared to being younger or earning a higher annual household income was associated with higher optimism in women only being a current or former smoker compared to those who never smoked drinking alcohol at lowrisk levels or highrisk levels compared to those who never drank alcohol or reporting low social support compared to being well socially supported were associated with lower optimism correlates of pessimism factors associated with higher pessimism for both men and women being lonely compared to not being lonely women 156 123197 or having low social support compared to being well supported was associated with higher pessimism factors associated with lower pessimism having more than twelve years of education compared to having twelve years or less being more physically active compared to less active and doing volunteer work compared to not was associated with lower pessimism living in a more socioeconomically advantaged neighbourhood compared to living in the least advantaged area earning a higher annual household income and living alone compared to living with others were associated with lower pessimism footnote horizontal bars present 95 cis seifa socioeconomic indexes for areas referent categories in order of variable appearance in the figure 12 years education aud 20000year least advantaged lives with others less physically active never drinks alcohol never smoked no volunteer work not lonely not socially isolated and socially supported as figure 2 indicates low social support and being lonely were associated with higher pessimism compared to the referent categories for both men and women higher level of education being more physically active doing volunteer work living in a socioeconomically advantaged area and earning aud 2000049999 were associated with lower pessimism compared to the referent categories for both men and women for men being a former alcohol drinker was associated with higher pessimism compared to the referent category figure 2 also indicates that for women only living alone and drinking alcohol at lowrisk amounts were associated with lower pessimism compared to the referent categories all the results were similar when a unidimensional measure of optimism was used gender differences for correlates of pessimism some correlates differed for men and women in women only living in the 4th quintile of neighbourhood socioeconomic advantage compared to the least advantaged area was associated with lower pessimism for men only being a former drinker compared to those who never drank alcohol was associated with higher pessimism as figure 2 indicates low social support and being lonely were associated with higher pessimism compared to the referent categories for both men and women higher level of education being more physically active doing volunteer work living in a socioeconomically advantaged area and earning aud 2000049999 were associated with lower pessimism compared to the referent categories for both men and women for men being a former alcohol drinker was associated with higher pessimism compared to the referent category figure 2 also indicates that for women only living alone and drinking alcohol at lowrisk amounts were associated with lower pessimism compared to the referent categories all the results were similar when a unidimensional measure of optimism was used discussion our study aimed to identify the factors associated with optimism and pessimism in community dwelling older adults while several factors were associated with both higher optimism and lower pessimism several factors were associated with either higher optimism and lower pessimism this also supports our recommendation that optimism and pessimism are independent constructs women were more optimistic and less pessimistic than men and more correlates were associated with optimism and pessimism among women in women higher optimism was associated with being older having a higher household income never smoking not drinking alcohol and having high social support while lower pessimism was associated with living in a lower socioeconomic advantaged neighbourhood for men higher pessimism was associated with being a former alcohol drinker our conclusions remained similar when we employed a unidimensional measure of optimism socioeconomic correlates our result that greater annual income was associated with higher optimism aligns with previous research 19 similar to our study in a study using a multifaceted definition of greater socioeconomic advantage encompassing area of residence and educational attainment greater advantage was reportedly associated with lower pessimism for men and women 20 we observed an association of higher level of education with higher optimism and lower pessimism evidence indicates that education level is associated with greater quality of life and improved living standards 42 individuals with higher level of formal education may have more positive expectations for the future because they are more likely to enjoy a better quality of life and higher living standards 42 a higher level of education is also associated with greater participation in social activities 43 and lifelong learning 44 this may contribute to increased optimism for those who are more educated it would be advisable for governments to fund educational opportunities for older adults such as the university of the third age in victoria australia 45 by providing accessible programs in the community to older adults such as affordable group lessons this may promote the prospects of this cohort increasing in their positive future outlook and the accompanying benefits to physical health in our study earning a higher annual income and living in an area of greater socioeconomic advantage was associated with lower pessimism this may be due to improved access to resources which enhance wellbeing 46 indeed research suggests that adequate access to resources promotes optimism 47 thus further studies are needed to replicate this association with lower pessimism having sufficient access to material resources in the latter years of life may provide confidence to older adults those with adequate economic resources can enable older individuals to support themselves in the future when they are no longer working thus they may have more positive future expectancies behavioural correlates our study reports that in both genders greater intensity of physical activity was associated with higher optimism and lower pessimism physical activity provides a sense of mastery purpose and selfesteem 21 which may influence optimism physical exercise also has moodenhancing effects for older adults 48 boosting levels of serotonin which also promotes good sleep 49 thus the underlying mechanism explaining the association with greater physical activity and higher optimism and lower pessimism may be physiological as well as behavioural we also report that drinking highrisk levels of alcohol was associated with lower optimism though smoking cigarettes was not associated with optimism or pessimism this could be because there are various social and environmental influences that influence why people begin to smoke and the subsequent smoking is largely a manifestation of nicotine addiction 50 the results related to smoking may need to be interpreted with caution as we do note that there was a relatively low number of current smokers in our cohort which comprised individuals who had lived to 70 years or older free of chronic disabling disease we observed that healthy behaviours may promote higher optimism and lower pessimism more optimistic individuals are also more likely to engage in healthpromoting behaviours including being physically active 51 and not smoking 22 this is because optimistic people are more likely to believe that their actions will be successfulie that their healthy lifestyle behaviours will result in improved wellbeing 52 we acknowledge that reverse causality may contribute to our findings in other words the associations with healthy behaviours reported may reflect the effect of optimism and pessimism 53 our results contribute novel findings on the association of healthrelated behaviours with both optimism and pessimism in older adults social health correlates social health describes someones abilities to adapt in social situations and form satisfying meaningful relationships and how someone interacts with and is supported by other people institutions and services 54 the concepts of social isolation loneliness and social support are often discussed in relation to social health social isolation is an objective count of having few to no social relationships or social contact with others 55 social support is a subjective perception of the availability of resources from others while loneliness is a subjective negative feeling of being isolated 55 there is overwhelming evidence that poor social health is associated with a greater severity of chronic disease risk factors 56 lower quality of life 5758 and mental ill health during cardiovascular disease recovery 59 as well as an increased risk of cardiovascular disease 60 61 62 dementia 6263 and mortality 64 we observed that older adults who do volunteer work or are less lonely are more likely to be more optimistic and less pessimistic while low social support was associated with higher pessimism since social isolation social support and loneliness are considered independent predictors for depression anxiety cognitive decline and even mortality in older adults 56 57 58 59 60 61 62 63 64 our novel results offer unique insights using a cluster of measurements of social health with future expectancies in older men and women promoting optimism in older adults could be a promising intervention to improve social health as well as reduce the detrimental effects of poor social health for example the best possible self intervention increases optimism 17 even among older adults 65 further group activities addressing other associated factors could additionally be improving social interaction and thereby improving optimismpessimism through social health for example affordable group educations such as the university of the third age 45 could improve education and socialisingboth identified factors in our study similarly nonclinical groupbased interventions prescribed through healthcare workers could target a range of other associated factors identified in our study social prescribing can be defined as a process that enables healthcare professionals to refer patients to a link worker to initiate a nonclinical social prescription to improve their health and wellbeing 6667 social prescribing is being proposed as a solution to poor social health as an innovative holistic communitycentred approach 68 there are systematic reviews demonstrating benefits of social prescribing to wellbeing 6970 and quality of life 71 a recent systematic review identified that while there was a lack of evidence on social prescribing for chronic disease risk factors the few groupexercise programs that were identified had benefits for physical activity 68 the authors highlight that social prescribing could be effective in improving social health as well as modifying the determinants of chronic diseases and promoting sustainable healthy behaviours here we would recommend that optimism and pessimism be incorporated in such evaluations to provide a comprehensive evaluation of the potential benefits volunteer work enables older individuals to keep busy create meaning in life and develop new social and role identities 72 this may promote a positive outlook previous researchers have observed that people who are more optimistic and less pessimistic are more likely to do volunteer work 23 be less lonely 73 and have adequate social support 74 we hypothesize that the relationship between the social health correlates measured and optimism and pessimism may be bidirectional gender differences we observed that women reported higher optimism than men which aligns with the findings of a study researching a german general population community sample aged 18 to 80 years 41 in our study and others 1840 women reported lower pessimism than men while in some studies no gender difference in pessimism was observed dataset 41 our results contrast with studies reporting no difference in optimism for men and women dataset 40 and higher optimism in men compared to women dataset the divergence in results may reflect the underlying differences in personality that are seen in all men and women gender differences have been noted in temperament emotions and behaviour such as aggression as well as various indicators of psychological wellbeing 75 several major theories including evolutionary theories and sociocultural theories attempt to explain these gender differences 76 men and womens personality may also be influenced by specific cultural aspects such as gender roles socialization and gender equity which could vary between study samples 76 gender differences in variability in optimism and pessimism through latter life are largely unknown though in the health and retirement study the pessimism of men declined more slowly than women in the latter years of life 18 further research is needed to clarify potential gender variability in optimism with ageing our study reports differences for the socioeconomic behavioural and social health correlates of both optimism and pessimism for men and women for women being older and reporting higher income was associated with higher optimism for women living in the 4th quintile of socioeconomic advantage was associated with lower pessimism for men being a former drinker was associated with higher pessimism our study also contributes unique results in that among women 70 years and older those who were older were more likely to be optimistic than the younger women our results add novel insights into why women and men display different optimism and pessimism it is plausible that in the populations sampled in previous studies characteristic features such as the age distribution lifestyles and socioeconomic position of participants differed thus explaining differences in the prevalence of higher optimism and lower pessimism of men and women we report more socioeconomic behavioural and social health correlates of optimism and pessimism for women compared to men these differences may suggest that for women life experience and socialization may play a more significant role in determining optimism and pessimism compared to men implications it has been demonstrated that optimism is associated with healthy ageing 7 however research into the biological mechanisms underlying this association is inconclusive 7778 our study has identified several socioeconomic behavioural and social health factors that are associated with optimism and pessimism among relatively healthy older adults however with the current lack of evidence as to the exact origin of personal optimismpessimism interpretation is limited to the association and not causation even when analysing longitudinal data on optimismpessimism changes associated with measured optimism andor pessimism may reflect other underlying traits or experiences that have been incurred outside the period of observation nevertheless our findings assist with progressing the literature in three facets first the associated factors can serve to identify highrisk groups which could be targeted for improving optimism and pessimism second interventions aiming to potentiate optimism and lessen pessimism could also serve to address these other factors if improvement in these factors also promotes optimism and decreases pessimism third older adults eager to improve their optimism and pessimism could aim to address the modifiable associated factors along with other strategies to promote wellbeing prior positive psychology interventions that also increase optimism have been shown to improve the mental and physical wellbeing of older adults and promote their independence 6579 however at a population level promoting healthy behaviours and positive social health for older adults may also increase optimism and decrease pessimism this would enhance the many benefits associated with such lifestyles as well as increase the odds of higher optimism and lower pessimism for example engaging in physical activity can also improve older adults global cognitive function 80 and build musclemass and strength 81 doing volunteer work can prevent premature mortality 82 as well as reduce depression and reduce loss of functional capacity 83 more physically fit older adults are likely to be more optimistic and contribute to society through volunteering which likely further promotes optimism campaigns to target one aspect of health have been shown to have modifying effects on others 84 which may also apply to factors related to ageing further research will determine whether biological factors can explain possible gender differences between optimism and pessimism as people age our results suggest that health promoting measures which target socioeconomic behavioural and social health correlates may possibly improve optimismpessimism and perhaps the overall wellbeing of older adults however we nonetheless acknowledge the complexities and challenges in addressing adverse health issues faced in later life future research could tailor interventions for older adults to promote optimism and minimize pessimism so that adults might have increased chance of ageing in the healthiest way possible strengths and limitations this is among the first studies of adults aged ≥70 years exploring the association of socioeconomic behavioural and social health variables with both optimism and pessimism in men and women the crosssectional study design means we were unable to determine causality between the independent covariates and optimism and pessimism therefore our findings are to be interpreted as potential factors identified which could improve optimism and pessimism among older adults however further research is required to ascertain this furthermore our results may not be generalisable given that our study population have reached the age of ≥70 years free of lifelimiting disease within 5 years dementia or major physical disability and are living independently some adults face their later years with multimorbidity 85 and poor health is associated with lower optimism 25 selection bias may reflect the fact that most alsop participants were more optimistic and optimistic people may be more willing to participate in a research study information gathered on potential correlates of optimism and pessimism was selfreported thus reporting bias may be evident particularly for behavioural measures we also acknowledge the potential consequences of performing multiple statistical tests particularly increasing the type 1 error rate conclusions in community dwelling adults aged 70 years and over those with favourable socioeconomic conditions positive behavioural choices and good social health are more likely to be more optimistic and less pessimistic older women are more likely to be optimistic and less likely to be pessimistic than older men and more factors were associated with optimism and pessimism among women the correlates identified can serve as a foundation to inform the development of interventions as we have identified highrisk groups which could be targeted as well as opportunities to improve optimism and pessimism such interventions could not only promote optimism and reduce pessimism but also encourage healthpromoting lifestyle behaviours and reduce social isolation and loneliness in adults aged 70 years and over data availability statement the dataset supporting the conclusions are not publicly available for legal and ethical reasons data cannot be shared publicly as data are part of a large ongoing observational cohort with a rigorous process to access data data are available from monash university for researchers who meet the criteria supplementary materials the following supporting information can be downloaded at institutional review board statement the current project was reviewed and approved by the monash university human research ethics committee reference number 21906 the aspree study complies with the declaration of helsinki and was approved by monash university as the primary ethics site in australia informed consent statement all aspree participants provided informed written consent prior to their subsequent participation in aspree participants provided consent for study results to be published no findings presented in this manuscript are previously published elsewhere

background optimism is a disposition characterised by positive future expectancies while pessimism is characterised by expecting the worst high optimism and low pessimism promote the health of older adults and may potentiate full engagement in life we identified socioeconomic behavioural and social factors associated with optimism and pessimism in older adults methods participants included 10146 communitydwelling apparently healthy australian adults aged 70 years and over from the aspree longitudinal study of older persons alsop optimism and pessimism were measured using the revised life orientation test crosssectional ordinal logistic regression was used to determine the socioeconomic behavioural and social health factors associated with optimism and pessimism results higher education greater physical activity lower loneliness and volunteering were associated with higher optimism and lower pessimism low social support was associated with higher pessimism higher socioeconomic advantage greater income and living alone were associated with lower pessimism women were more optimistic and less pessimistic than men the association of age smoking status and alcohol consumption with optimism and pessimism differed for men and women conclusions factors associated with higher optimism and lower pessimism were also those demonstrated to support healthy ageing healthpromotion action at the individual level eg smoking cessation or regular physical activity health professional level eg social prescribing or improving access and quality of care for all older adults and community level eg opportunities for volunteer work or lowcost social activities for older adults may improve optimism and reduce pessimism possibly also promoting healthy ageing

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institutions and workplaces many working people carry fastfood items while returning homes to be consumed as snacks or as dinner items fast foods are typically readytoeat and the consumer has no control over the portion size and nutritional content of these foods 5 fast food consumption has increased because of many factors such as an increase in income lack of time rapid urbanization online home delivery facilities and attractive advertisements 6 fastfood is a main factor which aids in socializing with friends most of the study respondents consumed fast food due to peer pressure the consumption of fast foods gives a feeling of modernization urbanization and a sense of belonging to the higher class among all age groups some of the participants of the study also admitted that it was a medium to flaunt their wealth 7 fast food is also known as junk food and it is high in calories and low in nutritive value it mainly contains refined flour refined sugars lowquality oil transfat and numerous other food additives which are harmful to human health 8 junk foods are given an attractive appearance by adding food colours and other food additives such as msg 9 noodles biscuits chips chocolates cake ice cream chowmien momos samosa soft drinks burgers pizza fried potatoes meat products etc are some of the popular fastfood items 10 increasing trends of fastfood consumption are a matter of serious dietary concern among adolescents and young adults as they are laden with calories and fat and are strongly associated with may obesity and obesityrelated chronic diseases 11 reasons for increasing fast food trends the busy schedule of office work makes fast food popular among adults globalization and other economic and social reasons are also responsible for the increase in consumption of fast food among young adults in an australian study on young adults by smith et al it was found that young australians who consumed takeaway fast food at least twice a week met fewer dietary recommendations 12 they also showed a moderately higher prevalence of abdominal obesity than those consuming fast food less frequently over the years the trends of fastfood consumption have spread out globally and mainly so in urban areas a dietary shift has been witnessed in many countries as they are consuming less local and traditional diets while increasingly consuming more fast foods and processed and packaged foods 13 according to a report by research and marketcom it is anticipated that the world fast food market will exhibit significant growth from 2020 to 2027 because for several reasons such as an increasing number of fastfood restaurants an increase in the working female population availability of online ordering options and changing consumers preferences 14 the global market for fast foods is expected to reach 9317 billion by 2027 according to deepthi and ashakiran indias fastfood industry is expanding by forty percent every year 15 mass media plays an important role to popularized fast foods other media like posters magazines billboards radio and cinemas are also used to promote fast food consumption 1 morning hurries and work pressure make young adults to skip breakfast in the morning and is also one of the main reasons for consuming fast food among them availability of a great variety of quickly prepared fast foods its affordability and readiness are also reason for consuming fast foods 7 working parents with nuclear families have less time for meal preparation at home they are exhausted at the end of the day from work other household activities and stress and they had very little energy to prepare a full dinner 16 fast foods are prepared with unhealthy ingredients which contain few nutrients they contain a high amount of saturated fat sugar salts and calories fastfood consumption is associated with several adverse health outcomes such as increases in the prevalence of obesity arthritis heart diseases blood pressure diabetes metabolic syndrome loss of muscle mass liver disease sexual dysfunction indigestion problems asthma and cancer it is also associated with the development of several mental deficiencies like anxiety insomnia depression sleep apnoea panic attacks and other anxiety syndromes 17 fastfood consumption with a lack of physical activity leads to obesity fast food consumption among young adults contributes to an increase in obesity rates and is a global concern 18 junk food consumption is rising in developing countries as well as in south asian countries the global junk food consumption among young adults is approximately 70 percent according to the world health organization southeast asian region is facing high prevalence of obesityrelated diseases such as diabetes and cvd 10 popular fastfood items and their caloric values has been presented in the table one globally traditional dietary pattern is being replaced with fast food items locally available nutritious recipes and dietary patterns have now been replaced by fast food items even though fastfood consumption negatively affects the health of people it is still popular among young adults this study focussed on fast food consumption trends in south asian and southeast asian countries south asia is a subregion of the asian continent it includes eight countries namely bangladesh pakistan india maldives sri lanka afghanistan nepal and bhutan southeast asia concludes eleven countries namely brunei cambodia indonesia laos malaysia myanmar philippines singapore thailand timorleste and vietnam fast foods are very popular among young adults limited studies have attempted to identify the magnitude of the fastfood consumption trends among young adults in south asian region factors associated with fast food consumption will also be covered in the same study fast food consumption patternglobal trends fast food is very popular among young american adults the fastfood industry first expanded in california in 1940 the consumption of outofhome food and fast food is a global concern fast food consumption is highest in countries such as australia usa and uk however it is equally a concern in urban cities of developing asian african middle eastern and latin american countries 19 according to a report from the national health and nutrition examination survey in usa in between 2013 to 2016 366 per cent of american adults consumed fast food on a single day the study showed that fastfood consumption was highest among young american adults the percentage of adults consuming fastfood decrease with age a higher percentage of nonhispanic black adults consume fast food than other population groups in the us with the increase in income the percentage of adults consuming fast food also increased men mostly consumed fast food for lunch however women reported eating fast food as a snack 20 another study revealed that us adults consumed 48 per cent of junk food items daily 21 kant et al revealed that more than fifty per cent of the us adults consumed food outside the home three or more times per week while 35 percent consumed it two or more times a week 1922 a study among young australian adults about their consumption of takeaway fast foods showed that australian men consumed more takeaway foods than women in this study 379 percent of australian men reported that they consumed takeaway food twice a week or more in the comparison to 177 percent of the women 12 various european studies showed that fast food consumption and takeaway food culture are increasing day by day a government report in the united kingdom found that 22 per cent of residents purchase takeaway foods at least once a week and 58 per cent purchased them a few times in one month 23 a crosssectional study in the uk conducted by the government reported that 22 percent of residents consumed takeaway fast food at least once per week and 58 per cent consumed it a few times a month another study among uk adults found that 27 per cent of adults and 19 per cent of children consumed meals outside the home food once per week 19 in a study in romania among young adults it was found that this age group consumed more fastfood products the price of fastfood items and convenience were the factors that influenced their decision to consume fast food 24 a german study reported that pizza was the most consumed fastfood item among adolescents in the same study it was reported that girls derived 65 per cent of their daily energy from fast food however boys received 78 per cent of daily energy from fast food boys consumed 600 grams of fast food per week while girls consume 400 grams per week 25 melkadze et al reported that most of the fastfood consumers in russia were working adults and one of the reasons for their fastfood consumption was having more than one job 26 working fulltime increases the probability of consuming fast food it also increases the frequency of fastfood consumption 27 jun et al revealed that in the past three decades most chinese people shifted to urban areas from rural areas 28 a study by zhao et al in china reported that fastfood consumption obesity and hypertension are high among children in urban cities of china 29 half of the respondents consumed western and chinese fastfood items respectively among these chinese children 111 per cent were obese 197 per cent were centrally obese and 9 per cent had hypertension it was also found that the chinese fast food consumption rate increased by 12 per cent every year general fast food consumption trends among south asian and southeast asian young adults fast food is very popular among teens and young adults in several south asian countries asian developing countries considered attractive segment for its market 3 trends in south asia the united nations economic and social commission for asia predicted that by 2020 fifty percent of the total population would be urban and half of that population would be from asia asian developing countries are potential markets for the growing fastfood industries according to baig and saeed pakistani college students and employed people were fond of fast food and preferred it as they had limited time and fast food was an easily available convenient option for them 3 college students and other people did not blame fast food and fastfood centers for increasing obesity rates in pakistan people normally bought and ate fast food between 6 pm to 9 pm and both nuclear and joint families consumed fast food as they liked its taste working people prefer fast food at their workplaces 30 fast food culture started in bangladesh in the early nineties international fastfood brands like pizza hut and kfc started their franchises in bangladesh in 2000 23 a study by bipasha and goon revealed that 98 of university students were greatly fond of fast foods and among them male respondents were more addicted to fast foods than female respondents 31 a study by bohara et al in nepal revealed that half of the respondents consume fast food as a replacement for breakfast 10 respondents who preferred and consumed junk food was 389 percent the study also revealed that peer pressure was a major factor influencing the consumption of junk foods fast foods are very popular among sri lankan youth and especially among those people who have the busiest lifestyle in south asian countries such as sri lanka rolls cutlets wade pastries patties and buns were popular fastfood items and fast food was becoming a part of the daily sri lankan diet further the study showed that 54 percent of the respondent consumed fast food daily and 21 percent consumed fast food more than once per week 32 junk foods and fast foods are very popular in bhutan and 99 per cent of boarding schools in bhutan served fried rice for breakfast overconsumption of fried rice is associated with heart disease in long term thursday is a junk foodfree day in schools in bhutan education ministry 2018 reported that no decline was being observed in junk food consumption among high school students of bhutan 33 the dining out culture is witnessing an increase in the indian society there is steady growth in the fastfood sector in india as the number of people eating out has increased various international brands are also catering to this increased demand 34 big brands of fastfood chains such as mcdonalds entered india in 1996 they were followed by the entry of other big fastfood companies such as dominos pizza hut kfc etc 4 the fastfood market is growing rapidly in india in the present scenario the fastfood industry is adapting itself to indian food requirements and tastes fast food is very popular among indian urban youth and is becoming a part of their lifestyle indian eating habits are changing and the preference for fastfood items is increasing the indian youth consume fast food for fun and change the fastfood industry is steading growing in india especially in urban areas in india people are shifting their food preferences from homecooked chapatis and dal to momos and burgers 35 indian fastfood market was growing by 18 percent annually till 2020 readytoeat packaged food has grown at a very fast rate in india with a compound average growth rate of eighteen percent to twentyfive per cent almost 45 per cent of people going to the restaurants goers in india were found to be below the age of 28 years 36 indias quick service restaurant market is expected to 23 per cent between the 2021 to 2025 fiscal years covid19 pandemic proves to be a booster for quickservice restaurants the net worth of these quick service restaurants in the year 2020 was 348 billion online food delivery services have further expanded the reach of these quickservice restaurants 37 india is a leading country in the asia pacific region several research shows that 70 per cent of the urban consumers in india consume takeaway fast food once a week 4 a crosssectional study conducted among young adults of tamil nadu and pondicherry revealed that male respondents were more habituated to consuming fast foods than female respondents 7 according to a survey conducted in 2021 fifty per cent of indians visited fast food restaurants during past three months 38 in the past indian families traditionally consumed homecooked meals and snack items however a drastic shift has been witnessed in the indian food consumption pattern especially in urban india reasons responsible for such a drastic change in the indian food consumption pattern are the influence of western culture changing consumer lifestyle convenience and increase in disposable income trends in southeast asia according to lipoeto et al rapid nutritional shift in southeast asia may be due to increasing food availability and food purchasing power in these countries 39 a study conducted on singaporean young adults found that 708 percent of young adults consumed western fast foods every week as compared to only 3 percent of the older age group 23 naidoo et al attempted to study the determinants of eating out behaviour of urban singaporeans and reported high frequency of eating out among the participants 40 the main venues for eating out were hawkers centres and school workplace canteen young people belonging to chinese and malay ethnicity were more likely to eat at western fastfood restaurants in comparison to indians the study recommended the need for interventions to improve food quality at eating venues in urban asian populations fast food consumption has increased and it is socially acceptable in cambodian society however little is known about fastfood consumption behaviours and its association with overweight and obesity among workingage cambodians 41 in one of the crosssectional studies conducted among 303 university students of brunei darussalam it was found that frequent snacking and consumption of fried fast food were common among university students they also had a low intake of daily fruits and vegetables the frequency of visiting fast food outlets was significantly higher in overweight obese students in this study it was also found that most university students had good nutrition knowledge however they frequently consumed fast food 42 in a crosssectional study conducted among sedentary staff in nay pyi taw union territory myanmar it was found that sedentary staff consuming readytoeat food once or four times per month and they were five times more likely to be obese factors such as age preference for rte food less physical exercise sedentary leisure activity and smoking were found to be positively associated with overweight and obesity among the sedentary staff this study stressed the urgent need to raise awareness about healthy lifestyle behaviours and the need for sedentary workers to be aware of foodbased dietary guidelines 43 an observational study among indonesian children and adults concluded that indonesia was going through a nutrition transition phase as was evident by the increased prevalence of overweight the consumption of ultraprocessed food was ubiquitous among children and adults and the level of physical activity had decreased among them in urban areas higher consumption of ultraprocessed food was associated with higher odds of being overweight among adults 44 vietnam is the 14 th most populous country in the world with more than 94 million people quantitative research on ho chi minh city viet nam found that youth here generally had a high startup spirit a busy lifestyle and needed convenience they wanted to save time to study and working so fast food has become their need the fastfood industry in vietnam for this reason showed great potential for development 45 malaysia is a country that is rapidly undergoing the urbanization process according to habib et al 84 per cent of malaysian university students consume fast foods which was very alarming 46 in a study by abdullah et al among 1173 malaysian adults it was found that fast food consumption was higher among young malaysian and it was significantly associated with age ethnicity and number of children in the house 47 the participants of the study reported that sociability was the main reason for consuming fast food the participants also regularly ordered meal packages the percentage of respondents who consumed fast food at least once a week was 17 per cent as well as the younger participants significantly consumed fast food more frequently the study expressed concern over the high prevalence of the fastfood consumption and stressed on the need to educate the community 47 in one of the studies on youth belonging to northeastern thailand it was found that approximately three quarters of the sampled youth were aware that fast food consumption led to obesity and half of the respondents were also aware about its association with heart disease however still half of the respondents consumed fast food regularly since fast food is considered a part of modern lifestyle a means to socialize interestingly 23 rd of the children from educated urban families thought that local foods be more popular 48 a study on philippines showed that jollibee and mc donald were the most preferred fastfood outlets among university students at polytechnic university 49 some of the popular fastfood items in south asian and southeast asian countries are presented in the table two below table 2 popular fastfood items in south asian and southeast asian countries south asian and southeast asian countries popular fastfood items western fastfood items bangladesh chicken hot mutton chop beef steak chicken tikka grill chicken role patties pakora tandoor chaat fuska 1 burger sandwich hotdog pizza patties rolls roasted chicken french fries 1 cambodia soft drinks meat meat with bread 41 pizza pasta spaghetti bakery 41 myanmar instant mixes nonalcoholic bever 43 instant noodles 43 indonesia fried chicken fritter chips and ice cream 54 chicken noodles and meat balls 54 brunei nasi katok honey garlic chicken and tuna delight chicken and beef rendang pizza 55 fried food56 philippines chowking mang inasal greenwich meatsweet diet 57 julibee and mc donalds 49 singapore mixed rice dishes such as fried rice coconutrice and biryani noodle dishes stirfried vegetables legumes soy poultry meat and fish dishes 40 mcdonalds and kentucky fried chicken 40 thailand kuaitiew and bamee chilled food and frozen foods 58 mc donald kfc mister donuts and chesters grill 58 health hazards of fastfood consumption among adults fast foods contain a very high amount of salt empty calories saturated fat and trans fats which are very harmful to our body fast food is high in calories and lacks many essential nutrients such as vitamins minerals dietary fibers essential amino acids phytochemicals and antioxidants 15 frequent consumption of such food may lead to the development of deficiencies of many important nutrients fastfood sellers mostly used hydrogenated oil for preparing fast food items and thus fast food is rich in transfats indian fastfood items such as bhatura contain 95 percent trans fats paratha 78 per cent and puris contain 76 transfat however french fries contain 42 percent transfat fast food sellers dont care for hygiene during the preparation storage and handling of food items poor hygiene invites microbiological contamination and causes a risk for many diseases 159 regular consumption of fastfood items was associated with an increase in energy intake among adults and children 23 past research also revealed that fast food is energy dense and provided 158 to 163 calories per 100gram fast food is also very poor in vitamin a carotenes and vitamin c which are good for health and have a role in prevention of prevents of cancer 3060 obesity obesity is the major problem among adults who consumed fast food frequently fast foods are high in added fats refined cereals sodium added sugars and sweeteners which increases the risk of obesity obesity is the main reason for several other health diseases in human beings that impact their quality of life 9 the study by anderson et al evaluated the prevalence of fastfood consumption among michigan adults and found a very strong association between fast food consumption and obesity 61 frequent consumption of takes away fast food twice a week or more than twice a week resulted in poorer diet quality and a higher prevalence of moderate abdominal obesity in young men and women 12 consumption of fast foods two or more times a week is associated with a 31 percent higher prevalence of moderate abdominal obesity in men and 25 percent in women 23 heart disease obesity is the main reason of heart disease and other noncommunicable diseases ncds have become a major public health concern all over the world unhealthy eating habits less physical activities and smoking are all countrys ncds prevented by consuming nutritive foods 6 obesity is associated with respiratory problems obesity causes shortness of breath or wheezing with exertion it is also caused by sleep aponia which is a condition in which sleeping is continuously disrupted by shallow breathing 23 a study done by duffey et al among young adults found that fast food consumption is associated with higher bmi 62 a descriptive crosssectional study among jamaican workers consuming fast foods revealed that 341 percent of participants were prehypertensive 131 had stage i hypertension and 23 percent had stage ii hypertension in this study most of the participants reported excessive consumption of fast food in the last week 63 asthma fast food consumption is also the main reason for the prevalence of asthma rhin conjunctivitis and eczema especially in children and the young generation 13 another study published in the journal thorax revealed that children who consume fast foods at least three times a week are at an increased risk of asthma and rhinitis which includes having a congested and drippy nose 23 a study by chandran et al found that frequently consuming fast food was positively associated with the risk of breast cancer 64 this study was conducted among women in the aged 2075 years fast foods generally contain a high amount of trans fatty acids which are associated with higher production of proinflammatory molecules especially in diabetic people tfas are also associated with the risk of obesity asthma and lung inflammation 65 according to mosquera et al fast food items hurt gut microbiome composition 66 conclusion the present study revealed an increasing trend of fastfood consumption in most of the south asian and southeast asian countries asian countries are potential markets for rapidly increasing fast food industries a busy office schedule skipping breakfast in the morning and an increasing the number of working females are some of the main reasons which is responsible for fast foods consumption fast food companies are targeting their customers through lavish promotion strategies and attractive advertisements in south asian countries pakistan college students and other consumers of fast food did not blame it for increasing obesity rates a study on bangladeshi respondents found that male respondents were more habitual to fast foods than females in nepal most of the respondents consume fast foods as breakfast fast foods are a part of daily sri lankan diet most of the sri lankan consumed fast foods on a daily basis fried rice is most preferred fast food in bhutan dining out culture has become more popular in the indian society fast food is growing rapidly in india young singaporean adults reported high frequency of consuming fast foods fast food consumption is socially acceptable among workingage cambodians snacking and consumption of fried fast food is very popular fastfood items in brunei darussalam university students factors such as preference for rte food less physical exercise and smoking were found to be positively associated with overweight of sedentary staff in myanmar the consumption of ultraprocessed food was associated with overweight among indonesian adults a study by li et al showed that thailand has the highest consumption of fast food in southeast asian region and it is lowest in pakistan high consumption of fastfood leads to many serious health problems various studies suggest a need for awareness programme regarding hazards of fastfood consumption young asian adults need to be educated about the adverse health effects of fastfood consumption nutrition counselling regarding healthy food item might help them make healthier and nutritious food choices and also motivate them to bring about positive behavioural changes funding no funding sources

nutritious food is necessary for the growth and development of the human body nutritious food choices on a routine basis are an integral part of a healthy lifestyle however fastfood consumption trend is constantly increasing among young adults and children food that can be prepared and served very quickly in a very short period is known as fast food 1 merriamwebster dictionary first introduced the term fast food in 1950 in britain the first fastfood restaurant began in the year 1960 when fish and chips were served according to the national institute of health nih fast food is defined as food that is easily accessible quickly served and cheap alternatives to homecooked food 2 restaurants street vegans takeaway online home delivery apps counter services drivethrough restaurants etc are all involved in the fastfood business fast food is also known as precooked food which is kept ready for being served to consumers fast food items are mostly available at many public places such as colleges schools malls movie theatres parks picnic spots corners of streets airports gas stations local shopping centers and even at hospitals 3 fast food has several advantages such as it is easily available within a few minutes and is also affordable the fastfood industry works speedily to fulfil orders and provide service to customers fast food was created as a commercial strategy to meet the needs of the laborers and wage workers as they didnt have much time to wait for a complete meal 4 in recent years trend of eating outsides the home has witnessed a huge increase it has been observed that fast food items are preferred by officegoing workers and by other people providing their services at various other abstract fast food consumption trend has become very popular worldwide globalization has led to rapid rise in the number of fastfood outlets in asian countries the present study focuses on reviewing the consumption pattern of fast food among young adults of south asian and southeast asian countries here a shift has been witnessed from consumption of traditional homemade food which included healthy nutritious locally available foods toward fast foods and processed foods an extensive review of existing scientific studies in several south asian and southeast asian countries was carried out to analyse fast food consumption patterns of young adults globalization affluence busy schedules increase in number of working female population mass media increase in fast food production and delivery outlets are some of the main reasons contributing to increasing fast food consumption trends several western fastfood franchises are now well established in developing asian countries dining out culture has increased in the asian society and is socially acceptable a rapid nutritional shift in southeast asia may be due to increase in food availability and food purchasing power consumption of fastfood items is associated with increasing obesity rates among young adults such trends are also associated with the increasing prevalence of noncommunicable diseases such as indigestion hypertension asthma and other several diseases among south asian and southeast asian adults

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introduction smokeless tobacco refers to all tobaccocontaining products which are not smoked existence of an association seems to have been established between the use of st products and some health risks although exposure to these products produces a lower level of harmful chemicals among users than is the case with cigarette smoking this does not make st a safer substitute for cigarettes most of them contain cancercausing chemicals and may expose users to addictive nicotine 1 different types of st products have been described such as chewing oral or spitting tobacco snuff or dipping tobacco snus and heated tobacco products the first category is presented as loose leaves plugs or twists of dried tobacco it is placed between the gums and the cheek and can be chewed the second has two subtypes dry and moist snuff dry snuff is a powder which is used by sniffing or inhaling the powder up the nose while the moist snuff is placed between the lower lip or cheek and gum the third type snus is packaged in small bags and placed between the gum and the mouth tissue 1 when it comes to heated tobacco products often known as heatnotburn a typical electronic heating component is used to heat tobacco in specifically constructed sticks and capsules the tobacco does not get hot enough to burn but the heat releases nicotine that can be inhaled into the lungs 1 the world health organization reports that more men are involved in tobacco use than women there is a high rate of men using st products globally 2 contrary to the who perspective a comparison between cigarette smoking and chewing tobacco in bangladesh showed that chewing tobacco was common in females at around 22 of the sample compared to the 19 of male smokers in addition it was noted that chewing tobacco was more common in rural areas than in cities 3 in south africa this practice of st such as chewing or snuffing tobacco was also noticed among the school learners it affected more grade 8 learners who were male than female and there was a strong correlation between the grade in school race socioeconomic status urbanisation and the prior use of tobacco 4 another south african study has shown that st products are being used more frequently by south african women of reproductive age they contain high levels of nicotine that could cause awareness of health risks associated with smokeless tobacco use among users in pretoria read online scan this qr code with your smart phone or mobile device to read online open access addiction and harm their health 5 considering the geographic distribution of use of st most users are found in southeast asia but the practice is also noted in central asia and in african countries such as nigeria algeria sudan and south africa 6 to find out whether there is an increased risk of myocardial infarction and stroke among st users in the united states and sweden a metaanalysis conducted in these two countries showed a higher risk of death from both health conditions there is therefore an association between the use of st products and the occurrence of fatal myocardial infarction and cerebrovascular accident 7 smokeless tobacco products have addictive and carcinogenic properties and contain high levels of nicotine and carcinogens this is related to the use of nicotiana rustica tobacco leaves during storage nitrites are released in high amounts which react with tobacco alkaloids to produce nitrosamines which are known to be carcinogenic other carcinogens such as polycyclic aromatic hydrocarbons aldehydes and phenols will also be produced 6 in addition the use of tobacco is associated with increased risk of other chronic and terminal diseases such as periodontal diseases oral and pharyngeal cancers erectile dysfunction pregnancyrelated issues such as stillbirth and low birthweight neonates heart diseases and more 8 regarding the users demographics for this practice it appeared that the majority were less than 30 years old according to a korean study 9 in a bangladeshi study current consumption of st products among married women was associated with age low education level occupation and religion 10 socially deprived groups are more exposed to the use of st products and the levels of knowledge about the harmful effects of this practice are low compared with such knowledge about cigarette smoking the high demand for these products has been attached to its availability and cheap price 6 and in sri lanka several workshops held among student nurses resulted in an enhanced knowledge and attitude towards the use of st as well as to areca nut 8 while assessing health knowledge and attitudes regarding st consumption and its health effects among married women in a rural bangladesh it appeared that half of the participants believed that st consumption had a positive impact on their health and they attached to it some medicinal properties such as it being able to resolve stomach pains however on the other hand in the same area some participants intended to quit the use of these products 10 sadly this is a false belief that might encourage the usage of st products similar to smoking snus use in sweden is associated with a higher risk of type 2 diabetes when attempting harm reduction by switching from smoking snuff to using it as a smokeless product this should be considered ten years of followup were conducted on two groups of male nondiabetics who used snus and cigarettes the oral glucose tolerance test was used in the followups to identify an elevated risk of developing diabetes mellitus in both groups this led to the conclusion that when used in large quantities both snus and cigarettes put their consumers at an increased risk of developing diabetes mellitus the effects of tobacco smoking on betacell activity may make it more common for people to develop diabetes mellitus 11 in southeast asian nations st products like paan and gutka have been popular the usage of these products has been linked to conditions such as low birthweight abortion oral throat and esophageal malignancies gum and tooth disease dyspepsia high blood pressure dyslipidemia diabetes mellitus and so on 12 while looking at the association between type 2 diabetes mellitus and st use in venezuela the users of chimo an st product used in this country were assessed during a crosssectional study there were more females in the sample but it appeared that there was an elevated rate of st use among males the respondents using st product had a lower body mass index body fat and total cholesterol and an elevated risk of type 2 diabetes mellitus this study led to the conclusion that chimo is associated with an elevated risk of type 2 diabetes mellitus and lower fat mass in venezuela 13 more than 90 of the global population of adults who use st products are concentrated in southeast asian and african nations with lowand lowmiddle incomes they are more prevalent in the poorest rural areas of these regions and males are more likely to use st than females therefore the burden of st use prevails more in those regions of the globe 14 similar findings were noted in another study where south and southeast asia seemed to have elevated rates of consumption of st products india was reported to have more than 50 of st users in the region with many lives lost because of oropharyngealoesophagus cancers and ischaemic heart disease associated with st use almost 70 of these strelated diseases are noted among men 15 in a crosssectional study carried out in lagos nigeria among 400 participants more than 50 were aware that st use was harmful to health however more than half of the sample were unaware of some of the health risks such as gum diseases and lip and tongue cancers associated with the use of st products less than onethird of the participants had a good knowledge of the health risks associated with this habit more than 50 felt that the habit was socially acceptable while almost half of the sample mentioned that it was a waste of money 16 given the popular rumour of st products being a safer alternative to smoking cigarettes a study was conducted in order to assess the heavy metals contained in the st products frequently used in nigeria the assessment evaluated the concentration of each and every heavy metal hazard found in the st products commonly used in the country and different heavy metals such as nickel cobalt chromium and cadmium were found the study did not find an apparent risk when analysing these metals individually but a likely risk has to be considered while putting together the impact of all of these heavy metals therefore there is a potential risk for the users of these nigerian heavy metals 17 twentyfour percent of smokers were willing to switch to snuff on account of the likely role of reducing harm from smoking only if they are not used to skipping smokefree laws related to reduced open access smoking when trying to find the possibility of south african smokers switching to an imaginary reduced damage that can be provided by those products 18 while exploring the views on the practice of st interviews with traditional healers in the south african province of limpopo were conducted to learn more about what they thought about st usage and its potential health implications the participants average age was 55 years and they had an average of 17 years of healing experience the participants considered the use of st as essential in divination thirtytwo percent of them under the instruction of the ancestors have prescribed this practice to their clients while others who were even st users themselves did not appreciate the danger of the recreational use of these products since it is addictive 19 in a qualitative study exploring attitudes towards the use of st the northern province of south africa 22 of women and 11 of men revealed using snuff and the most popular st product was homemade snuff which is made from tobacco products and some plant leaves snuff can be used as medication and offers a reduced degree of relaxation and pleasure but this practice was pushed despite the fact that they were aware of its addictive potential 20 comparing cigarette smoking and st use in southern african countries when using the statistics and health surveys it appeared that the rate of cigarette smoking is high in the urban areas while st use is high in the rural areas this outcome has been noted in both genders 21 the current studys objectives included defining the sociodemographics of st users as well as the level of awareness of the health risks associated with the practice of st the study sought to ascertain the degree of awareness of the health risks associated with st use among users in a pretoria community methods study design this was a descriptive crosssectional study a piloted structured and selfadministered quantitative survey questionnaire was used setting the study was conducted at ramotse clinic a day clinic located in ramotse which is part of tshwane region 2 it is 43 km to the north of central pretoria alongside the national road referred to as the n1 census 2011 showed the estimated population to be around 15 760 in an area of 6003 km 2 22 population recruitment sampling and estimated sample size the population of ramotse which was approximately 15 760 as per the census 2011 was used to determine the sample size 22 the required sample size for such population was determined to be 376 using the net sample size formula also called sample size calculator raosoft 23 with a confidence level of 95 and a 5 margin of error the final sample size was determined by accepting an oversampling during the data collection process because of the participants desire to participate two retired nurses acted as research assistants and were trained by the researcher on how to introduce the study to participants every day in the early morning while patients were waiting for their files at ramotse clinic the first research assistant introduced the study to them this introduction was repeated several times during the day to other new patients who arrived from the consulting rooms patients were advised to meet with the second research assistant who explained the aim and objectives of the study to each patient for the second time those patients who consented to take part in the study were given a consent form to sign which confirmed their willingness to participate they then received a questionnaire to complete collection tool the four authors based on their prior research experiences created the questionnaire which was subsequently tested at the new eersterus clinic one of the clinics in region 2 of tshwane health district nearly 30 km separate it from ramotse clinic where the study was conducted the decision to employ this new eersterus clinic was made since it is a day clinic somewhat remote similar to the ramotse clinic and their clients share similar sociocultural traits no data from the pilot was taken into account in the ramotse study so as not to contaminate the studys findings after the pilot study opinions on the questionnaire were gathered from the participants to make sure that it accurately assessed the health risks related to st 24 four authors also reviewed and adjusted the questionnaire to make sure it was in line with the aim and objectives of the study 24 when the same sample from the pilot study was reviewed and subjected to the same questionnaire a week later the results were consistent with those from the initial exposure 25 the questionnaire had two parts the sociodemographics and the health risks associated with st use the questionnaire was written in two languages english and setswana which are the two languages commonly spoken in ramotse area the setswana translation was done by the two ras who are fluent in both languages the sra helped those who could not read and write but were willing to be part of the study data collection took almost seven months data analysis all data from the spreadsheet was imported to the statistical package for the social sciences version 28 where descriptive analysis was done tables 1 and2 and figure 1 that depict frequencies and percentages are used to present the results in the second section of the tool relative to the awareness of health risks associated with some health conditions a yes response indicated that the participant open access was aware of the relationship between health hazards and the condition while a no or not sure response indicated that the participant was not the level of awareness is supposed to be indicated by dividing the sum of all yes responses by the total number of responses whereas the level of unawareness is indicated by dividing the sum of all no and not sure responses by the total number of responses ethical considerations ethical clearance to conduct this study was obtained from the sefako makgatho university research ethics committee of the sefako makgatho health sciences university results a selfadministered questionnaire was used and some participants although being instructed did not entirely fill out the selfadministered questionnaire as a result certain missing data were discovered during data analysis the sample size was 479 most of the participants were from the age group 3039 years followed by those aged 50 years and above most of them were females unemployed married had a secondary level of education did not have any chronic illnesses and used snuff by nose as shown in table 1 question to the participants are you aware that using st products is a health risk that is associated with the occurrence of health conditions listed below the answers no and not sure meant that the participant was not aware of the association between health risks and the conditions listed below while the answer yes indicated that the participant was aware according to table 2 the majority of participants were unaware of the use of st products to be a health risk therefore they were also unaware of the associated health conditions as listed in table 2 figure 1 derived from table 2 shows that 560 of the 5176 responses were yes whereas 4616 were no discussion according to this survey conducted in a pretoria community more women than males reported using st with snuff being the most common form this finding is similar to that of a bangladeshi study with regards to the gender distribution but differs in terms of the mode of use in bangladesh chewing tobacco was used more than snuff there is also a similarity when it comes to the area although the tshwane district seems not to have a rural areacommunity in the entire district ramotse where the study was conducted seems to be a remote zone in the district and has a high rate of st use among women like the rural women in bangladesh 8 this observation of st being used more in the rural areas while smoking is used more often in urban areas was also highlighted in a southern african survey 18 the pretoria study deviates from the who viewpoints on gender in that it depicts men as using st at higher rates and refers to smoking as a sign of masculinity 2 despite the fact that primarily women use st products according to a recent pretoria study south africa as a whole has a more complex picture when it comes to this topic some papers showed greater interest among primary school students 4 whereas other studies focused more on womens childbearing 5 in ramotse pretoria the majority of participants were from the age group 3039 years this is inconsistent with what was observed in wonju korea where the majority of the st users recruited were aged under 30 years 7 this discrepancy might be explained by participant availability particularly as it was in the pretoria trial one of the research projects cited in this paper also shows that teenagers in south africa are engaged in st use 4 and this is one of the studys limitations because children under the age of 18 years were not taken into account although married women in madaripur bangladesh are also involved in st use they differ from the group in pretoria in that in the latter there is no association with any of their sociodemographic data while for the women in bangladesh there are associations 8 this inconsistency is also observed in relation to a study conducted in ethiopia where the use of st was strongly associated with the lifestyle of the community here religion was considered as one of the defensive factors and a high degree of social pressure was dependently connected to the practice 17 the use of tobacco products has been linked in the literature to a greater number of diseases and a higher death rate 2 in contrast to the evidence in the pretoria trial in the literature it has been described that more health conditions and a high death rate have been established as related to the use of tobacco products 2 globally the lowand lowmiddle income nations pay the most price for this use of st especially in the rural communities this is in line with what was stated about bangladesh where it is anticipated that this practice will lead to significant noncommunicable diseases 8 sadly this runs counter to the pretoria study where only 58 of respondents claimed to have chronic illnesses and since the questionnaire did not specifically ask about medical problems it was challenging to connect the health risk with the disorders smokeless tobacco use increases the risk of heart and brain conditions that most of the time lead to death as described in the united states of america and sweden 4 the practice of st use was linked to some of the chronic and terminal health conditions such as oral and pharyngeal cancers strokes periodontal illnesses erectile dysfunction stillbirth and low birthweight of newborns as stated in a study carried out in sri lanka 6 in sweden many cigarette smokers opted for st use with the idea that snus or st causes less harm than the combustion of tobacco products surprisingly a study done in the country among users of snus or snuff and also users of cigarette smoking found that participants in both groups had an increased risk of diabetes mellitus type 2 10 same observation of high risk of diabetes mellitus was also noted in australia among pregnant women who chewed pituri 11 and in venezuela among users of chimo 12 in asia asthma diabetes mellitus dyslipidaemia abortion and low birthweight were described in those who used paan and gutka 10 in india st use was associated with conditions such as oropharyngealoesophagus cancers and ischaemic heart disease this study was able to determine the level of awareness of the aforementioned association in pretoria and discovered that participants ignorance of the relationship between health risks and health issues is common in both pretoria and nigeria 17 strengths and limitations although these are primary data the findings cannot be generalised because not all ramotse st users and no individuals under the age of 18 years participated in this study lack of measurement for heated tobacco products is also a limitation for this current study hence it is advised that future studies evaluate heated tobacco product use conclusion this study has demonstrated a poor awareness of health risks associated with st use among users in a pretoria community as a result health education at various levels of the community could be one strategy for resolving the problem data availability data will be available on request from the corresponding author tb 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 necessary reflect the official policy or position of any affiliated agency of the authors and the publisher

background smokeless tobacco st refers to all tobaccocontaining products that are not smoked but rather consumed through other means contrary to the popular belief that st products are safe the use of such products exposes users to health risks to assess the awareness of health risks associated with st use among users in a pretoria community the study was conducted in ramotse community located in tshwane region 2 gauteng south africa methods this was a crosssectional design using a piloted structured and selfadministered questionnaire results of 479 participants with a mean age of 43 years ranging from 18 to 89 years most were in the age group 3039 years 148 316 followed by ≥ 50 years 138 294 there were more females 371 775 more unemployed 263 549 married 236 497 had reached the secondary level of education 270 564 did not have any chronic illness 274 572 used snuff by nose 338 706 and were unaware of health risks associated with st use 452 944 this study has demonstrated a poor awareness of health risks associated with st use among the users in a pretoria community as a result health education at various levels of the community clinic schools wardbased outreach team or wbot etc could be one strategy for resolving the problem

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background poor mental health in children and adolescents include anxiety and depressive symptoms as well as mental disorders 1 beyond its detrimental effects on the individuals quality of life poor mental health in childhood is a major risk factor for future shortand longterm mental health problems as well as other adverse social educational and workrelated outcomes 2 3 4 5 6 accordingly it has been shown that selfrated health status in adults is associated with access to healthrelated and material resources in childhood and is influenced by school factors in youth 78 clearly school is highly important for young peoples general wellbeing and for establishing future opportunities understanding the relationship between mental health and school achievement is key in this regard particularly given the current deterioration in both mental health and school results in sweden and worldwide 9 10 11 12 13 increasing income inequality in sweden 14 further calls for research into circumstances early in life that can influence future health as well as social and economic outcomes for the individual as well as society consequently from an equity perspective it is important to explore how schoolrelated outcomes are affected when young people are in distress and if these outcomes differ depending on gender and socioeconomic background it is well established that academic achievement and other schoolrelated outcomes are associated with mental health status in children and youths 15 16 17 as well as young university students 18 however due to the predominance of crosssectional studies the direction of the association is unclear nevertheless based on longitudinal analyses several models have been proposed in order to understand this relationship according to the academicincompetence model poor academic performance is related to later mental health problems 1719 the adjustmenterosion model on the other hand suggests that adolescents with poor mental health perform worse in school than their mentally well peers 5172021 others propose a cascade process of the interplay between internalising and externalising problems in relation to academic difficulties across time 22 23 24 a possible contributor to the inconsistencies regarding direction of associations is the vast range of measures applied to reflect different dimensions of poor mental health as well as educational outcomes 23 most research also rely on selfreported or parent assessed data on both mental health problems and academic achievement 2123 25 26 27 28 only a few studies within the field are based on information from registers 29 30 31 we argue that it is of value to utilise nonself reported data in exploring the longitudinal relationship between poor mental health in childhood and adolescence and later academic achievement apart from possibly avoiding risk of reporting bias register data also provide information on more severe mental health problems than is typically investigated in relation to academic achievement from a large number of individuals although both childadolescent mental health status and academic achievement are gendered and socially patterned 32 33 34 35 36 there is a knowledge gap relating to gendered and social gradients in the relationship between poor mental health and academic achievement some evidence suggests that the association is stronger in girls than in boys 17193738 others argue that associations depend on types of symptoms and age 1525 the role of socioeconomic factors such as parental level of education and income is even less explored the limited evidence available suggest that socioeconomic factors are stronger predictors of academic achievement than various health indicators 39 and that children of low socioeconomic background are disadvantaged both academically and mental health wise 26 findings indicate that strong family resources and high neighbourhood socioeconomic status can compensate for the negative impact of mental distress on school achievement 4041 research on the socioeconomic patterns of social determinants of health and the consequences of health suggest that the most privileged would experience fewer and less severe negative educational consequences of prior mental health problems than their less advantaged peers 324243 accordingly it is likely that the risk of adverse future outcomes for mentally distressed adolescents differ depending on social background and is greatest among youths from low socioeconomic status families 4445 however it is not clear whether mental health status is consistently related to academic achievement across socioeconomic groups this knowledge gap is especially pronounced in the swedish context despite the contribution of brännlund and edlund who concluded that family socioeconomic background moderate the relationship between poor mental health in childhoodadolescence and later graduation failure and grade points in upper secondary school students especially among girls 46 systematic reviews of research on emotional problems and school outcomes in children and adolescents conclude that existing evidence to a high degree rely on crosssectional studies in order to establish directions of associations prospective longitudinal designs are needed longitudinal research is also important to prevent potential negative or positive affectivity which would occur if for example adolescents with poor mental health were more likely to report poor school performance or if their healthy peers tend to overrate their achievements 2048 affectivity can be minimised by examining register data rather than selfreported information the present study is based on longitudinal register data with yearly observations the aim of the present study is to investigate social gradients in the prospective association between childhoodyouth mental disorder and academic achievement at age 1516 in swedish boys and girls methods the study is based on administrative data from the umeå simsam lab umeå simsam lab is specifically designed to investigate questions on childrens health and wellbeing 49 data are longitudinal and incorporate medical and social individuallevel information from several registers covering the entire swedish population between 1960 and 2010 each individual is assigned a unique and fully anonymised personal identification number that links them to family members across registers in addition to the total population register this study also used information from other registers as described below the regional ethical vetting board in umeå approved all research based on data from the umeå simsam lab including the present study population the population comprises all individuals born between 1990 and 1994 who were alive and resided in sweden in 2010 these individuals are hereafter referred to as index persons as all data were retrieved from registers no active consent was given by participants outcome academic achievement is defined as the sum of the index persons 16 best subject grades during the final year of compulsory schooling when the index persons were 1516 years old data were drawn from the swedish national agency for educations pupil register for each subject a student is assigned a grade ranging from 0 to 20 the summed grade points thus range from 0 to 320 and indicate the childs general academic achievement this variable was standardised into zscores predictors in the current study we use the term mental disorder to conceptualise the included indicators of poor mental health psychiatric hospitalisation events and psychoanaleptic drug prescriptions these are further described below both hospitalisation and medical treatment indicate relatively severe conditions and should therefore neither be conceptualised as for example poor mental health in a broad sense nor as the more serious conditions of mental illness 1 another possible term would have been psychiatric disorder however as the icd 10 uses the term mental disorders 50 we believe that consistency in conceptualisation is preferred the term mental disorder has also been used in a recent similar study 51 psychiatric hospitalisations indicates the number of hospitalisation events due to a main diagnosis of mental disorder according to the international classification of disease obtained from the swedish national patient register 52 this variable indicates the total number of hospitalisation events between birth until the year before the index person received their compulsory school grades in sweden children with mental health problems receive outpatient care at primary care centres or psychiatric specialist care units psychiatric hospitalisations occur only in response to acute events or if a patients health status becomes significantly impaired despite outpatient treatment psychiatric hospitalisations therefore corresponds to one psychiatric inpatient care event which indicates severe psychiatric disorder psychoanaleptic drug prescriptions to complement the hospitalisation data and detect individuals with less severe psychiatric health problems records of prescription drug sales were retrieved from the swedish prescribed drug register these data included details of the patient and the active substance prescribed classified using the anatomical therapeutic chemical classification system the information from the pdr was only available to us for the years 20052010 when the index persons were 1116 years of age the psychoanaleptic drug prescription indicator indicates whether the individual under consideration was prescribed any medication with an atc classification of n06 at least once over this 5year period this category includes attentiondeficit hyperactivity disorder medications and drugs for sleeping problems and anxiety drug prescription has been used as an indicator of poor mental health in similar studies 53 indicators of socioeconomic position parental level of education is a widely used indicator of family socioeconomic position 54 especially in studies on academic achievement 5556 in this study parental level of education was operationalised as the highest level of education attained by either parent when the child was 7 years old prior to 2018 children in sweden started school at age 7 years the indicator is based on the status of the index persons parent with the highest education level four levels were defined compulsory school 2 years upper secondary education 3 years upper secondary education and postsecondary education these four groups correspond to the existing levels of education in sweden when the parents attended upper secondary school a 2 year upper secondary education includes vocational training whereas 3 years of upper secondary education qualifies for tertiary studies data were obtained from the longitudinal integration database for health and labour market studies 57 family income was used as an alternative indicator of socioeconomic position it measures the total earned income for both the father and the mother from the year of the index persons birth to the year of their compulsory school graduation the total earned income for each year was summed and then averaged over the years since the index persons birth index persons were grouped into quartiles based on the income variable using a similar approach to that applied for the parental education variable covariates four covariates potentially related to mental disorder and academic achievement were included maternal country of birth family type number of siblings and maternal and paternal psychiatric morbidity the latter two covariates use data from the npr and indicate whether the corresponding parent had been hospitalised with a main diagnosis of mental disorder since the birth of the index person gender was used as both a covariate and a stratification variable statistical analyses analysis of variance and ttests were used to examine mean differences in the main variables of the study between boys and girls in different socioeconomic positions bivariate and multivariate linear regression were used to investigate associations between the indicators of mental disorder and grade points outcomes were analysed using four models model 1a reflects the association between psychiatric hospitalisation events and school grades only model 1b is adjusted for all the covariates model 2a shows the association between psychoanaleptic drug prescriptions and school grades and model 2b is adjusted for all the covariates because we examine complete cohorts rather than a sample of the total population pvalues and standard errors are superfluous and not presented instead beta coefficients of zscores of grade points with upper and lower 95 confidence intervals are presented interaction analyses were performed using the fully adjusted models to compare the effects of mental disorders on grade points between children in different social groups and between boys and girls within these groups stratified analyses were performed when interaction effects of p 005 were identified all analyses were performed in stata v 14 results table 1 shows a stepwise social gradient in mental disorders where mean number of psychiatric hospitalisation events as well as proportions of prescribed psychoanaleptic medication decreased by increased parental level of education and income similarly there was a clear gradient in academic achievement a oneway anova was performed to compare the mean grade points between the four groups of parental level of education which revealed a statistically significant difference 2714640 p 0001 η 2 123 thus 123 of the total variance in academic achievement was accounted for by group membership given the benchmarks provided by cohen to define small medium and large effects these differences are quite large a second oneway anova was performed to compare the mean grade points between the 1st 2nd 3rd and 4th income quartile which also showed a statistically significant difference 1637132 p 0001 h2 0075 here 75 of the total variance in academic achievement was accounted for by group membership indicating a mediumsized effect these results show that the variance in academic achievement to a larger degree is explained by parental level of education than family income additionally girls obtained higher grade point scores than boys t 13 p 001 d 033 the two indicators of mental disorders were slightly more common in girls than in boys girls had more days hospitalised than boys t 203 p 0001 d 036 and a higher frequency of psychoanaleptic drug prescription χ 2 4511 p 0001 d 005 while the differences in grade point scores and hospitalisation events were small to mediumsized the differences in psychoanaleptic drug prescription were very small 58 the regression analyses show that both indicators of mental disorder were associated with reduced academic achievement the unadjusted and adjusted beta coefficients for psychiatric hospitalisation were 036 and 033 respectively in other words each hospitalisation event due to a mental disorder was associated with a decrease in grade points of 033 standard deviations when taking a range of possible confounders into account the corresponding coefficients for being prescribed psychoanaleptics were 075 and 070 given the identified gender pattern in both the predictors and the outcome stratified analyses by gender and sep were performed as shown in tables 2 and3 mental disorder was more strongly associated with reduced grades among boys than among girls regardless of sep category the negative association between psychiatric hospitalisation and grade points was strongest among boys in the highest sep among girls the association was strongest in the second highest sep to further explore these gender and sep patterns interaction analyses were performed using the highest sep categories as reference as shown in table 4 and5 the interaction effects of sep and psychiatric hospitalisation were more pronounced among girls than among boys the grade points of girls in the mid sep groups were particularly negatively affected by psychiatric hospitalisation for example hospitalisation events among girls whose parents had completed 3 years of upper secondary education was associated with 015 standard deviations in grade points per event compared to those with parents with a postsecondary education the corresponding result for girls in the second family income quartile was 013 table 4 further shows that this ushaped pattern among girls also was detected for psychoanaleptic medication prescription and the sep indicator of parental level of education no interactions were identified among boys with regards to psychoanaleptic medication prescription worth noting are the statistically significant positive coefficients among boys compared to their high sep peers psychiatric hospitalisation was associated with an increase in grade points by 008 standard deviations per each hospitalisation event for boys in the twoyear upper secondary parental education category among boys in the lowest family income quartile the grade points improved by 013 standard deviations per each hospitalisation event the interaction analyses for family income and prescription of psychoanaleptics showed a linear pattern the interaction decreased by increasing level of income primarily among girls discussion this study aimed to investigate social gradients in the association between mental disorder in childhoodadolescence and academic achievement at 1516 years of age both indicators of mental disorder were associated with lower grade points in all sep groups these findings confirm previous results 5172021 interaction analyses showed that level of parental education primarily moderated the association between mental disorder and academic achievement among girls this is consistent with the conclusions of brännlund and edlund although the present study analysed the social gradient more closely than was done in their work for example by using a fourcategory measure of parental education rather than twocategories and also family income girls whose parents had completed 3 years of upper secondary education or belonged to the second family income quartile experience the most severe adverse effects on school grades due to mental disorder however it should be noted that boys grades were by no means unaffected by previous mental disorder in contrast to several other studies 17193738 our study showed stronger negative associations between mental disorder and grade points in boys than in girls however there appears to be no typical social gradient in this association among boys although some findings deserve attention which will be discussed below based on previous findings 4445 and theory on the importance of access to cultural and economic resources 56 we expected that both boys and girls in the lowest sep categories would exhibit the strongest adverse effects on school grades due to mental disorder and that severity would decline as level of parental education and income increased instead the findings indicate a ushaped pattern among girls and no or inverse gradient in boys several interpretations of our findings are possible first low sep families might experience elevated and varying types of stressors combined with greater barriers to accessing resources relative to other groups this is likely to affect both mental health and school achievement 5960 for example because children of low sep parents already have the lowest level of achievement of the four groups it is possible that they do not have much further to fall even when exposed to adverse circumstances this potential floor effect was identified in a european study on the educational consequences of parental divorce divorce does not worsen the school outcomes of children from poorly educated families because they already have limited educational opportunities 61 second it is possible that children and adolescents with poor mental health from less educated families actually benefit more from hospital admission and medicine prescription than their more advantaged peers do school success has for example been identified as a positive effect of mental health medication 62 the unexpected results for boys with regard to indications of improved grade points due to hospitalisation for the 2nd categories of both sep measures might reflect this however more research is required to understand this interaction further and to determine whether this effect is equally strong in all socioeconomic groups third schoolrelated stress may help explain the identified drop in academic achievement among girls of parents with intermediate levels of education it has been table 3 associations between psychiatric disorder indicators and academic achievement by family income quartiles and gender beta coefficients of zscores of grade points adjusted for all covariates suggested that schoolrelated demands explain the higher incidence of poor mental health in adolescent girls compared to boys 38 it has also been established that while schoolrelated stress is prevalent in youths from midhigh socioeconomic backgrounds those from low socioeconomic backgrounds are more stressed about relationships and lack of money 63 64 65 66 there might also be an incongruence between ambition and available resources for girls in the mid sep categories in other words they and their parents might experience pressure and have high ambitions relating to school performance but lack familial resources to buffer the negative impact of mental disorder on the childs school achievement 566367 such buffers may include familial or social academic support networks private tutors or other privately financed educational interventions 67 a similar argument would be probable for income categories a child whose parents have high income but relatively little experience of studying will probably have other kinds of academic socialisation and adopt different study strategies to a child whose parents are more highly educated but less wellpaid leading to differences in school grades although level of education typically represents access to cultural capital relevant to academic achievement educational outcomes must be considered in combination with resources such as income 56 these sep indicators are typically highly correlated however the difference between parental education and family income can be explained by supposing that parental education represents a type of cultural capital necessary for childrens academic achievement that extends over and beyond income for example blue collar professions do not require extensive theoretical study but can nevertheless be wellpaid while other occupations that require longer educations provide relatively low wages 68 with regard to the gender patterns identified in this study it is noteworthy that despite swedens high international rankings with regard to gender equality income levels and the labour market are strongly gendered in sweden on a group level women are disadvantaged relative to men 69 it is likely that these circumstances influence the aspirations of girls and boys although girls receive better grade points than boys do achieving good grades may be seen as a more important route to future financial security and labour market opportunities for girls than for boys this might lead to greater stress about school performance among girls from mid sep backgrounds even if they generally show better school results than their male peers do the strengths of this study include its use of high quality data and a large sample size which enable broad generalisation the use of register data reduces the risk of recall and selection bias however some limitations deserve attention first the chosen indicators of mental disorder psychiatric hospitalisation is rare and is a rather crude indicator because it can result from a wide range of disparate diagnoses including drug abuse depression and schizoaffective disorders prescription of mental health medication is more common but is still a relatively imprecise measure of poor mental health our conclusions therefore relate to mental disorder in its broadest sense we acknowledge that other types of mental health problems are not captured by these indicators and that we cannot distinguish which disorder if any that is most strongly related to academic achievement therefore given the limitations of hospitalisation and medication as indicators of mental disorders and that many children might never receive the appropriate attention andor diagnosis future studies should differentiate between types of diagnoses and also include symptomatology second the categorisation of family income based on quartiles likely does not capture the same people as within the education group hence these are not directly comparable conclusions this study suggests that in contrast to an expected linear social gradient there is a ushaped social gradient in the relationship between mental disorder in childhood or adolescence and grade points at age 1516 years especially among girls specifically the school grades of girls from families of intermediate socioeconomic position were more strongly affected by mental disorder than those of their peers in the low and high sep categories this study shows the importance of recognising several indicators of socioeconomic position as well as gender when investigating links between mental health and academic achievement future research should address both socioeconomic background and gender disparities to clarify the links between mental health and schoolrelated outcomes in children and adolescents table 2 associations between psychiatric disorder indicators and academic achievement by parental level of education and gender beta coefficients of zscores of grade points adjusted for all covariates additional file 1 authors contributions el cb and ms developed the rationale for the study cb and el analysed and interpreted data as well as wrote up the initial draft of the manuscript ms reviewed subsequent draftsms is the principal investigator of the project in which this study is included all authors read and approved the final manuscript authors information competing interests none

background it is well established that academic achievement and other schoolrelated outcomes are associated with mental health status in children and youths however few studies have examined the influence of socioeconomic background on the relationship between poor childhoodadolescent mental health and school performance from an equity perspective it is important to explore how schoolrelated outcomes are affected for young people with mental disorder and if these outcomes differ depending on gender and socioeconomic background this study aimed to investigate social gradients in the prospective association between childhood adolescent mental disorder and academic achievement methods this register based study used data from the umeå simsam lab of linked swedish registers on all children born between 1990 and 1994 and their parents n 642 558 the outcome was school grades achieved upon compulsory school graduation age 1516 mental disorder was indicated by number of hospitalisations due to icd classified mental disorders and prescription of psychoanaleptic drugs indicators of socioeconomic position were parental level of education and family income in four categories respectively parental history of mental disorder was controlled for linear regressions including interaction analyses were performed results mental disorder in childhoodadolescence was related to lower grades particularly in boys the drop in academic achievement among youth with mental disorder was more pronounced among girls in mid sep categories than among their less and more advantaged peers a less clear interaction pattern was identified in boys conclusions based on theory and existing research we expected a typical social gradient in the strength of the association between mental disorder and academic achievement however we identified a ushaped social gradient among girls analyses of the links between mental health and academic outcomes need to take both gender and social position into account more research is needed to investigate these patterns further

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background mental health problems increase during the period of adolescence 47 and for young people aged 1024 years mental disorders are the largest contributor to the global burden of disease 25 many risk factors and health problems faced by adolescents as they transition through this period are gender specific 3 and on some indicators of mental health such as suicide adolescent boys and young men are at particular risk 1 despite this adolescent male health has long been neglected however there is now growing recognition of the extent to which this population is underserved particularly in relation to unmet mental health care needs 54 globally suicide is the third most common cause of death for adolescent males 65 and in australia suicide is the leading cause of death for males aged 1524 years 1 it is often during adolescence that the onset of suicidal and selfharming behaviors occurs 29 and rates of selfinjury are typically higher among adolescents than among adults 45 research examining risks related to adolescent suicide have typically focused on family factors and psychiatric disorders but it is recognized that other underresearched factors may also be important and should be investigated 29 masculinity and its associated practices and behaviors is one potential avenue of investigation conceiving masculinity conceptualizations of masculinity have shifted away from the notion of a singular masculinity toward recognition of a multiplicity of masculinities 1432 among these multiple masculinities there exists an idealized or hegemonic masculinity that represents the currently accepted ideal 1432 the norms of masculinity are contestable as well as relational consistent with this there is evidence that conformity to masculine norms varies by age 53 and that conformity to masculinity is most strongly endorsed by younger males 53 the social norms that define appropriate masculine roles and behaviors are assimilated from a young age 7 the pressure to conform to masculine ideals can be immense 2 and there are often social penalties for boys and men who deviate from normative masculine roles and behaviors 57 confinement to the set of behaviors considered to appropriately affirm masculinity can also severely delimit healthy behaviors and emotional responses 2 that might otherwise buffer young males during the often stressful period of adolescence masculinity among adolescent males australia is a diverse country with many cultural and historical influences shaping its masculine identities for australian adolescent males the physical practice of masculinity is principally located in two key domains sexuality and sport 15 for many adolescent australian boys sport provides an arena for ritualized combat camaraderie and strength heterosexuality is central to normative australian masculinity and sport has traditionally been a key setting for the display of heteromasculinity 15 this is similar for young males elsewhere a recent systematic review of studies from 29 countries examining gender attitudes indicated that physical strength toughness and competitiveness and heterosexual prowess were central to adolescent masculine norms 34 recent evidence indicates that young australian men are becoming more progressive on some elements of masculinity with lower endorsement of norms regarding violence more openness to partaking in traditionally female activities such as household tasks and cooking and greater openness to having gay friends being recently observed 59 some masculine norms however remain entrenched many young men retain ideals of acting strong being the primary breadwinner and fighting back when pushed around 59 the gender paradox in suicide while suicide is a leading cause of death among adolescent males in australia 1 and worldwide 65 there is little understanding of why researchers have also observed evidence of a gender paradox in suicide with males more likely to die by suicide while females have higher rates of nonfatal suicidal behaviors 938 evidence among 1415 year old australian adolescents also reflects these international patterns with more girls than boys reporting suicidal behaviors 20 and more young males dying by suicide 1 ideationtoaction framework suicidal ideation is recognized as a putative and proximal risk factor for suicide attempts 37 and contemporary models of suicide recognize this relationship 375862 the process by which suicidal thoughts progress to action is poorly understood and this lack of understanding is posited to underpin the limited success in reducing suicides worldwide 37 it is recognized that many commonly cited risk factors for suicide such as depression hopelessness and impulsivity also predict suicidal ideation and do not necessarily differentiate those who have attempted suicide from those who have reported ideation but have not attempted 37 the ideationtoaction framework proposes that the development of ideation and the progression from ideation to attempts be conceived as distinct processes with separate predictors and explanations 37 acquired capability for suicide is considered to be a key factor that may explain the progression from ideation to attempts 3337 there is some evidence that males may be at greater risk of death by suicide because they are socialized to conform to certain masculine norms that foster engagement with painful and provocative life events resulting in greater acquired capability for suicide 26 it is known that certain physical practices more common among men and boys such as physical violence and risky behaviors such as drinking smoking and dangerous driving are associated with increased health risks 1518 given these factors the effect of masculine norms and socialization on health and health behaviors has become an increasing focus of investigation 121349 it is argued that high conformity to masculine ideals of toughness and emotional neutrality may have harmful effects on the mental health of males 18 this has prompted calls to apply a masculinities perspective to suicidal behavior 13 masculinity as a risk factor for suicidal ideation there is an emerging body of work examining masculinity and gender roles as a risk factor for suicidal ideation and suicide in young adults and adolescents 1350 in a large sample of us college students there was evidence that what the authors termed traditional masculinity was associated with suicidal ideation 13 psychological autopsies of young men aged 1830 who had died by suicide in norway indicated that identifying with unattainable masculine ideals was a key risk factor in these suicides and death by suicide was theorized to represent an act of masculinity that compensated for this perceived failure to attain idealized masculine standards 50 relatedly among a group of young men aged 1830 years who had attempted suicide it was found that conformity to masculine norms about emotional containment prevented young men from disclosing the extent of their distress 12 among young men of a similar age being in a peer group that valued selfreliance and repudiated helpseeking inhibited helpseeking by young men at risk of suicide and drove them to adopt risky coping behaviors such as alcohol use 39 consistent findings emerged from a recent metaanalyses with evidence that certain masculine norms are related to poorer mental healthrelated outcomes 64 not all masculine norms are associated with adverse effects however 64 and it is likely that some dimensions of masculinity are positively associated with mental health and wellbeing further while endorsement of certain masculine norms such as selfreliance is associated with suicidal ideation 49 and poorer mental health in adults 43 less is known about adolescent males study aims suicidal ideation is an understudied phenomena particularly in relation to masculinity 13 and to our knowledge no quantitative study has prospectively examined associations between masculinity and suicidal ideation in an australian populationbased sample of adolescent males the aim of the study was exploratory and sought to examine associations between conformity to different masculine norms and suicidal ideation among australian adolescent males better understanding of potentially damaging masculine norms among adolescents is critical if we are to identify ways to promote the mental health and wellbeing of male adolescents and young men methods study design and setting we used data from waves 1 and 2 of the australian longitudinal study on male health 6 ten to men is a longitudinal cohort study of australian boys and men aged 1055 years at baseline and collects data on five broad domains details of the sampling recruitment and data collection methods of the ten to men study have been published elsewhere 19 the study commenced in 2013 2014 with a cohort of 15988 males aged 1055 years wave 2 of data collection was conducted between november 2015 and may 2016 with 76 of the original cohort participating surveys were selfcompleted the current analysis drew on the ten to men sample of adolescents who were 1518 years at baseline and 1720 years at followup measures exposure variable conformity to masculine norms the conformity to masculine norms inventory was used to assess masculinity and was collected at wave 1 the cmni was designed to measure the extent to which males conform to masculine norms the cmni22 is an abbreviated version of the original 94item scale using the two highest loading statements to assess conformity to each masculine norm subscale 46 it should be noted that in some research the fourth subscale is referred to as disdain for homosexuals following the precedent of other work 49 we refer to this factor as heterosexual presentation noting that the two items used to derive this factor reflect the importance of being perceived to be heterosexual and a fear of being perceived to be gay rather than homophobia the cmni instructs respondents to consider their actions feelings and beliefs when rating their agreement or disagreement with each statement response options range from strongly disagree to strongly agree responses to each item were summed to provide a conformity score for each subscale ranging from 0 to 6 41 scores from each of the 11 subscales were summed to present a continuous global score of conformity to masculine norms from 0 to 66 studies typically report associations using the total cmni score however there is evidence that different subscales can be associated with different outcomes and reliance on the overall score can obfuscate such associations 24 we therefore examined the different subscales as well as the overall score these were analyzed as continuous variables outcome variable suicidal ideation the primary outcome variable used in this analysis was a singleitem from the youth risk behavior survey and asked have you seriously thought about killing yourself in the past 12 months 10 responses were coded as a binary variable and collected at wave 2 only approximately 2 years after wave 1 data collection covariates previous work has shown associations between adolescent suicidesuicidal behaviors and area disadvantage 28 raceethnicity 38 and indigenous australian identity 21 it is also known that masculinity varies by race ethnicity 27 and area disadvantage 12 given these associations we included the following covariates as confounders in analytical models country of birth indigenous australian identity area disadvantage the area disadvantage variable was derived using the australian bureau of statistics 4 index of relative socioeconomic disadvantage irsd values were categorized into quintiles with the lowest quintile reflecting areas of greatest disadvantage analytical approach to our knowledge no previous study has examined the scale properties of the cmni with australian adolescents given this we firstly assessed the internal reliability of the cmni and then conducted confirmatory factor analysis descriptive analyses of exposures confounders and outcomes were conducted followed by logistic regression in which models were adjusted for potential confounders as we were interested in the effect of each masculinity subscale independent of the other subscales separate regression models were conducted for each masculinity subscale sensitivity analysis as it is possible that conformity to masculine norms varies by sexual orientation we conducted sensitivity analysis in which we adjusted for sexual orientation in further analyses we also restricted analysis to the sample of young men identifying as heterosexual results we conducted confirmatory factor analysis to assess the factor structure of the cmni among the adolescent sample we employed an oblique rotation as this accommodates the assumed correlated nature of the factors following kaiser criteria we retained eigenvalues of 1 or higher in the derived 11factor structure item loadings confirmed the factor structure of the cmni internal consistency of the overall cmni among the adolescent sample was assessed using guttmans λ4 and was calculated to be 086 table 1 shows the characteristics of the final sample in wave 1 in this sample 30 were aboriginal andor torres strait islander and for most respondents both parents were born in australia eight percent of the sample reported suicidal ideation within the past 12 months the extent to which the sample conformed to masculine norms varied across the different subscales there was greatest conformity to pursuit of status heterosexual presentation and emotional control results of the unadjusted and adjusted logistic regression models of the relationship between conformity to masculine norms and suicidal ideation are reported in table 2 in adjusted models conformity to violence norms and selfreliance norms were both associated with increased odds of reporting suicidal ideation greater conformity to heterosexual norms was associated with reduced odds of reporting suicidal ideation there were no associations with suicidal ideation for any of the other masculinity subscales while most of the sample identified as heterosexual n 63 identified as gay bisexual not sure or other we therefore considered the possibility that associations may vary by sexual orientation and ran models in which we further adjusted for sexual orientation these produced estimates consistent with the main analyses we also restricted analysis to those adolescents identifying as heterosexual and found results consistent with the main analyses discussion this study contributes new understandings of the associations between masculinity and suicidal ideation among adolescent males specifically we found evidence that some dimensions of masculinity were associated with suicidal ideation notably high conformity to violence and selfreliance among adolescents at 1518 years was associated with higher odds of reporting suicidal ideation at 1720 years and higher conformity to norms related to heterosexuality was associated with lower odds of reporting suicidal ideation to our knowledge this is one of the first studies to quantitatively examine the associations between masculinity and suicidal ideation among young males the results for violence indicate that each unit increase in conformity to violence was associated with 23 higher odds of reporting suicidal ideation this is consistent with evidence showing that violent behavior is a risk factor for suicide in adults 17 while as a whole the sample did not overwhelmingly endorse violence as a mechanism to solve problems those who did were more likely to think about suicide illustrating the risky nature of this dimension of masculinity there is some evidence that males may be at greater risk of death by suicide because they are socialized to conform to certain masculine norms that foster engagement with painful and provocative life events resulting in greater acquired capability for suicide 26 it is also known that compared to females males are more likely to die by suicide using violent means 61 importantly while hegemonic masculinity values physical strength and toughness it does not equate with physical violence violence however is sometimes used to demonstrate this physical strength and toughness 8 the associations observed in this analysis for selfreliance show that each unit increase in selfreliance is associated with 40 increased odds of reporting suicidal ideation these results are concordant with other work among adults where selfreliance has been associated with suicidal ideation 49 and mental health problems 43 the selfreliance items used in this scale tap into affective and behavioral responses to helpseeking critically then these results reveal that some of the young men in this sample reporting suicidal ideation have also reported high conformity to norms that indicate resistance to helpseeking on facevalue selfreliance can be a positive attribute if it fosters independence however the potentially positive effects of selfreliance may be circumscribed if it also inhibits communication and helpseeking in times of distress or crisis mental health stigma is known to be a barrier to helpseeking however recent work highlighted that for young men this is perhaps more keenly experienced because poor mental health and helpseeking are both at odds with their internalized masculine norms 39 our findings that heterosexual presentation was associated with reduced suicidal ideation was unexpected the results may evince the protective effect of conforming to socially condoned norms hegemonic masculinity is clearly heteronormative alignment with dominant masculine norms and more pointedly the knowledge that one does not deviate from this heterosexual norm is likely to confer some level of protection for young males mental health the obverse of the relationship that we observed between high endorsement of heterosexual norms and low suicidal ideation is that low endorsement of heterosexual norms is associated with increased odds of reporting suicidal ideation such results do not indicate that being heterosexual is protective but rather highlight firstly the broader buffering effect of conforming to heterosexual masculine norms and secondly the potential to avoid the penalties that arise if deviating from socially accepted norms given that there is a wellestablished literature documenting the fact that sexual minority young men and adolescents are at elevated risk of suicide and selfharm 205155 we conducted sensitivity analysis in which we firstly controlled for sexual orientation and then restricted our sample to heterosexualidentifying table 2 the relationship between conformity to masculine norms and thoughts of suicide unadjusted and adjusted logistic regression models adolescents the results persisted in both sets of sensitivity analysis it is widely accepted that heterosexuality is a core component of constructions of hegemonic masculinity 1432 and that to a greater or lesser extent hegemonic masculinity is constructed as a gender position that is as much not gay as it is not female certainly the importance of heterosexuality among adolescents in this sample was evidenced by the high mean score for that subscale although we note that the large standard deviation suggests that this was not uniformly endorsed compared to 1855 yearolds in the same dataset 49 the adolescents in this sample expressed greater conformity to heterosexual norms the practice of constructing and affirming masculinity through the assertion of heterosexuality among young males has been observed elsewhere 23 froyums research revealed the ways that adolescent males disassociate themselves from homosexuality and other nonheterosexual sexual identities to construct and affirm their heterosexuality 23 given that they are situated outside the heteronormative bounds of hegemonic masculinity it is not surprising that those young males in our sample not conforming to the hegemonic norm of heterosexual presentation fare less well this is problematic not only for the negative impact on young people who are not heterosexual but also because homophobia and or the fear of being thought to be gay can act as a barrier to intimacy among men 14 something that may impart other negative impacts on them in the future even if not observed now these findings suggesting that certain elements of masculinity may place young men at risk of suicidal ideation have implications for suicide prevention programs among adolescent boys at a broad level these results indicate the pervasive power of social norms in defining consensual expectations about what group members do and should do 11 previously gender norms have been examined in relation to the way they delimit the roles autonomy and control that women have over their lives yet it is increasingly recognized that gender norms and attitudes may also underpin adverse health behaviors and outcomes in boys and men 3435 recognizing the challenging and often conflicting messages that young adolescents face regarding masculinity is vital 40 there is clearly a need to destigmatize mental health and also foster new understandings of masculinity that incorporate helpseeking into masculine ideals 39 jewkes et al 31 proposed an ecological approach to the transformation of masculinities in adolescents such an approach seeks to understand and address the drivers of social norms at all levelssocietal institutional interpersonal and individual and should seek to understand how different factors or identities might intersect 31 jewkes et al 31 proposed that interventions must move away from one dimensional homogeneous depictions of masculinity drawing on connells work 1416 they proposed that interventions should emphasize the heterogeneity of masculinity avoid stereotypes focus on similarities between men and women engage with and acknowledge fears and vulnerabilities and address homophobia 31 it is possible that relaxing rigid norms regarding masculinity and encouraging acceptance of more diverse masculinities will deliver benefits beyond suicide and mental health improvements for adolescent boys and contribute to better health and wellbeing in the wider population 2236 further work is needed to examine the associations observed in this analysis over time and across different age groups to understand whether these associations reflect cohort effects or developmental stages it is also crucial to understand how these changes relate to other personal occupational and wellbeing indicators regardless of the drivers furthermore it is possible that specific dimensions of masculinity are both protective and also risk factors at different developmental stages the dynamic nature of these associations needs to be understood dismantling masculine norms to facilitate helpseeking is vital however it is also important that once adolescent males do seek help mental health services are available and appropriate to meet their needsideally personcentered approaches that acknowledge the diversity of men and the diversity of their needs 56 there are several strengths of this analysis we used a large sample of australian male adolescents which strengthens the basis for statistical inference we also note the use of a validated measure of masculinity the original 94item cmni had good construct validity and discriminant validity and the 22item instrument has been shown to correlate well with the original scale 60 additionally the cmni22 has been widely used and is positively regarded while in this study basic psychometric parameters of the cmni were analyzed it should be acknowledged that an exhaustive evaluation of its psychometric properties has not been conducted on an australian adolescent sample we also raise the possibility that the construct validity of some of the subscales was low in particular it is possible that the items for heterosexual presentation do not align with the construct they are purported to measure in this population we note that significant measurement differences across ethnic groups have been observed with evidence that the scale is more theoretically consistent for white american men compared to asian americans 30 other evidence also indicates that masculinity may be understood experienced and expressed differently across different ethnic groups and cultural contexts 27 thus the results may not be generalizable to indigenous australians and australians of ethnic minority backgrounds further work using qualitative methods is needed to examine how conformity to masculinity may vary across ethnicity and indigenous identity in australian adolescents as both masculinity and suicidal ideation were selfreported dependent measurement error which can arise when two or more variables are based on selfreported subjective responses from the same respondent 63 may have biased findings while there is a precedent for the use of singleitem suicidal ideation measures 4448 there is some evidence that singleitem measures may result in a higher proportion of false positives and false negatives 42 if this occurred in this study there is potential that it led to some degree of misclassification bias and potentially spurious findings a further limitation of singleitem measures such as this one is that they inadequately capture differences in the severity or frequency of ideation or attempts 42 it is impossible to ascertain for example whether a person was actively planning to engage in suicidal behavior whether a suicide behavior was stopped or whether these were simply fleeting and nonserious thoughts selection bias due to missing data potentially affected these results although we note that for most variables there was 4 missing from the eligible sample and this is unlikely to have biased results because our sample comprised of adolescent males common socioeconomic confounders were either unavailablenot obtained or not yet realized we were therefore unable to include these possible confounders of the relationship between masculinity and suicidal ideation in analytical models this may have introduced some bias as there is evidence that constructions of masculinity differ across socioeconomic position 14 and that more disadvantaged groups are at greater risk of suicide 28 however we note that while we were unable to control for individual sep we did control for area sep given evidence that for adolescent males enactments of masculinity 12 and suicidal behaviors 5 are known to vary by neighborhoodarea deprivation we contend that by controlling for area sep we have captured much of the confounding that may have been induced by individual sep conclusions in conclusion this study presents quantitative evidence of associations between elements of masculinity and suicidal ideation in a sample of adolescents among the adolescent males in this sample we found that high conformity to norms of violence and selfreliance was associated with greater odds of reporting suicidal ideation while high conformity to norms of heterosexual presentation was associated with reduced odds of reporting suicidal ideation maximizing adolescent health is key to optimizing adult health and wellbeing and these results highlight the potential importance of presenting multiple ways of being a male among adolescents facilitating a relaxation of norms regarding selfreliance to encourage helpseeking is vital and dismantling heteronormative masculine norms is likely to benefit the broad population of males not only those who do not conform to heterosexual and other masculine norms fellowship tk is supported by a university of melbourne early career researcher grant and vs is supported by a university of melbourne early career researcher grant the funding bodies had no role in the design of the study data collection analysis interpretation of results or the writing of this manuscript funding supplementary information supplementary information accompanies this paper at 1186s128880202475y additional file 1 table s1 summary of missing data table s2 sexual orientation statistics table s3 the relationship between conformity to masculine norms and thoughts of suicide controlling for sexual orientation table s4 the relationship between conformity to masculine norms and thoughts of suicide restricted to heterosexual young men additional file 2 table s5 factor loadings based on confirmatory factor analysis of the cmni among ten to men sample of australian males aged 1518 years table s6 concordance between cmni scales and factor loadings authors contributions tlk conceived the study interpreted the results and wrote the manuscript ms conducted the analysis and contributed to drafts of the manuscript vs contributed to interpretation of results and drafts of the manuscript gd contributed to interpretation of results and drafts of the manuscript dc contributed to interpretation of results and drafts of the manuscript ao contributed to interpretation of results and drafts of the manuscript kk contributed to interpretation of results and drafts of the manuscript am contributed to interpretation of results and drafts of the manuscript all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background adolescent boys and young men are at particular risk of suicide suicidal ideation is an important risk factor for suicide but is poorly understood among adolescent males some masculine behaviors have been associated with deleterious effects on health yet there has been little quantitative examination of associations between masculinity and suicide or suicidal ideation particularly among boysyoung men this study aimed to examine associations between conformity to masculine norms and suicidal ideation in a sample of adolescents methods a prospective cohort design this study drew on a sample of 829 australian boysyoung men from the australian longitudinal study on male health boys were 1518 years at baseline and 1720 years at followup masculine norms wave 1 were measured using the conformity to masculine norms inventory cmni22 suicidal ideation wave 2 was a singleitem from the youth risk behavior survey logistic regression analysis was conducted adjusting for available confounders including parental education indigenous australian identity and area disadvantage results in adjusted models greater conformity to violent norms or 123 95 confidence interval ci 103147 and selfreliance norms or 140 95 ci 115170 was associated with higher odds of reporting suicidal ideation greater conformity to norms regarding heterosexuality was associated with reduced odds of reporting suicidal ideation or 080 95 ci 068091 conclusions these results suggest that conforming to some masculine norms may be deleterious to the mental health of young males placing them at greater risk of suicidal ideation the results highlight the importance of presenting young males with alternative and multiple ways of being a male facilitating a relaxation of norms regarding selfreliance and encouraging helpseeking is vital furthermore dismantling norms that rigidly enforce masculine norms particularly in relation to heteronormativity is likely to benefit the broad population of males not only those who do not conform to heterosexual and other masculine norms

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introduction the coronavirus disease pandemic has spread to 198 countries with approximately 555 million confirmed cases and 635 million deaths globally as of 12 july 2022 the 2019 coronavirus pandemic led governments across the globe to enforce movement restrictions and social segregation orders across countries leaving only essential services open this also included suspending the traditional classroom setting in all educational institutes and shifting to remote methods of teaching as well as assessment the continuous spread of the virus travel restrictions and the indefinite closure of educational institutions are reported to have had a substantial impact on students education social lives and mental health 1 2 3 it is estimated that 8 to 71 of students in higher education institutions across the globe have suffered from acute stress disorder depression andor anxiety symptoms during the covid19 pandemic 1 2 3 4 5 6 the large discrepancy in reported prevalence may be due to the different questionnaires and methodologies used the time of assessment may contribute to the difference in prevalence reported this is because most of the psychological sequelae especially those of disasterrelated events only occur a period of time after a crisis for example the wenchuan earthquake survivors exhibited suicide ideation mostly six months after the crisis 7 growing acknowledgement of the psychiatric implications of covid19 may be due to the social impact of the current pandemic and government policies including social distancing measures travel restrictions personal hygiene etiquette quarantine and businessrelated restrictions 89 the whole community including those infected or noninfected were susceptible to the sequelae of such policies andor movement such as higher levels of anxiety stigma unemployment rates and financial difficulties 10 a study on chinese students found that 25 of them were experiencing some level of anxiety due to the changes 11 students were forced to live away from their parents during this period of time causing their psychological wellbeing to deteriorate 11 various studies carried out this past year have gone on to show that female students and those who were living in rural areas in particular manifested higher levels of stress and depression as they had a fear of losing out in their academic year 312 a study by szuster 13 also highlighted the plight of young women whose depressive symptoms and fear intensified with subsequent lockdowns furthermore the overnight change to online learning platforms coupled with a lack of information technology knowledge amongst nontechnical educators also caused frustration among students 12 these are some of the reasons why this current review aimed to focus on students in higher education institutions the novelty of this scoping review is in summarizing all works that have been published during the very first year of covid19 pandemic lockdowns specifically where the demographic was students in higher education institutes within the asia pacific region in identifying the risk factors this study found that students adopted various coping mechanisms to deal with the pandemic to the best of their ability evidence shows that depression stress and anxiety prevalence increased as time progressed 14 15 16 as an example wong 16 assessed the status of mental health among malaysian people using several timelines ranging from may 2020 to september 2020 with results indicating that depression prevalence increased dramatically as the pandemic progressed therefore there is a need to update and extend the literature to encompass more recent studies particularly a year after the beginning of the covid19 pandemic across the affected population recently published systematic review studies have looked into the impact of covid19 on the mental health of children adolescents and college students 1718 elharake 17 conducted a review study on children adolescents and college students however it focused on the impact of covid19 on the mental health of college students where they discussed the prevalence of various mental health conditions such as depression ptsd stress and anxiety furthermore the number of papers reviewed in that study was only 16 while 64 articles were reviewed for this study making this study more comprehensive other review studies are country specific 19 20 21 and some review studies looked at comparing mental health prevalence pre during and post pandemic 22 23 24 this systematic review aims to specifically identify risk factors that contribute towards depression anxiety and stress among the higher education student population in asia pacific countries identify coping strategies adopted by students to battle mental health issues that arose during this period to the best of our knowledge our systematic review is the first to examine the risk factors as well as the strategies adopted by students in the asia pacific region to cope with depression stress and anxiety during the covid19 pandemic methodology this is a sub study of a wider review study that was undertaken utilizing a flexible and iterative methodology to address a broad variety of research 2526 a fivestage framework 2728 was used and reported in congruity with the regulation in the preferred reporting items for systematic reviews and metaanalyses extension for scoping reviews 29 each step will be explained in detail as follows studies identified for this scoping review were part of a larger systematic review study identifying prevalence of depression within the asia pacific region during the covid19 pandemic the interest of this review was to look into published work relevant to the asia pacific regions and understand the impact covid19 had particularly on students at higher learning institutes within this region therefore scholarly publications were sought within the domain of mental health in the region of asia pacific three electronic databases were used to search for articles that had been published from january 2020 to march 2021 the search method employed several keywords using boolean and wildcard operators including mental health and pandemic mental health and c mental health and outbreak and mental health and epidemic additionally specific keywords such as mental health with mental issues stress depression anxiety emotion and psycho were also used resulting in 1979 articles extracted in total endnote was used to manage the review process as well as to eliminate any possible duplication step 3 studies selection during this phase an initial screening was conducted by drawing out the inclusion and exclusion criteria where papers that fulfilled the following were removed the research question of this scoping review is to identify the factors affecting the mental health of students resulting from a direct impact of covid19 therefore papers that did not fulfil the objective of this research question needed to be removed papers that met the eligibility criteria include • papers where the cohort under study was strictly students in higher learning institutes recent systematic reviews related to mental health during covid19 were also checked upon to ensure that a study of a similar kind had not been carried out recent systematic studies focused their efforts on frontliners and healthcare workers 30 31 32 the review done on adolescents looked into the prevalence of depression and anxiety within the populations of adolescents 33 however this paper is looking to bridge the gap within the research by looking into the mental health impacts from the students perspective within the asia pacific region step 4 charting the data studies that were screened from the previous step were then individually looked into where the study characteristics as well as the narrative synthesis was deducted three reviewers looked into the studies independently in order to identify and screen studies that fulfilled the two research questions in step 1 step 5 collating summarizing and reporting the results an iterative approach was adopted to report the findings each journal identified in steps 2 and 3 went through several cycles of screening keeping the objective of answering the research question in mind before a finalized list of articles was agreed upon results the initial search yielded 1929 papers which was reduced to 1073 after checking for the first stage of inclusion and exclusion criteria as explained in step 3 and was further reduced to 870 papers after deduplication sixty four articles were distilled after fulltext review description data table 1 displays the characteristics of the included articles more than half of the studies were published in 2020 the largest portion of studies were from east asia ie mostly china followed by south asia and bangladesh and north america ie mostly in the united states of america the majority of the studies were conducted on university or college students from nonmedical backgrounds overall the most common form of study design used was cross sectional and the commonly used sample size was between 100999 the general anxiety disorder and patient health questionnaire scale was the most frequently used scale among the other scales used were zhungs self rating anxiety scale 3435 centre for epidemiological studies depression 36 37 38 and the perceived stress scale 39 40 41 etc social demographic factors impacting mental health of students in the 64 papers included in this scoping review study the factor that affected students mental health the most was gender where the female gender was found to be impacted more than the male students who were in their final year of studies and postgraduate students who had almost completed their studies were affected more than students who were still in the midst of their academic years other factors identified were age economic and financial stressors geographical location of students ie urban or rural and current living conditions ie living alone or with family and friends five studies also identified race and ethnicity as being a factor for example charles 39 found that white students were mentally more affected by the pandemic compared to african americans contradicting hoyts 40 who found that african american students reported marginally higher anxiety compared to white and asian students in a mixed region study of thai indonesian and taiwanese students it was found that thai students reported the highest levels of anxiety 42 studies have been categorized according to the mental health outcomes identified depressionlike symptoms anxietylike symptoms stress and other psychological distress while acknowledging an overlap between these categories depressive symptoms thirty four studies looked into depressive symptoms amongst students the female gender was most associated with depressive symptoms 12437 43 44 45 46 47 48 however one study did not report any significant difference between genders in their study 36 ten studies reported depressive symptoms amongst students who were in the final stages of their academic years 143644 48 49 50 51 52 the estimated depression prevalence from within the 64 studies was between 444 and 72 the range difference includes studies that have identified mild depression to severe depression anxiety symptoms thirty nine studies looked into anxiety symptoms amongst students and the estimated anxiety prevalence recorded was between 09 and 587 the range difference includes studies that have identified mild anxiety to severe anxiety similar to depressive symptoms the female gender 12 34 35 36 40 44 45 46 47 48 53 and year of study 1 34 35 36 44 48 49 50 51 52 were associated with elevated levels of anxiety among students however all studies using medical field students 111 54 55 56 57 reported anxiety symptoms as students were unable to complete their clinical training due to the pandemic situation stress thirteen out of 16 studies that looked into stress amongst students were from the asian regions of asia pacific the prevalence of stress among students in higher education institutes was recorded as between 206 and 701 similar to depression and anxiety the female gender reported higher levels of stress 14044464858 however economic stressors and financial constraints seemed to be an avid cause of stress amongst students 1485961 psychological distress eleven studies looked into psychological distress amongst students with the prevalence ranging between 11 and 356 lower selfesteem 123954556263 was found to be one of the factors that lead to psychological distress as students who suffered from lower selfesteem and low selfefficacy were found to succumb to psychological distress li 64 found that students living closer to the city of wuhan experienced higher levels of posttraumatic stress disorder compared to those who lived further away since wuhan was the city where the virus broke out yang 65 revealed that students in wuhan felt victimized by the covid19 situation and this took a negative toll on their mental health coping strategies adopted by students to overcome mental health impact in the process of reviewing studies that were identified in steps 2 and 3 of this scoping review it was found that students directly or indirectly adopted different coping mechanisms to help them adapt to the pandemic situation table 3 displays the coping mechanisms discovered increased screen time the present study found eighteen studies that showed an association between increased screen time and anxiety and depression 134638414244 five studies found that students who were distracted by screen time also suffered from sleep deprivation 4384469 islam 44 found that students who live with more than five people around them spent more hours on the internet two studies also found that students who followed online classes suffered from depression and anxiety 4168 maladaptive coping mechanism maladaptive coping mechanisms generally increase stress and anxiety 69 thirteen studies reported students resorting to maladaptive coping mechanisms and they found that increased smoking was the most common a study by kamaludin 53 found older male students using more maladaptive coping mechanisms additionally students from different study discipline areas used different coping strategies ie students from the medical field adopted an acceptance strategy more than students from nonmedical fields 53 some of them may use more intense maladaptive coping strategies such suicidal ideation which is believed to have a significant relationship with sleeping problems and cigarette smoking 69 social support fourteen studies found students relying on a good social support systems in order to survive the pandemic four studies revealed that living with parents and families with sound financial backgrounds were protective factors against anxiety 11537075 one study unveiled that students who were enrolled in campus support group programs reported having better moods and were mentally prepared to face the covid19 situation 75 additionally a positive family cohesion was found to buffer the effect of moral disengagement on relational aggressive behavior for females 70 which goes to show that a good social support system is crucial in reducing the impact of mental health conditions religiousspiritual there were four studies that focused on the religious and spiritualrelated coping strategies among the students one study found that for students taking up meditation and an interest in religion during the pandemic lockdown helped buffer against psychological distress 47 kamaludin 53 identified that different race and ethnicity affected the way students embraced religious and spiritual acceptance towards the pandemic in particular students from indian heritage were more prone to divert towards spiritualism a study in pakistan found students were turning to religion and spiritualism as a means of coping 47 two studies 7074 also found students adopting rumination techniques which include meditation to help cope with the pandemic situation staying active eight studies found students reverted to exercise and engagement in some form of physical activity to cope with being in lockdown 34374467687678 shailaja 68 found that students who engaged in physical activities or indulged in some form of hobby were able to moderate their mood better thus causing less impact on their mental health condition in another study zhang 78 also discovered students who were more active reported less psychological distress discussion the systematic search for published articles related to the impact of covid19 on the mental health of students in the asia pacific region yielded 64 studies four mental health outcomes were identified depression anxiety stress psychological distress and others socio demographic risk factors the current review estimates a prevalence of depression and anxiety among students during the covid19 pandemic of 572 and 7715 respectively this was consistent with most of the studies that reported students psychological distress had increased during the pandemic a systematic review found that the prevalence of anxiety in 17 studies was 319 prevalence of depression in 14 studies was 337 and prevalence of stress was 296 77 this is consistent with the trend related to psychological distress during previous epidemics such as severe acute respiratory syndrome 79 the contagious emotion among the community led to a higher level of anxiety and other psychological distress this was exacerbated by feelings of helplessness and uncertainty or a sense of losing control especially with the rapidly changing and inconsistent policies given by the authorities during the pandemic those who followed covid19 related news experienced more anxiety and misreported information about covid19 exacerbated students depressive symptoms 43 there was a prevalence of anxiety of 2025 among medical students prior to covid19 1168 this finding was also lower than the prevalence of anxiety in the general student population where it could have increased by twofold 577 this may be due to the higher perceived sufficiency of information on covids prognosis and transmission and a broader official source of information than students in other fields that contributed to the reduction in their fears and anxiety 80 the common factors found among students who experienced depression stress and anxiety symptoms were gender age year of study and study discipline the female gender specifically were more prone to the aforementioned mental health issues across studies this is because studies have revealed that females are more perceptive emotional and prone to strain compared to their male counterparts 81 saraswathi 1 found that as opposed to males females are more proactive in their response and awareness of the pandemic and therefore tend to succumb to depression anxiety and stress easily younger students have less resilience and selfefficacy towards handling change which leaves them vulnerable to stress and anxiety 54 cheng 82 also argued that younger students exposed to information through social media were more susceptible to greater anxiety this may be due to a developmental mismatch between the mature subcortical regions that lead to risk taking emotion dysregulation and their higher executive functioning 83 with respect to year of study it has been found that students in their final year of studies 5684 were very concerned the moment lockdown was issued particularly because there was no information on how they would be assessed in their final year and if graduation would be possible similar concerns were also raised by postgraduate students 345368 and even more so among those postgraduate students who were on scholarships 5784 dodd 84 explained how an impact on scholarship among postgraduate students had a ripple effect as they were forced to face financial constraints and relocation coupled with finding the time to complete their research at home and bearing the load of housework and childcare all these factors added to the anxiety depression and stress faced by those in the final years of their education the last common factor identified was the study discipline students were in this particularly affected students who were in the science fields as their lab research clinical rotations and residency were affected due to the pandemic medical students also reported feeling burnout as they had to replace healthcare workers due to shortages but they did report that the constant communication and updates from their relative schools provided them with the comfort they needed with regard to their education 57 furthermore the fear of covid19 infection was also high among students in the medical field as they were sent to conduct swab tests and help out in hospitals during the pandemic 56 although a higher degree of knowledge of the disease could boost a feeling of safeness and showed a greater compliance with the proper standard operating procedure 80 most of the science fieldrelated students were found to have more neurotic and maladaptive perfectionistic personalities as the mediator that made them more susceptible to depression and anxiety 85 they are prone to fuse with negative evaluations of self and intense negative feelings of shame embarrassment and inadequacy 85 the current covid19 pandemic adds to the feelings of uncertainty and loneliness in students that heighten their levels of anxiety and depression 86 addressing the effect of covid19 on this specific group of students the urgent need for a preventionmental health promotion programme is of uttermost importance coping strategies the results of this scoping review revealed that different cohorts dealt with the pandemic by using different coping mechanisms males were found to be more prone to maladaptive coping mechanisms for example distraction leading to suicidal ideations 369 females coped more adaptively in a period of crisis by helping others in need which is consistent with their social role in society 6165 different ethnicities also reported different means of coping western white students were more affected by the pandemic compared to african american students 39 and resorted to substance abuse to cope the coping strategy adopted by asian students reflected their culture and they were more submissive to the conditions at hand and resorted to religious and spiritual means of coping 4753 students who were surrounded by a good support system were less affected by mental health issues throughout the pandemic 75 compared to those who did not have a proper support system similar findings were also reported by 87 where they found students tended to act out aggression due to fear of covid19 however positive family cohesion was found to buffer the effect of this aggression student aggression was also found to be related to the geographical location 79 of students students in urban areas of high density felt like they were trapped as they were not able to meet with their friends and had to stay indoors most of the time due to the pandemic students who were living together with more than four people under the same roof reported having higher levels of anxiety and stress 48 as they found themselves to be competing for the usage of internet connectivity for online classes to cope with boredom and agitated feelings of not being able to leave their premises students found themselves spending more time online 64145 this included playing online games with their friends as a form of connection they were otherwise denied leading to sleep deprivation 13 and lack of physical activity 3788 based on the literature in this scoping review this paper identified four strategies that could help students to mentally cope with the pandemic by eventually being mindful of the time spent on screen students would be able to maintain a healthy lifestyle despite being in the pandemic situation 3768 spending too much time staring into screens can not only be harmful to their mental health but also to their physical health 89 as revealed in this scoping review females tend to be more aware of the condition of the pandemic as they spend more time reading about it through online resources 1 although gathering information should reduce anxiety maxfield 90 revealed that information overload also contributed towards increased anxiety and stress this showed that how to spend screen time and the quality of time spent online is the issue if students can utilize technologies in a healthier way for example using an online mindfulness app or counselling services 3 it helps students to alleviate their psychological issues despite that having a good support system contributes to safeguarding their mental health studies have revealed that those who live with family tend to have less anxiety and depression compared to those living alone 496972 psychologists have found that humans thrive better when they are surrounded by people who they can lean on 90 therefore having a good support system in place in times of crisis reduces the burden on their mental capitals exercise or participation in physical activity and pursuit of a hobby were all associated with decreased anxiety perceived stress and depressive symptoms 91 therefore despite being in a pandemic situation students should seek out some form of physical activity such as home workouts gardening learning a skill such as cooking or painting students who have turned to meditation during the time of pandemic reported less anxiety 47 burtscher 92 also suggested that a daily athome physical activity could facilitate the routine back to university the last strategy would require a change in the online class system this is especially true for disciplines that require lab work to be done chakraborty 56 found students were dissatisfied with webinars in replacement of lab sessions therefore schools and higher education institutes should come up with another strategy to make online classes more bearable for students in the future although this scoping review used a thorough search strategy to uncover published research on the impact of covid19 on the mental health of students in asia pacific there are limitations to the study to be acknowledged firstly the search was only conducted on three online databases and the papers taken into consideration were published up to march of 2021 secondly this paper did not look into the prevalence of anxiety depression stress etc in students in the different regions of asia pacific as there were some papers that did not report prevalence of depression anxiety and stress thirdly the definition of students in this paper was capped to those in higher education institutes therefore perhaps a study in the future looking into the mental health condition of students in primary and secondary school could be looked into it should also be noted that although the factors identified in the current review paper might be strengthened under the covid19 circumstances some of these stressors protective factors and risk factors have been previously identified in a nonpandemic context 9394 thus it will be beneficial to use the current paper as a baseline and compare studies again after the pandemic has ended conclusions in conclusion the overall level of mental health issues among students in higher institutions does not appear to have increased during this covid19 outbreak the present paper found that the common risk factors were younger age being female being in the last year of study and studying sciencerelated fields by reducing their screen time using a healthier coping system and having an increased availability of support within the family and community as well as actively engaging in beneficial activities students could alleviate general negative emotions specifically during the pandemic data availability statement all data generated or analyzed during this study are included in this published article supplementary materials the following supporting information can be downloaded at table s1 summarize of studies included in the review funding this research received no external funding

the impact of covid19 has forced higher education institutes to go into lockdown in order to curb the situation this sudden change caused students within the institutions to forgo traditional face to face classroom settings and to attend immediate online classes this review aims to summarize the evidence of the social demographic mental health impacts of the covid19 pandemic on students in higher education institutes within the asia pacific region and identify the coping mechanisms adopted during these times a systematic literature search was conducted using three databases pubmed google scholar and scopus out of which 64 studies met the inclusionexclusion criteria the findings revealed that the social demographic groups most at risk were female students those who were in the final years of their studies ie students who were almost graduating and postgraduate students as well as students studying medical fields nursing dental medicine health sciences etc the majority of the studies identified that students were relying on mobile devices and extended screen time to cope with the pandemic having proper social support be it through a network of friends or positive family cohesion can be a good buffer against the mental impacts of covid19 students in higher education institutes are at risk of mental consequences due to covid19 by reducing their screen time finding a healthier coping system increasing the availability of support within the family and community as well as actively engaging in beneficial activities students may be able to alleviate general negative emotions specifically during the pandemic

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introduction climate change and automation pose unique challenges to agricultural health and safety this is compounded by a reliance on fossil fuels making agriculture a driver and a victim of global economic and environmental pressures 1 2 3 a key question is then how can research and policy account for the dynamic pressures of these macrolevel challenges in shaping agricultural populations exposure to risks considering that the impacts of climate change and rapid automation vary locally across geographies and commodities while the field of agricultural health and safety has studied both the role of weather and the role of automation in shaping agricultural populations health and safety outcomes 4 5 6 7 climate change and rapid automation are dynamic not static forcesbringing on novel challenges such as higher heat less predictable local weather patterns new plant chemical and machine technologies all of which augment the nature safety and risks associated with farm work increasing global surface temperature has dramatically shifted local environments and produced a number of agricultural challenges from crop adaptability to systems resilience and to owneroperator and worker health and safety 8 9 10 11 12 in parallel increasing automation has been a hallmark of the industrialization and digitalization of agriculture promising to lower the negative health safety and economic externalities of labor in agriculture 1113 while these trends impact future trajectories for agriculture the industry remains highly dangerous 14 with workers farm operators and their families facing exposure to hazardous chemicals equipment and environmental conditions 15 16 17 understanding these dynamic and complex challenges will require observing relationships between environment technique and health risk exposures the agricultural health and safety field is particularly suited for such observation given its disciplinary grounding in engineering health sciences and public health in addition a deeper understanding will require analysis of social structures cultural factors and attitudinal shifts that relate to and inform technological and environmental change over the years social scientists have enhanced the agricultural health and safety field by studying the impact of mechanization and industrialization on health risk behavior the social determinants of rural health particularly rural health inequalities 18 19 20 21 their research addressing environmental change agrifood tech and science and technology more generally holds still more relevance for understanding the challenges brought on by climate change and rapid automation in these bodies of work social scientists have elucidated the intersection of material and social worlds along with the politics ideologies and outcomes of dynamic pressures related to innovation and climate change 18 19 20 21 as a baseline it is essential for researchers to have a clearer understanding of the existing agricultural health and safety research that examines climate change and automationto achieve this we have conducted a scoping literature review designed to explore the contours of the field as currently arranged we consider both what this scholarship has covered and what it has not covered using a preferred reporting items for systemic reviews and metaanalysis framework to map out the work and identify gaps where additional research trajectories may be beneficial we then summarize key themes using concepts from environmental social science science and technology studies and rural social science while as we will discuss these social science bodies of literature touch on topics not currently covered by the agricultural health and safety literature they expand the theoretical boundaries of agricultural health and safety to better consider the social structural obstacles and opportunities for safer and healthier farm work in the future thus in the third and last section of our article we suggest novel synergy between the agricultural health and safety literature and the social science bodies of literaturehighlighting how theories explaining the coconstitutions of society environment and technologies reframe the impacts of climate and technology change in agricultural health and safety the resulting paper contributes to disciplinary knowledge by scoping the existent research in the area of agricultural health and safety and provides avenues for productive disciplinary crosspollination in future research design literature review approach we used the prisma framework as the basis for this literature review to systematically identify and link relevant agricultural health and safety research with agriculture technology and climate change 22 as we sought links between these topics our search terms required that a term from each group was present in the search our boolean phrase reads and and searches were performed in pubag pubmed and google scholar databases and limited to articles published in english over the last ten years two years prior to the 2014 intergovernmental panel of climate change report calling attention to the important links between land use and climate change while drawing a specific before and after is somewhat arbitrary we suggest that this represents a threshold where climate change and land use entered a new degree of attention and a new phase of scholarship we identified a total of 710 articles we conducted an initial screen by assessin healthsafety relevance of titles and abstracts leaving 164 remaining articles in a se screen we reviewed full articles and removed those that did not have sufficient relev to the topic of health and safety in agricultural work leading to 127 remaining art finally additional articles were introduced based on citation searches particu through existing literature reviews this process led to the addition of 10 articles in our review results constitute 137 articles we synthesized key terms emergent in the ature to develop three thematic foci 1 outcomes related to the adoption of environm adaptation strategies 2 discrete causes of farm injuries under climate and technolo change and 3 society care and wellbeing in the future of automated farm work t themes are each explicated below the production of these themes developed from n we took on the goals of each study their content area and geographic scope and population focus technology and climate change in the literature as it pertains to agricultural safety and health notably our synthesis of these subtopics found health and safety research dev ing three silos of thematic material papers aligning with these themes tend not to cit teract with the others in ways that substantially inform their key findings thus w these themes should not be read as the total encapsulation of the research field but ins a generalization about the contours of the literature as it stands it will become cle later parts of this review how these themes can better illuminate one anothers findin theme 1 outcomes related to the adoption of environmental adaptation strategies one core consideration of the literature regards how automation and climates agriculture are adapting in response to climate change 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 from this literature a tion focuses on the holistic wellbeing with an emphasis on economic factors of we identified a total of 710 articles we conducted an initial screen by assessing the healthsafety relevance of titles and abstracts leaving 164 remaining articles in a second screen we reviewed full articles and removed those that did not have sufficient relevance to the topic of health and safety in agricultural work leading to 127 remaining articles finally additional articles were introduced based on citation searches particularly through existing literature reviews this process led to the addition of 10 articles in total our review results constitute 137 articles we synthesized key terms emergent in the literature to develop three thematic foci 1 outcomes related to the adoption of environmental adaptation strategies 2 discrete causes of farm injuries under climate and technological change and 3 society care and wellbeing in the future of automated farm work these themes are each explicated below the production of these themes developed from notes we took on the goals of each study their content area and geographic scope and their population focus technology and climate change in the literature as it pertains to agricultural safety and health notably our synthesis of these subtopics found health and safety research developing three silos of thematic material papers aligning with these themes tend not to citeinteract with the others in ways that substantially inform their key findings thus while these themes should not be read as the total encapsulation of the research field but instead a generalization about the contours of the literature as it stands it will become clear in later parts of this review how these themes can better illuminate one anothers findings theme 1 outcomes related to the adoption of environmental adaptation strategies one core consideration of the literature regards how automation and climatesmart agriculture are adapting in response to climate change 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 from this literature a portion focuses on the holistic wellbeing with an emphasis on economic factors of farm owneroperators 252933 meanwhile another portion examines the impacts of environmental change on worker health most notably as that populations health is impacted by dynamic changes in temperature and high heat exposure 3839 our prisma search revealed only a small number of publications focused primarily on climate change and agriculture that also discussed the significant impacts of climate change on the lived experience of farm workers 41 42 43 44 45 this small number belies the larger body of work that does study farmworkers and implicitly addresses their experiences of climate change in many cases 71644 46 47 48 49 50 51 however as described in the conclusion it remains clear that the body of literature examining impacts of environmental change and automation on agriculture could further consider those whose lives and wellbeing are most directly affected by these changes the danger to worker wellbeing compounds when considering that these same populations tend to have the least agency to make their own decisions or negotiations around the adoption use and interaction with forces of automation and environment 52 of the articles we identified wellbeing received less attention than health and from that only research on automated milking systems examined their impact on farmer wellbeing 262753 research on worker wellbeing in relation to automation was not clearly available theme 2 discrete causes of farm injuries under climate change and technological change the second theme regards discrete causes of farm injuries under climate and technological change the majority of this work examined outcomes related to heat and repetitive tasks with an emphasis on extreme heat a subsidiary group of scholarship examined automated and aidriven surveillance of these same factors 232934 37 38 39 41 42 43 44 45 the literature focuses primarily upon the discrete forces shaping negative health outcomes while literature exists considering the social determinants of health and inequalities farm workers face while exposed to these forces 498081 few draw correlations between social environmental and technological forces at play on the farm notable exceptions hail from the field of anthropology including holmes 49 study on the naturalization of social suffering among farmworkers particularly a group of oaxacan workers with whom he conducted an ethnographic study his work alongside that of arcury and others 46 47 48 highlights the value of social science approaches to the agricultural health and safety field from this approach inquiry into the social and political forces in farm works material and embodied reality centers and illuminates the changing dynamics in worker health and wellbeing in the context of automation for labor intensive agriculture and climate changes new health risks theme 3 automation care and wellbeing on the farm the third theme groups dairy farmers and farmworkers and the impact of automation in their industry with considerations of society care and wellbeing in the future of the automated farm while some overlap exists with aspects of theme 1 this body of literature highlights inputs and societallevel considerations in the context of climate change and automation this research also primarily focuses in us and european contexts and considers holistic wellbeing the physical impacts of farm labor and the relationship between farmers and farm workers on dairy operations in the changing landscape of agriculture in the last ten years 5653658283 notably this research has at times adopted approaches from other disciplines described belowas is the case of arcury and holmes work with workers in laborintensive plant agriculture 4647498184 in both the cases of arcury and homes respective work inequalities along class citizenship race and ethnic lines everts into health outcomes on the farm in the case of dairy research where behavioral factors and attitudinal concerns about farmers impact wellbeing outcomes for those adopting automations we see that the material world of farm safety is also socially embedded and these societal consideration are themselves implicated in specific environments and technological practices the interplay of these spheres supposedly discrete in their professional specialties reveals that multivariate health and safety concerns arise from climate change and automation however such interplay also reveals the potential for insights relevant not only to specific industries and cases but also to social science and health research more broadly as principals of behavior attitude and social norms play out in cognate areas of health and safety research gaps in the current research we now turn to the gaps we identified and postulate on the source of these gaps the identification of these gaps and potential explanations provide the justification for drawing in outside literatures and our conclusions about how to advance the literature of agricultural health and safety on automating farms and a warming planet we identified three primary gaps in the current literature the first limitation is that much of the research examines environmental change technological change and health impacts as separate rather than as coconstituting forces this is a significant problematic as other outside research makes the convincing case that environmental change technological change and health impacts are all tightly linked outcomes for example we might consider research on the production of new avenues of agriculture and the working quality and decisionmaking capacities of agricultural communities such a consideration might show how suites of new technologies climate change and rural community dynamics together influence agricultural outcomes 8586 in other words while our review was designed to detect the intersection of these forces the majority of the studies we examined did not study these forces as directly related secondly few of these studies examine how these changes are distinctly socially embedded and therefore informed by social structures agricultural work is a distinctly social arrangement and its contours character and outcomes are all informed not only by policy frameworks but also by group attitudes social norms cultural expectations and socioeconomic inequality for example there are wellknown inequalities in income and income security which stem from citizenship legal status and access to services 80 however these were seldom operationalized with the exception of a handful of studies focusing on dairy workers 683 and farmworkers 4748 while these studies represent an exception they exemplify how research into social inequality and socially embedded practices can reveal numerous agricultural health and safety problems from workplace conditions to health services delivery 54653 the third gap is the lack of research addressing broad trends or extrapolating lessons from particular industries into agriculture more broadly much of the research instead confines itself to the particular parameters of specific industries drawing out the health and safety considerations for dairy production 5683 for example studies for this industry are robust without deducing trends or implications across industries the critical scholarship thus becomes less broadly accessible or critical as the results are not already in direct conversation with other researchers working in cognate industries with lower attention paid to the intersection of technology change climate change and worker health and safety a gap swallows the opportunity for the field of agricultural health and safety filling such a gap could be addressed with a simple enjoinder to pay attention and increase scholarly activity on the overlaps however a simplistic research mandate for this or that industry or specific population could potentially limit this work a counterproductive approach particularly because researchers need a wider theoretical toolkit to seriously identify and analyse these complex intersections put differently a small research conversation on the topic itself produces a second challenge a lack of theoretical diversity in the research discourse without a broader scientific conversation and diverse theoretical approaches the scope of inquiry has a small theoretical and methodological toolkit for addressing the concerns scholars often translate approaches from other areas of inquiry without context or start from scratch we suggest that considering the way other disciplines including science and technology studies rural sociology and environmental social science address subsections of these concerns agricultural health and safety researchers must also look further afield to address the intersection of agricultural automation and climate change social sciences contributions to the environmentaltechnological change intersection and agricultural worker health while social scientists have not traditionally played an important role in the field of agricultural health and safety three disciplines have made important contributions at the intersection of environmental and technological change rural sociology sts and environmental social science we suggest that these contributions can be leveraged to deepen our understanding of agricultural worker health and safety as it pertains to climate change and automation and to provide resources for future research inquiry we now describe these disciplines drawing from our own background we recognize that each have their own research communities and agendas as such we do not wish to misrepresent our discussion as authoritativebut rather as a provocation to highlight the value some specific social science research communities hold regarding the problem of agricultural health and safety and the way these dynamics are theorized by the scientific community contributions from rural sociology rural sociology arose in tandem with the landgrant university system and has long used a sociological lens to develop both original and applied research on rural society with an emphasis on agricultural change and natural resource use 87 88 89 rural sociology also has a long history of situating health agriculture technology change and climate change though rarely across all four of these domains 91021 90 91 92 93 94 one of the strengths of rural sociology is the disciplines willingness to adopt toolkits from other disciplines based on the diverse and intersecting needs of this interdisciplinary field one particularly relevant adoption includes adding an agricultural technology approach from the sts field 109596 which we will look at more closely below rural sociology also adopts mainline sociological approaches to understanding power and politics in rural food production 9798 and public health approaches to rethinking rural health contexts 99 while there are many frameworks that this body of scholarship may offer we suggest two productive avenues for studying the intersections of automation environmental change and health in agricultural practices which we introduce and then further examine in the conclusion rural sociology retains disciplinary roots in small communities embedded in and thus immediately dependent on the natural landscape the fields has always had to draw empirical and theoretical connections between society and place 89100 pragmatically this has meant drawing relationships between place as a materiality meaning its physicality has social ramificationsalongside the overarching or embedded social structures that govern society in these contexts be it community resilience farmer wellbeing agricultural sustainability or rural development 375393101102 rural social science is not siloed inside sociology alone a body of anthropologists at the margins of agricultural health and safety research likewise have shown how placebased ethnographic research into the specifics of agricultural communities and praxis help understand environmental and technological change on the farm and the health and wellbeing of farming communities 103 104 105 106 107 108 yates doer in particular critically reassesses how health research of rural sites imagine and inform social determinants and argues that the social nature of such health determinants also receive more consideration 108 such connections are much needed for future research which would benefit from considering theoretical approaches that account for the interrelationship between place and materiality as rural sociology does instead of considering as separate factors or occasionally as an addition layer that rests beneath or above material concerns contributions from sts sts has always been an interdisciplinary field drawing on useful frameworks from other areas of inquiry not unlike rural sociology central to this body of work however are the methods and theories by which sts scholars have situated material environments including the built and natural worlds alongside societal outcomes ranging from health 109 110 111 to industry 112113 to environmental outcomes 114 115 116 similar to rural sociology which embeds society in the landscape sts provides a useful way of relating the materiality of technology in this case agricultural technology and automation with societal structure that inform their development and which are informed by their specific technical arrangement a process called coproduction 117 118 119 120 for example recent research in the development of robotics for the apple industry have shown how farmers considerations about robotics and their anticipation of new norms around agricultural robotics inform development of agricultural robotics and the adoption patterns that resultindicating how the technologies and societal norms around those technologies make each other 121 recognizing that society engages the making of technological futures and the reciprocal nature of this process emphasizes how technology shapes societal outcomes in agricultural work we might consider how economic ideologies inform the need for farms to scale while at the same time automated smart technologies and datadriven practices such as precision agriculture enable and encourage that scaling coconstituting one another 1058 122 123 124 these constructions are not imposed from above interdisciplinary approaches reveal that practitioners at all levels engage in this making of knowledge and therefore the resulting social material and lived outcomes mol et al use such a framework in the particular case of nurses who tinker with medical technology arrangements of hospital rooms to improve care outcomes rethinking and remaking knowledge 111 likewise when considering agricultural health technology and environmental change an sts approach highlights not just the politics of knowledge production from the top but also its interaction and reinterpretations with all those who interact with those technologies such as the many farmworkers engaged with machines plants and animals on the farm 49125 above we noted that in some us and european settings sts concepts have already demonstrated useful synchronicity with rural sociological considerations and with environmental sociological approaches in many ways these demonstrations indicate the utility of these theories across fields and their potential use value to agricultural health and safety and other occupational scholarship 116 117 118 126127 consider for example lundstrom et als work on care in dairy agriculture where automated milking systems are deployed 83 this was one of the few studies our literature review identified as applying an sts approach to agricultural safety similar to many stss and stsinflected works in agriculture the scholarship borrows in this case from social psychologys activity theory to consider in more typical sts fashion the relationship between attitudes and beliefs of farmers and material changes on the farm in this case the researchers found that the deployment of milking systems had for some farmers improved overall wellbeing when said farmers could adapt to a continuous learning frame thus their study demonstrates that automation in dairy and the changing ecological pressures on agriculture intersect and impact farm work contributions from environmental social science environmental social science but particularly environmental sociology has long connected environmental change the uniquely material operations of societies in their physical environments and the role of these societies in environmental change while this research primarily discusses environmental sociology the field of research on environmental justice is itself interdisciplinary with practitioners from backgrounds in many disciplines but with a close relationship with political ecology that has an impact on anthropology and human geography 128129 from the beginning of this field researchers have shown an interest in how social hierarchies such as those based on race class gender ethnicity and nationality produce inequality with particular interest in inequitable experiences with pollution and with a focus on urban settings 130 131 132 core areas overlap with farm labor such as arcurys work identified through our literature review 45 employing environmental justice framings arcury examines the inequalities farmworkers face including the politics involved in pesticide exposure 47 this approach has been useful for understanding how environmentally embedded practices such as agriculture energy production and city design are impacted by social structures and particularly those that result in placebased inequalities 133 134 135 136 in many ways we might think of each of discipline discussed in these three subsections as clarifying how the intersection of automation health and climate change in agriculture is embedded in material domains of place technologies and environments the environmental social science scholarship offers two key considerations for use in agricultural health and safety scholarship the first is a theoretical framework for describing how societal norms of production and growth reproduce inequality in environmental outcomes while multiple approaches exist to describing this phenomena a popular approach in environmental sociology is the study of treadmills by which production in industry creates stable reifications of inequalities with negative societal or environmental outcomes 137138 somewhat different than the treadmills discussed in rural sociological discourse these approaches articulate the way neoliberal markets forms loops of production that reproduce environmental harms without developing offramps or environmentally beneficent improvements in the productive system we suggest that this may be a useful theoretical tool in the toolkit as it provides a way for relating or differentiating the extent to which automation and climate change exacerbate reinforce or ameliorate the treadmills of production existent in previous formations of agriculture over the last centuryparticularly as the treadmill approach is useful for examining the offloading of harms and the production of inequality in a wide variety of industries this leads to the second theoretical approach closely paired to the first the maintenance and production of environmental health outcomes resulting from unequal exposure to chemicals pollutants and other environmental harmsan approach often applying ej theory 130 131 132 136139140 in these approaches the structures that produce inequality are studied with the explicit motivation to ameliorate these outcomes this renders ej approaches specifically welladapted to producing research with policylevel and interventionlevel insightsa key outcome goal of many agricultural health and safety research practitioners unlike much agricultural health and safety research which focuses on farm operators and owners as key collaborators and recipients of interventions an integration of justiceoriented approaches such as ej could provide frameworks for better involving and including disenfranchised and underrepresented populations such as farm workers in research practices and in intervention outcomes conclusions rapid automation coupled with the effects of climate change raise alarms for the safety and wellbeing of those who work in agriculture consistent with review frameworks we took a systematic but exploratory approach to review existent literature and then drew connections with synchronous outside disciplines drawing on our teams expertise we found that while the agricultural health and safety field has studied the roles of automation and weather in health and safety outcomes we argue that rapid automation and climate change present novel challenges connected to unpredictability for example current research has adapted to consider the linear progression of higher heat but the many dynamic outcomes that are difficult to predict as mechanized practices shift new technologies are adopted and less predictable weather events occur with greater frequency science based interventions in agricultural health and safety will require research that is adaptive inventive and futureoriented in order to observe and explain the dynamic risks associated with these novel pressures in a timely manner in this article we leveraged a review of 137 articles to understand how links between agriculture technology and climate change as relevant to safety and health have been studied overall we identified three key themes in the literature the adoption of adaptation strategies including automation and climatesmart agriculture in response to climate change the discrete causes of farm injuries under climate change and technological change and a discussion of society care and wellbeing to the future of automated farm work with a primary focus on dairy farmers and farmworkers and the impact of automation in the industry while environmental and rural social science scholars have noted the social embedded dimensions of technology and environmental change on the health and safety of those who work in agriculture 161741424580 we note a small number of studies examining these dimensions furthermore in addition to being socially embedded environmental change technological change and health impacts are coconstituting forces a key contribution and recognition offered by sts researchers 141 however we note that the agricultural health and safety field still largely examine these forces as separate to address these gaps we suggest that rural sociology sts and environmental social science provide relevant tools given their longstanding traditions examining the socially embedded practices of food producing communities alongside the coconstituting forces of environment technology and society drawing from the disciplinary frames we brought into the conversation above we suggest three avenues of further inquiry to make progress towards the research gaps in the agricultural health and safety literature that we identified first we suggest that increased attention to the multiplicity of this experience as relevant to the generalized agricultural regime in qualitative research in rural places will be required to identify new determinants of worker health and wellbeing this avenue for inquiry has broad relevance to and could draw heavily from the methods theories and discourses being pushed forward in rural sociological research that examines the placebased examples of social structures in rural locales for example legun and burchs work 121 examines the particular case of apple producers adaptations in anticipation of new robotics yet the insights they provide our grounded in in broader environmental and agricultural theories and their results characterize both a component of the agricultural tableau through a particular industry in a particular place but they also demonstrate insights that have relevance beyond the discipline second continuing to develop empirically grounded industryspecific research is key relating themes trends and theories between industries will also be essential in the dynamic agricultural landscape of the 21st century furthermore more robust research into the politics outcomes and social structures engaged in the making deployment and practice of new technologies on farm this work will be key both for understanding the contemporary impacts of climate change and technological change but also to theorize and produce anticipatory scholarship on the future trajectory of farm work and its health and safety outcomes inquiries and research projects in this area have significant overlap with sts scholarship and the theories and approached introduced in our discussion have impacts for potential research in this area see for example mol et als work on care and practice on farms and in healthcare settings 111 last we suggest that increased attention on the shared inputs and impacts between society and environment in health outcomes on dynamically shifting farms will be key for understanding the longevity of our agricultural system its sustainability and its role in producing equality for example consider arcury and holmes respective work on the social and health support or klerkx et als work on the social sustainability impacts of digital and automated agriculture 4648498486111 again this has significance in environmental sociological and ej approaches and onboarding these theoretical frames can be the basis for productive inquiry in agricultural health and safety in each case we suggest that expanding the literature will benefit by borrowing from the valuable work being carried out in other fields to dynamically adapt our research to the quickly changing landscape of automating agriculture on a warming planet in and out of itself this is an integral research goal if we are to better understand and design programs resources and policies to promote safer and healthier farm work throughout the 21st century data availability statement not applicable data may be retrieved from the databases described in the review

in this review we first assess the state of agricultural health and safety research as it pertains to the dynamic challenges facing automating agriculture on a warming planet then we turn to social science fields such as rural sociology science and technology studies and environmental studies to leverage relevant insights on the introduction of new technologies environmental risks and associated workplace hazards increased rates of automation in agriculture alongside new risks associated with climate change create the need for anticipatory governance and adaptive research to study novel mechanisms of worker health and safety the use of the prisma framework led to the 137 articles for our review we identify three themes in the literature on agricultural health and safety 1 adoption outcomes 2 discrete cases of health risks and 3 an emphasis on care and wellbeing in literature on dairy automation our review led to the identification of research gaps noting that current research a tends to examine these forces separately instead of together b has not made robust examination of these forces as socially embedded and c has hesitated to examine the broad transferable themes for how these forces work across industries in response to these gaps we suggest that attention to outside disciplines may provide agricultural health and safety research with a toolset to examine needed inquiry into the multiplicity of experiences of rural stakeholders the industry specific problems arising from automation and climate change and the socially embedded aspects of agricultural work in the future

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introduction cultural variety has become a prominent factor for ongoing research lately as the world has begun to be accepted as a global village in which people from different cultures come together and coexist in a multicultural setting just as globalization has considerable effects on societies nations and countries in various aspects the concept of multiculturalism naturally comes to the forefront in societies differing dimensions these include areas such as politics the economy health and education multiculturalism is a versatile concept that includes race ethnicity language sexual orientation disabilities social class religious tendencies and other cultural dimensions and entails a philosophy that seeks and fosters the involvement of views and contributions of different members of society while maintaining the respect for their differences and withholding the demand for their assimilation into the dominant culture upon defining a society as multicultural özensel claims not only that societies members vary regarding their values customs and traditions but also there are differences among them in respect to the understandings people hold about beliefs towards justice and issues related to the ethical values of the culture which they feel liable to follow in such multicultural communities there is a need for an institutionalized training system that could provide a standardized education on a free peaceful respectful and tolerant platform for students from different sexual racial ethnic religious and cultural backgrounds such an educational form is addressed in multicultural education banks provides a recent description for the term as multicultural education incorporates the idea that all studentsregardless of their gender sexual orientation social class ethnic racial or cultural characteristicsshould have an equal opportunity to learn in school in a multicultural society the diverse nature of the community should be represented in each of the institutionalized learning systems including students curricula values norms and staff these constitute the foundation of multicultural teaching with the objective that each learner should have similar opportunities for learning regardless of language gender race or social class all indispensable facts like immigration and globalization trigger multilayered and multicultural societies now and in the future a truly multicultural education will always be a necessity and a way of providing relevant training to students from various cultural backgrounds accordingly in multicultural societies which try to set more multicultural based educational policies many other related components like schooling opportunities and curriculum need to be further analyzed teachers are positioned as being the ones who will apply practice guide and update current policies that satisfy the needs of multicultural education principals that is as being the most prominent influencers in the education field teachers are therefore inevitably involved in the education policies with respect to multicultural teacher training in this study the attitudes of preservice teachers from three departments were inquired to reveal their points of view about multicultural education what they associate with the term multicultural education their professional readiness to embrace the differences in and to provide training for multiple student groups with different cultural backgrounds their attitudes towards multicultural education were exclusively examined to gain an insight into the mental representation of the concept of multicultural education for them the following research questions were posed in the study • what are the preservice teachers attitudes towards multicultural education • do the preservice teachers significantly differ in their perceptions of multicultural education considering their gender and field of education • what are the preservice teachers metaphoric attributions to the term multicultural education theoretical framework multicultural education and multicultural teachers according to the 2020 statistics of the international organization for migration there are about 272 million international immigrants around the world their immigration was likely due to many reasons including wars and poverty migration might directly influence the social structures of national communities that already have longterm national level multicultural structures if immigrants are in need of longer residency and equal rights as the formal citizens of a country they often migrate for the sake of pluralism which means new policies and regulations are needed for the integration of those migrant populations to meet their health employment education and other necessities as globalization moves forward in regards to pluralism the related issues and requirements are open to be handled appropriately to achieve the ultimate goals of multiculturalism addressing migration as one background part of multiculturalism many countries with multicultural mosaics like the usa germany and france were once transformed into culturally diverse places after receiving massive migration often considered a country of crossroads or a gate for immigration towards europe turkey has lately become a permanent settlement for regular immigration by receiving numerous refugees from several countries despite being a historical hub for ethnically and culturally diverse groups of all ages changes in the dimension of populations caused by the recent constant immigrations have created new multilayered and multicultural structures in modern day turkey its social and cultural structures have been influenced by the latest migration wave which made it the country that has welcomed the most refugees growing in population by 5 since 2011 by 2021 more than 55 million people from 196 countries including syria afghanistan iraq and iran migrated to turkey the majority of them were syrian and approximately half of this population were children the immigrants are currently under temporary protection in turkey various policies have been developed considering education and schooling of these immigrant children which made it possible for them to receive formal education at state schools alongside turkish children yet these developments profoundly affect the education system of the country by raising challenges with the capacity of schools and instructional issues teachers are in the the foreground to face these challenges since they are expected not only to teach the curriculum subjects to these students most of whom lack the required proficiency in the medium of instruction but to integrate these students into the school systems with a multicultural understanding according to the current statistics of the turkish mone more than 700k refugee children under temporary protection have access to education in turkey where teachers are the primary figures needed to deliver a formal education to these children from various cultural backgrounds hence gradually expanding multiculturally rich classroom settings call for future teachers readiness and preparedness for such blended communities tutkun and aksoyalp point out that factors such as the disappearance of personal social and geographical boundaries contemporary understandings and a necessity of their implementation yielded multidimensional and multicultural perceptions of citizenship and made innovations in teacher training and inservice training programs compulsory they also underline a characteristic of the 21st century society is to have a philosophy of life that is differentiating in terms of culture and perceptions and is also gradually acceptant of globalization values and issues such as increasing diversity in culture and language international dialogue having access to information instantly socioeconomic inequality and the inability of a wide range of people to benefit from democratic rights are becoming more prominent in the 21st century in this context since teachers are at the forefront of influencing change it is essential to prepare teachers for the 21st century and its requirements qualified teacher training is therefore fundamental in maintaining teacher participation effectively and voluntarily in reform movements to be held in education teachers are the most essential and significant component of every kind of revolution to be made in education teachers should have active participation in every type of educational reforms under these circumstances and newly developing social and educational philosophies and requirements in line with the communities transformations teachers are expected to have a multicultural sensitivity awareness and understanding that influence the success of multicultural education processes figure 1 displays the essential position of teachers for multicultural education in a multicultural setting figure 1 the cycle of a multicultural approach in education alongside the current global assumptions some real life situations provide a clear picture of the conceptualization of multicultural education contextually although the starting point of the issue can be attributed to globalization the reality is more challenging and runs much deeper globalized contexts have coined their own terms for various interrelated globalbased terms such as multicultural societies multicultural education and multicultural teachers naturally the last one is dedicated to 21st century teachers who witness constant and rapid global developments in this era and need to be positioned parallel to these multifaceted phenomena since multiculturalism and its reflection on education require culturalsensitivity as the basic foundation teachers are expected to be culturallysensitive to be qualified as multicultural teachers a closer look at the teacher training programs from the multicultural education perspective indicate a considerable negation in turkey polat and kılınç emphasize that the nonexistence of a course or instruction about multicultural education is a huge gap within teacher training programs in turkey thousands of novice teachers are assigned to teaching duties at state schools each year and meet new cultures in their initial workplaces in a country where cultural richness dominates the regional communities novice teachers attitudes towards differences are extremely important as they are the major figures needed to reconstruct the society they are living in that is to say preservice teachers attitudes towards multicultural education have a special place in teacher training in line with global developments the formation of their teacher identity technopedagogical knowledge and teaching skills upon these references and perspectives the initial teacher training process will become highly significant in terms of multicultural education being multicultural will become an indispensable feature rather than a matter of choice for future teachers as world cultures intertwine and gradually prevail in many countries without certain instructions on multicultural education preservice teachers have only an external idea or intuition of multicultural education which is far from the fullyrealized conceptualization of a truly multicultural teacher related research most of the relevant studies that investigated multicultural education and teachers were based on teachers views beliefs or attitudes considering the fact that they are essential components of all educational processes including multicultural education a remarkable study by forrest et al focused on primary and secondary school teachers views on multicultural education in australia and reported partial traces of racism against students with aboriginal origins studying state primary secondary and high school teachers attitudes toward multicultural education karataş reported positive results in general and found significant difference considering teachers professional experience and seniority level except for their gender in a similar study tonbuloğlu et al investigated primary school teachers views and pointed to a generally positive perceptions of multicultural education along with some prejudicial views the researchers also claimed that the concept of multicultural education was not adequately emphasized in the school curriculum başaran and başarır examined preservice teachers views on multicultural education in a quantitative study which revealed positive scores significantly in favour of female participants in a more recent study akçayoğlu and arsal concluded that preservice teachers hadnt received a course on or any other acknowledgement of multicultural education by their 3rd year at university and had not encountered the term culture in relevant courses methodology participants this quantitative research was conducted with the participation of 160 senior students attending teacher training programs at three state universities in turkey as indicated in table 1 70 of the participants were female and 30 were male preservice teachers at the time of data collection 88 of them were in the 2025 age group 9 in the 2631 age group and 2 in the 3236 age group approximately 47 28 and 26 of the participants were studying elt turkish teaching and classroom teaching respectively data collection the research data were gathered through a survey form comprised of two sections the first section was designed to elicit demographic information of the participant preservice teachers such as their gender and age the second section was devoted to the teacher multicultural attitude scale developed by ponterotto et al and adapted to turkish by yazıcı et al the scale contained 20 likerttype items pointed from 1 to 5 seven items with negative wording were reverse coded high scores on the scale were the indicators of positive attitudes held towards multicultural education in this research the coefficient of the scale was calculated above 70 the qualitative data of the study were gathered via openended questions such as what are the first three words that come to mind when you hear the term multicultural education this question was intended to elicit the participants general perception of multicultural education and the concepts they associate it with another openended question posed required them to define multicultural education in one sentence to gain an insight into their general understanding of the concept data analysis the data were quantitatively analysed using spss 210 demographic features of the participants were reported in frequencies and percentages while the mean standard deviation and skewness values of the scale and its subdimensions were shown in a table of descriptive statistics the skewness and kurtosis coefficients were used to test the normality of the scale total and item scores the scores could be interpreted as not showing a significant deviation from the normal distribution when the skewness and kurtosis coefficients used in the normal distribution feature of the scores obtained from a continuous variable are within the limits of ±1 the mann whitney u test and the kruskal wallis h were used to compare the scores that did not show normal distribution in the scale regarding gender and major respectively subsequently the independent samples ttest and anova were used to compare the normally distributed items and the scale score in terms of gender and major respectively the lsd post hoc test and the mann whitney u test were conducted to determine from which group the difference originated when a significant difference was found as a result of the anova test and kruskal wallis h test respectively the level of significance was determined as 005 the participants responses to the openended question on their metaphorical perception of the multicultural education were qualitatively analysed a list of the mostly preferred terms that were associated with the concept was formed to gain a qualitative insight into the research findings and discussion the results obtained from the descriptive analysis of the preservice teachers attitudes towards multicultural education are shown in table 2 as displayed in table 2 the preservice teachers hold highly positive views on multicultural education the following are the statements with the highest scores 13 in order to be an effective teacher someone must be aware of the cultural differences of their students 2 teaching methods must be adapted to the needs of culturally diverse classrooms and 18 irrespective of the composition of my classroom it is important for all of my students to be aware of multicultural differences the statements with the lowest scores are as follows 20 teaching multiculturalism to the students will only cause classroom conflicts 12 the training of teachers about multiculturalism is not necessary and 15 students should learn to communicate in turkish only preservice teachers attitudes towards multicultural education regarding gender the subsequent analysis was conducted to see whether the participants significantly differ in their attitude towards multicultural education with respect to gender the related results are displayed in table 3 as seen in table 3 statistically significant differences were found between the female and male preservice teachers attitudes towards multicultural education in the overall scores and the following items 11 i can learn many things from students with different cultural backgrounds 13 in order to be an effective teacher someone must be aware of the cultural differences of their students 14 training about multicultural awareness can help me in order to work more effectively with a culturally diverse audience 17 i am aware of the different cultural backgrounds in my classroom 18 irrespective of the composition of my classroom it is important for all of my students to be aware of multicultural differences and 20 teaching multiculturalism to the students will only cause classroom conflicts moving from the results displayed in table 3 the female preservice teachers significantly differ from their male colleagues in that they are more prone to believe that they can learn many things from students with different cultural backgrounds that they should be aware of the cultural differences of their students to be an effective teacher that training about multicultural awareness can help them in order to work more effectively with a culturally diverse audience and that their students should be aware of the multicultural differences irrespective of the composition of the classroom they also significantly differ from the male preservice teachers in the awareness of different cultural backgrounds in classrooms and their attitudes towards multicultural education all in all the female preservice teachers hold more positive attitude towards multicultural education than the male preservice teachers this can be referenced to the existing research the male preservice teachers scores on the view that teaching cultural differences will create conflict in the classroom were found to be significantly higher than those of the female preservice teachers in other words their attitudes towards teaching cultural differences was statistically more negative than that of their female colleagues preservice teachers attitudes towards multicultural education regarding major the results of the anova kruskal wallis h test for the comparison of the scores of the preservice teachers attitudes towards multicultural education regarding major were given in table 4 2 table 4 shows that the preservice teachers significantly differ in their attitude towards multicultural education regarding major and the following items 5 i often meet with the family members of my students to get to know their culture better 6 it is not a teachers responsibility to encourage ones pride in ones own culture 9 when dealing with bilingual children their communication style is often interpreted as a behavioural problem 15 students should learn to communicate in turkish only 17 i am aware of the different cultural backgrounds in my classroom and 18 irrespective of the composition of my classroom it is important for all of my students to be aware of multicultural differences in order to determine from which group the difference originated the lsd post hoc test was conducted the results and possible causes are listed below the preservice classroom teachers displayed a statistically higher tendency to meet with family members to get to know the students culture better than the turkish and english preservice teachers this might be attributed to the fact that classroom teachers need to spend more time with fewer students than branch teachers in turkey namely they are supposed to teach a group of 20 or 30 students for a period of four years it is noteworthy that these teachers educate their students in almost all subjects identified in the primary curriculum which means they mostly work with the same students an average of 30 hours per week while the turkish and english language teachers teach each group only three or four class hours per week furthermore the turkish and english language teachers may teach each group only for only two semesters while classroom teachers as noted above teach the same students for four years therefore classroom teachers feel the need to get to know their students more closely and to contact their family members more frequently than other teachers besides as the curriculum assigned to classroom teachers offer more activities that require parental involvement than the english and turkish course curricula classroom teachers need schoolfamily collaboration for students achievement more than the other teachers thats why the participant preservice classroom teachers may want to contact family members of the students in order to know the whole family and the students social economic and cultural background as much as possible and plan their teaching effectively accordingly the statistical results also indicated that the turkish preservice teachers displayed a higher tendency of such kind than the english preservice teachers this could be attributed to different roles assigned to the english language teachers working in expanding circle countries including turkey to be more specific foreign language teachers are supposed to teach the language and to represent the target culture associated with that particular language they are also expected to develop and participate in eu projects in collaboration with schools in other countries more than other teachers considering the nature of the subject they are teaching and their competence in foreign language these factors could increase their workload and responsibilities and make it hard for them to get to know the family members of the students they teach if they were assigned a lower number of groups they could seize the opportunity to benefit from parental involvement in the foreign language teaching process which is almost never the case in turkey turkish language teachers are not on the other hand expected to teach a language they are still learning or to represent a culture that is entirely unfamiliar to the students neither are they expected to take an active role in the development or organization of eu projects due to these differences between the two groups of teachers roles and responsibilities the participant preservice turkish teachers could display a more positive approach towards contacting students family members to get to know their culture better the preservice english and turkish teachers are statistically more convinced that it is not a teachers responsibility to encourage ones pride in ones own culture than the preservice classroom teachers this outcome was a surprising result and has further implications to be explored in later research the preservice classroom teachers displayed a statistically stronger tendency to interpret the communication style of bilingual children they are dealing with as a behavioural problem when compared with the english preservice teachers this might be related to the frequent stress on the immediate relationship between language and culture and intercultural differences in the content of the english language teacher training curriculum namely the students studying english language teaching in turkey take a variety of courses on linguistics and language teaching methodology which cover linguistic and cultural diversity and intercultural communication through these courses they tend to embrace diversities with more ease and interpret differences in communication styles of people as an outcome of cultural differences rather than a behavioural problem however there are no specific courses in the classroom teaching curriculum that enable preservice teachers to gain awareness of such differences and encourage them to interpret behavioural differences among students as an outcome of cultural diversity the preservice turkish and classroom teachers displayed statistically higher attitudes towards students learning to communicate in turkish only than the english preservice teachers this particular result is not surprising since the english course curriculum favours the use of target language as the medium of instruction rather than students l1 in order to teach it for communicative real life purposes in this respect it is noted that use of english is emphasized in classroom interactions of all types supporting learners in becoming language users rather than students of the language as they work toward communicative competence teaching accurate and fluent use of turkish is on the other hand identified as the priority duty of turkish and classroom teachers working at primary and middle schools in turkey this specific purpose is also declared in the turkish course curriculum for 1st to 8th grades as the first key competence among the turkish qualifications framework accordingly communication in the mother tongue requires the students to have the ability to express and interpret concepts thoughts feelings facts and opinions in both oral and written form and to interact linguistically in an appropriate and creative way in a full range of societal and cultural contexts including education and training the workplace home and leisure it is predicted that students who are not communicatively competent in their mother tongue will fail other courses as well in view of the fact that turkish is the medium of instruction in schools where the medium of instruction is not exclusively specified as a different language in turkey moreover at the time of data collection the preservice english teachers had already taken a variety of courses that encourage teaching english by using it frequently in the classroom with the aim of enabling students to attain communicative competence quite similarly the preservice turkish teachers had taken many courses that underline the significance of teaching accurate and fluent turkish to the students finally the preservice classroom teachers had taken the turkish teaching course which required them to analyse the abovementioned the turkish curriculum for primary schools as part of their undergraduate curriculum thereby the statistical difference between the groups could be interpreted as an outcome of the training they received up until that point the preschool classroom and turkish teachers scores on the awareness of the different cultural backgrounds in classroom were statistically higher than those of the preservice english language teachers the difference in favour of the preservice classroom teachers could be justified with the aforementioned fact that classroom teachers teach the same group of students for a much longer period while english language teachers teach different groups a limited number of class hours for a couple of semesters the preservice classroom teachers scores on the view that students should be aware of multicultural differences irrespective of the classroom composition were statistically higher than those of the preservice turkish teachers this finding could also be justified with classroom teachers relatively higher desire to get to know their students well considering the immediate relationship between recognition of the students and their school success to build an effective teaching and learning environment they need a completely peaceful classroom where the students respect each other and no conflicts arise due to sociocultural differences among them all teachers need these learning environments and are aware of their significance for effective teaching but seemingly the preservice classroom teachers who participated in this research attached more significance to that awareness most probably because they will work with a particular group of students for longer periods unlike the preservice turkish teachers who will teach only a couple of hours to various groups for quite short periods the preservice classroom teachers attitudes towards multicultural education were statistically higher than the preservice english language teachers this could be interpreted as them being more prone to fulfil the requirements of multicultural education and are more aware of the cultural diversity of the places they will be teaching they could also be more aware of the globalizing world where countries are forced to design their educational policies by taking into consideration the characteristics and needs of students from different sociocultural backgrounds this higher awareness might be attributed to the fact that classroom teacher training programs are attended by more foreign students than english teacher training programs this might have raised consciousness of the preservice classroom teachers about the significance of knowing the cultural background of their students for effective teaching by offering them a kind of firsthand experience responses to openended question in order to support the statistical analysis the participants conceptual perceptions of multicultural education were elicited and analysed in a semiqualitative and frequencybased manner the preservice teachers metaphorical understanding of multicultural education may influence their future teaching activities in the present study therefore a question that required them to report the first three words that come to their mind when they think of the term multicultural education was added to the questionnaire most frequent concepts expressed by the participants matching with the notion of multicultural education were calculated to find out their frequency a list of the obtained codes was examined to see a general picture of the conceptual expressions by the preservice teachers as seen in table 5 the overall results revealed some common words by the participants who reflected their cognitive conceptualisation of multicultural education in and between groups when each group is considered diversity and language are the most frequented metaphors used for multicultural education in all groups and the first two in the total group race tolerance and religion are also in the list of the metaphors extensively expressed by the participants to describe multicultural education which overlaps with the study conducted by akçayoğlu and arsal when these outcomes are considered from the perspective of teacher cognition and perception of a teachingrelated concept the preservice teachers have a certain mental conceptualization of multicultural education to some extent it is not surprising that their use of such metaphors that have no direct conceptual link to education and pedagogy as indicated in previous research the preservice teachers studying different majors associate multicultural education with diversity language ethnicity religion and tolerance indicating that they are aware of the reality and the dimensions of multiculturalism though they did not receive a course on multicultural education during their undergraduate education the following are some of the participants responses to the item that required them to define multicultural education in a sentence all in all most of the responses pointed to the fact that it stimulates diversityembracing and variety in teaching while some rare responses called our attention to the problematic side of the concept it is important for future teachers to consider the inner dynamics of the concept of multicultural education and their practitioner role in this form of education in a multicultural society conclusion caused either by immigration or globalization the concept of multiculturalism has been on the agenda of many countries as a necessary term to consider due to the existence of global issues including refugee problems the climate crisis and worldwide financial fluctuations that simultaneously influence various societies while handling the incidents from national or international perspectives multiculturalism holds its position and forces decisionmakers to provide solutions for multicultural communities due to the fact that quality in education for all stands out as one of the global goals even though multicultural education has been a favorite topic in the field of education for researchers and practitioners concrete results of reflections in teacher training or curriculum studies are still in progress the growing interest and the increasing need for a multiculturalist perspective in societies and indeed in education has entailed an opportunity to update teacher training programs content thus providing a step for future teachers to construct multiculturalbased teacher identities three groups of preservice teachers who would probably work in culturally diverse and integrated classrooms were selected as participants whose general perspectives on multicultural education were considered worthwhile to inquire prepared in line with the research objective the first and second research questions interrogated the attitudes of preservice teachers towards multicultural education and a possibility of meaningful statistical difference among them regarding the variables of gender and major the results indicated that they generally hold positive and promising attitudes towards multicultural education the female preservice teachers relatively better scores could be evaluated as a sign of a need for a more extensive and complete understanding of multicultural education through welldesigned instruction that the classroom teacher candidates obtained significantly better scores than the preservice english teachers might be attributed to the fact that a higher number of foreign students were studying classroom teaching in turkey in addition the findings elicited from the participants cognitive conceptualizations of multicultural education showed that they mostly associated it with the concepts of diversity and language which constitute two dimensions of multicultural education furthermore most of the descriptions they offered for multicultural education comply with the formal description of the concept proposed by banks as an equal learning opportunity for all students regardless of gender race or other cultural features that is the current training they receive provides a motivating and opentoimprovement impression for their future jobs which is an expected learning outcome for such programs with more multicultural instruction that meets the need for constructing a more global and humanistic understanding the preservice teachers could be supported to become more global and multicultural teachers or namely 21st century teachers the present study was limited to the investigation of the attitudes of three groups of senior students studying at different teacher training programs in turkey towards multicultural education it might be furthered with the participation of a higher number of preservice teachers studying in other majors such as preschool education math teaching and psychological counselling and guidance through different data collection tools such as interviews author details muzaffer pınar babanoğlu mersin universityturkey email id reyhan ağçam kahramanmaraş sütçü i̇mam university turkey email id

this study attempts to investigate the attitudes of preservice teachers towards multicultural education senior students studying in three different majors namely english language teaching classroom teaching and turkish teaching were administered a questionnaire that comprised of likerttype statements measuring their attitudes and openended questions interrogating the metaphorical conceptualization and description of the concept of multicultural education the general scores of the participants are positive and high with female participants have considerably better scores in certain statements the cognitive conceptualizations of multicultural education by the participants indicate a diversity in language terms as most were associated whereas descriptions of the concept display a synonymous sense with ones in the related literature though participants do not receive formal instructions about the concept

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introduction in brazil the atlantic forest is one of the most biologically diverse ecosystems responsible for harboring a large number of endemic species 12 it extends from rio grande do norte to rio grande do sul 3 and given its location in the coastal area is currently under strong pressure from real estate speculation in addition there are the pressures generated by timber extraction the cycles of sugar cane coffee and gold and more recently the expansion of farming and forestry with exotic species human populations living in the surrounding areas of the atlantic forest play an important role in its exploitation as they often rely on forest resources for their subsistence and extract biological resources from it on a daily basis 4 understanding how these people use such resources is a task of great current interest which may contribute to the discovery of products of economic interest and to the conservation of biological resources thus ethnobotanical studies can contribute to assessing how local knowledge is distributed among members of a community and the relationship between that knowledge 2 evidencebased complementary and alternative medicine and the increase of exotic species in the local repertoire of medicinal plants 5 6 7 common knowledge about plant resources especially medicinal ones is highly dynamic and subject to several influences may vary according to gender age education level income roles that individuals play within the family skills and abilities 8 9 10 11 and may represent key elements of the knowledge of the diversity and richness of species 12 different social patterns have been reported to impact the knowledge of medicinal plants emphasizing the need of studies that address such questions for instance almeida et al 13 did not observe any differences between the knowledge of men and women whereas age and income were correlated with the number of citations for a given plant and its indication suggesting that older people with a higher income had greater knowledge about such plant resources thus the goal of this study was to assess the intracultural knowledge of the use of medicinal plants in an urbanrural community in an atlantic forest fragment in northeastern brazil in order to document the importance of native and exotic species within the group of plants mentioned and the effects of gender and age on the knowledge of medicinal plants and to compare the quality of information gathered from different groups of informants materials and methods study area the study was conducted at igarassu located in the microregion of itamaracá and the mesoregion of recife in pernambuco state 30 km from the state capital 14 15 16 the climate is tropical hot and humid with autumnwinter rains the average annual temperature is 27 • c and the average annual rainfall is approximately 2000 mm 14 15 16 the municipality has a total area of 3042 km 2 with a population of 72990 people 749 of which live in urban areas 14 the predominant vegetation is composed of remnants of atlantic forest secondary forests mangroves palm trees and areas of commercial and subsistence agriculture there are ecological reserves in the city such as the são josé plant forest with tall dense vegetation located on transcanavieira highway and with an area of 32330 ha 17 the community studied is known as três ladeiras and is located on the lands of the são josé plant a sugar refinery the são josé plant is surrounded by atlantic forest fragments belonging to an ecological reserve 18 the forest is part of the conservation area of the botafogo river basin in accordance with state law no 9860 which since august 12 1986 has been aimed at protecting the landscape soil and river basin 19 the fragments occupy a total area of 210 ha 18 the community lies 30 km north of the county seat and is located at the back of a large hill whose extension contains three elevations that give the community its name the district has 1794 inhabitants of which 1077 live in urban areas and 687 in rural ones 20 most men from the community work at the plant although the number of people employed by the refinery oscillates during the year increasing and decreasing according to season and periods of land preparation planting and harvesting 15 it is not unusual to find among the residents of the community families with small fields that provide nutritional andor economic support during periods when there is no work at the plant 15 there is no sanitation medical care takes place in a health clinic for minor health problems and disease control is provided by health workers through weekly home visits patients who require extra care are relocated to hospitals in the county seat of igarassu data collection ethnobotanical data were obtained through the freelist technique followed by semistructured interviews 21 the interviews were conducted with the senior member of the family over 18 years old present on the visit of the interviewer initially we obtained a term of informed consent from those willing to participate in the study in accordance with the legal and ethical aspects of resolution 19696 from the ethics and research committee 22 because the community had a large number of residents we sampled 51 of all households and conducted 194 interviews between june 2007 and january 2008 the age of informants ranged from 18 to 93 years for the interviews one main question was asked what medicinal plants do you know in a second event we gathered information on each species mentioned the part of the plant used the method of preparation its indication and contraindication as well as socioeconomic data from informants such as gender age family income and number of residents in the household ages were grouped into five different groups ranging from 18 to over 68 years we used the data obtained in this study and in the work of gazzaneo et al 15 to compare the information obtained from the general community and local experts respectively the latter study was conducted in the same community in 2003 and was attended by six informants identified as local experts given their more detailed knowledge on the use of medicinal plants 23 this group of informants was composed of three men and three women with ages ranging from 51 to 102 years the data sampling performed by gazzaneo et al 15 was intentionally nonrandom and assumed that local experts provide more specific highquality information about medicinal plants to select this group of informants the authors used the snowball method 24 data were collected using semistructured interviews that gathered information related to the knowledge of medicinal plants species categorization and indications mentioned by informants all plants mentioned during interviews were identified and classified as either native or exotic species according to their biogeographical origin we considered native species those endemic to the study region and also native to south america exotic species were considered to be those of extracontinental origin cultivated in the region and widely distributed such as tropical invasive and cosmopolitan species to calculate the relative importance of species all indications mentioned by the informants were grouped into 18 disease categories according to the classification from the world health organization 25 digestive respiratory gynecologicalurinary circulatory nervous sensory motor puerperium cutaneous scarring poisoning neoplasia hematopoietic nutritional infectiousparasitic sexual inappetence and antiabortion and postpartum diseases not categorized by the aforementioned system were grouped into the category undefined ailments and pains by virtue of their symptoms and signs of multiple origins 26 all species mentioned by informants excluding those commercialized were collected identified and deposited in the herbaria of professor geraldo mariz at the federal university of pernambuco professor dárdano de andrade lima at the agricultural research company and professor sérgio tavares at the federal rural university of pernambuco data analysis we calculated the value of relative importance for all species 27 with the following formula ri nbs np where nbs is the number of body systems treated by a particular species divided by the total number of body systems treated by the most versatile species and np is the number of attributed properties of a particular species divided by the total number of properties attributed to the most versatile species the chisquared adherence test was used to check for differences between the following factors number of native versus exotic plants and number of plants observed in each life form we also compared the richness of exclusive species between different age groups richness of families total number of mentioned species and number of exclusive species between local experts and the general community we used the kruskalwallis nonparametric test to test for differences in the richness of ethnospecies and mentioned indications between men and women and between each age group and to check for differences between the relative importance of species mentioned by local experts and the general community we used williams gtest to compare the proportion of the number of native and exotic species mentioned by local experts and the general community the spearman correlation test was applied to check for the relationship between the number of ethnospecies and the number of mentioned indications according to the age of the informants and to check for a relationship between relative importance of species mentioned by the general community and the ri calculated for local experts all statistical analyses were performed using the statistical package bioestat 50 28 results richness of medicinal plants mentioned by informants in total 209 ethnospecies were mentioned during interviews 151 were identified to the species level and 21 to the genus level only the plants were distributed in 74 families and most families were represented by up to two species the most represented families were lamiaceae caesalpiniaceae and curcubitaceae asteraceae euphorbiaceae and mimosaceae with respect to the origin of the identified species we observed that 89 were exotic and 62 were native and the difference was statistically significant that result indicates that informants knew more exotic plants that could be used for medicinal purposes with respect to the life form of plants there was a predominance of herbs followed by trees and shrubs but we only observed statistical differences when we compared the richness of shrubs with that of herbs and trees the number of herbs and trees was not significantly different indicating that the richness of herbs and trees was similar in the pool of plants mentioned by informants however when considering the distribution of species according to their origin we observed a different pattern for exotic plants there was a higher number of herbaceous plants compared to the other two life forms whereas for native plants there was a higher number of trees the most mentioned species were schinus terebinthifolius raddi alpinia zerumbet b l burtt r m sm pithecellobium cochliocarpum macbr plectranthus amboinicus spreng mentha piperita l and cymbopogon citratus stapf except for s terebinthifolius and p cochliocarpum all these plants are exotic emphasizing the importance of exotic plants to the knowledge of medicinal plants in the region influence of gender and age on the knowledge of medicinal plants there were significant differences in the knowledge the number of plants and indications mentioned by each informant correlated with their age however when we compared the average number of ethnospecies and indications in each age group we observed different patterns the number of known plants only varied in informants from the 1828yearold age group suggesting that the richness of known plants was smaller in younger participants which may reflect the limited experience and contact of young informants with plant resources from the region although informants aged 4958 years old had greater knowledge of medicinal plants in the region they were only significantly different from younger informants with respect to the number of indications mentioned in each age group we observed a similar pattern to the previous one with younger informants knowing a smaller variety of indications however the knowledge of informants was significantly higher for the age groups 4958 years old and older than in other age groups when we analyzed the influence of gender and age on the distribution of knowledge we observed a few patterns that often differed from the data presented by the general community younger women also had less knowledge of the richness of medicinal species while in other age groups knowledge was homogeneous for women we observed the formation of two groups regarding the number of indications one group consisting of the three younger groups with a lower number of indications and the other consisting of older age groups with a higher number of indications for men knowledge of plant richness and indications showed a different pattern the knowledge of informants in the 1848yearold age groups did not present any statistical differences that difference only appeared in the age groups 4958 years old and older indicating an increase in the number of species known and the variety of indications occurring only in older age groups whereas for women it was also observed in younger age groups we observed a continuous increase in the number of ethnospecies mentioned with an increase in age for both men and women when total plant richness was considered up to the age group with the highest richness of plants mentioned in subsequent age groups plant richness started to decrease among women the 4958yearold age group had the greatest knowledge of plants whereas for men the greatest knowledge of plants was observed in an older class these results indicate that in the community of three hills the commitment of women to family care compels them to know from an early age a large number of plants with medicinal purposes following the age groups with a higher number of plants there was a decrease in plant richness in older groups evidencebased complementary and alternative medicine possibly related to memory loss which is common among older people we did not observe the same pattern when the mean number of plants mentioned by informants was analyzed as previously noted in this case people still mentioned a high number of citations even in the oldest age group exclusive species were mentioned in all age groups with a total richness of 78 exclusive species distributed in the six age groups the 4958and 5968yearold age groups stand out for their higher richness although there were no statistical differences in the number of exclusive species between age groups indicating that in every age group informants had a repertoire of exclusive plants that was not shared by people from other age groups analysis of the knowledge of medicinal plants between local experts and the general community data obtained from the general community presented a higher richness of plant families and medicinal species when compared with data obtained from local experts the difference was highly significant for total species richness and exclusive species richness but was not significantly different for the richness of plant families the results indicate that the knowledge of local experts managed to represent the richness of useful plant families cited by the general community but not the total number of species however the most species mentioned by at least 20 informants from the general community were also mentioned by local experts this result indicates that expert informants mentioned medicinal plant species that are better known among other members of the community the numbers of exotic and native species mentioned by local experts and that by the general community were not significantly different according to williams gtest among exclusive species we also did not observe any significant differences between native and exotic plants suggesting that local experts and the general community presented a similar citation repertoire of native and exotic species there was no significant difference between the relative importance of species mentioned by local experts and that by general community we observed a significant correlation between local experts and the general community in the number of indications per species according to the spearman correlation test this result suggests that local experts and the general community provided similar information regarding the indication of medicinal plant species among the ten species with higher ri mentioned by local experts and the general community the species borreria verticillata l g mey hymenaea martiana hayne mentha piperita l pithecellobium cochliocarpum macbr and schinus terebinthifolius raddi occurred in both studies these results show that using local experts to provide information on the indications of medicinal plants was useful in the given context however the same was not observed for data on species richness thus we recommend engaging the whole community to gather such data such precaution may prevent a large number of known species from being neglected as in our study discussion richness of medicinal plants mentioned by informants the study showed high diversity in the knowledge of medicinal plants with significant results for species prescribed for basic health care the acceptance of folk medicine and the limited access to public healthcare services in the community may be factors contributing to the knowledge of medicinal species in local medical practices a few plant families prominent in this study such as lamiaceae and asteraceae are reported as very diverse taxonomic groups in the literature their high diversity probably reflects a greater amount of bioactive compounds 29 which may explain their prominence in this study and in similar ones in other regions 3031 most medicinal plants used in the study area are exotic herbs that usually grow in anthropogenic areas such as agricultural fields gardens and roads other studies performed in forest environments in different regions have shown that traditional communities select anthropogenic areas as important resource sources 32 33 34 35 36 the frequent citation of herbs in the community of três ladeiras may be a consequence of the importance of this life form in anthropogenic areas also due to the presence of strong bioactive compounds in a study conducted in the same community gazzaneo et al 15 also reported that more of the medicinal plants used by experts were herbs collected mainly in the backyards of homes and small farms according to voeks 37 weeds are often abundant in easily accessible places and rich in bioactive compounds and as a result they are widely represented in tropical medicinal floras influence of gender and age on the knowledge of medicinal plants women had greater knowledge of medicinal plants when compared to men in the community studied that result was probably due to women being the caregivers for their families a trend also observed in other studies 5 38 39 40 this scenario may also reflect the different activities performed by men and women in the community because the latter must dedicate themselves to their homes and families which help them assimilate the knowledge they will need to keep their homes healthy at an earlier age we should add that most species from the list of mentioned plants were exotic and herbaceous plants that are found in places women are more familiar with such as backyards the study showed that young informants had less knowledge of medicinal plants when compared to older ones which can be attributed to a lack of interest in learning and practicing such knowledge in younger generations who are increasingly influenced by modernization several studies have reported similar results 38 41 42 43 44 45 it is also important to notice that older people are more experienced and have had greater contact with plant resources and time to exchange knowledge with other informants from the region moreover older people are more often affected often by various illnesses which may help to increase their repertoire of plants and indications in addition they are responsible for preparing home remedies for themselves and for younger people favoring the retention of knowledge and prompting younger individuals to use the plant resource without necessarily having knowledge of the remedy or its preparation analysis of the knowledge of medicinal plants between local experts and the general community this research showed that studies focused on experts can generate useful information with a satisfactory level of reliability but these are eminently suitable for quick diagnosis about the knowledge and use of medicinal plants in a community that approach has the advantage of minimizing costs and time evidencebased complementary and alternative medicine when collecting ethnobotanical data in the community surveyed however studies aiming to gather such information in greater detail should ideally engage other members of the community that may prevent a large number of known species from being neglected vandebroek 46 reports that the careful selection of informants is a key task of the ethnobiologist and cannot be a simple step the author suggests that for a scientifically rigorous research should be involved as many participants as possible but if time is really a limiting factor it is necessary to select key informants who have a high degree of knowledge about plants in the region as well as a high level of consensus with others within this scenario the association between both groups of informants is also possible 45 46 47 in fact the information gathered from key informants in those studies helped prepare semistructured forms and consensus analyses among informants in some cases local experts are used as facilitators for data collection accompanying the researcher during interviews with other members of the community these studies serve as examples of the advantages and limitations of different informant profiles and emphasize the importance of clearly establishing the goals the researcher hopes to achieve to best engage the most appropriate informants it should be noted additionally that there was a fiveyear interval between the data obtained from local experts and the general community the influence of such a gap could not be measured or controlled given the sampling design of each study and the dynamic character of human knowledge and this limitation restricts the possibility of extrapolating the considerations discussed here moreover we could not completely rule out the possibility that the socalled local expert informants have been added to the sample of the present study

this study assessed the intracultural knowledge of the use of medicinal plants in an urbanrural community in an atlantic forest fragment in northeastern brazil we examined the importance of native and exotic species and the effects of gender and age on that knowledge we also compared data obtained from different groups of informants local experts and general community we conducted 194 interviews between june 2007 and january 2008 using the freelist technique and semistructured forms to collect ethnobotanical data information obtained from the community was compared with that from six local experts who participated in a survey in 2003 from a total of 209 ethnospecies exotic and herbaceous plants presented higher richness with respect to the number of citations women and older informants were shown to know a higher number of medicinal plants comparing knowledge of local experts with that of the general community we noted that experts know a similar wealth of plant families and therapeutic indications but the community knows a greater species richness these results indicate that local experts may provide useful information for studies that search for a quick diagnosis of the knowledge of a given community

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introduction social science researchers engaged in primary data collection often consider a range of ethical issues during planning but rarely discuss them in published articles we believe that building explicit steps for considering and discussing ethical issues can lead to better research better communications about research and thus better impact of research as wellwe propose a structured appendix to accompany social science papers that report on primary data collection efforts we believe that sens capability approach provides a useful framework to inform a structured appendix as it focuses on peoples opportunities to set and achieve activities and goals for themselves this framework along with rawls is familiar to most social scientists and applies to both participants and affected nonparticipants we acknowledge the diversity of life goals across people but there is a higherorder common requirement to have the capabilities to set and pursue those goals ethical research should be designed to generate socially valuable information to advance these basic capabilities while protecting the basic interests of participants this requires research protocols not only be procedurally ethical as per international research standards but ethical after considering specific contextual factors such as cultural gender and local institutional norms london starts from a principle of equal concern that every participant is the moral equal of all members in the community and derives several operational criteria that serve as guideposts for this paper and proposal these include the avoidance of unnecessary risk special concern for the basic interests of participants and social consistency the latter requires that the sum of incremental risks to participants minus their direct benefits must not be greater than the net risks faced by those in other socially sanctioned activities like emergency workers london acknowledges that this calculation is difficult but the moral goal of such judgements is clear the point is to ensure that there is a publicly available justification for the claim that each study participant is treated as the moral equal of every other participant … and of the community members in whose name research is conducted these criteria motivate our proposal that authors include a structured ethics appendix in working papers and published online appendices such information will highlight the substance of the ethical consideration underlying the study and could also be used in grant applications we provide a framework below as a starting point for guidance institutional review boards when present aim to protect research participants but ultimately examine a narrow set of ethics issues there are no ethics review boards with a mandate over all ethical issues in research indeed a broad range of important ethical issues pertaining to primary data collection research and especially randomized controlled trials and are outside the purview of irbs such issues often left to selfregulation and peer review during grant applications and publications deserve more thorough reflective consideration active consideration and discussion of these matters can build more consistent norms improve the philosophical consistency of the norms and also improve adherence to those norms we propose a structured ethics appendix for social science researchers engaged in primary data collection social science writing style is often fairly terse on methods issues in particular information relevant for an understanding of ethical issues many journals require an irb approval number and nothing more this leaves readers to fill in the unstated information with potentially incorrect assumptions the shortform nature of some public discussions can then exacerbate misunderstandings the proposed appendix is not a checklist instead it is a structured but brief set of nine questions which hopefully provide researchers a concise and consolidated platform to spark thoughtful reflection and consideration of ethical issues before a project begins and provide relevant information to readers of completed papers the topics discussed are policy equipoise role of researchers with respect to implementation potential harms to participants or noparticipants from the interventions or policies potential harms to research participants or research staff from data collection or research protocols financial and reputational conflicts of interest intellectual freedom feedback to participants or communities foreseeable misuse of research results and other ethics issues we are writing as economists with experience in primary data collection and design and implementation of randomized controlled trials not as trained ethicists our discussion is undoubtedly albeit unintentionally driven by issues that have arisen in our own work the questions were selected after several rounds of community feedback from social scientists involved in implementing interventions and from a wider online audience we incorporated several suggestions in this version we intend for the appendix to be a means of prompting discussions too often left in the background and offer this as a living document that we and others can improve through use and feedbackthis article accompanies articles on a set of six harmonized randomized controlled trials of community monitoring of common pool resources the trials randomly assigned the introduction of community monitoring to communities community monitoring is a form of governance that aims to improve cpr management in these trials for groundwater surface water and forests the community monitoring was typically introduced by nongovernmental organizations we have no reason to believe the researchers failed to adhere to strong ethical practices however this kind of collaboration between implementing entities and researchers do make salient many of the points we raise points that we believe are better off spoken about explicitly these interventions introduce new governance institutions and thus ethics questions that pertain to potential harm to both participants and nonparticipants the role of the researchers vis a vi the intervention and the implication that has for informed consent and the multiple roles of researchers in organizing reporting and providing feedback on the interventions themselves needs to explicitly discussed policy equipoise and scarcity is there policy equipoise that is is there uncertainty regarding participants net benefits from each arm of the study relative to the other arms and to the best possible policy to which participants could have access if not ethical randomization requires two conditions related to scarcity was there scarcity ie did the inclusion of multiple arms change the expected aggregate value of the programs delivered do all exante identifiable participants have equal moral or legal claims to the scarce programs freedman argues that the therapeutic obligation of doctors generates a clinical equipoise ethical requirement for medical trials the expert community must not have certainty that any arm in a trial is better therapeutically than any other arm 2 for social science in particular the word certainty can render such a requirement toothless just note that even theories with strong empirical evidence will have some level of uncertainty regarding their applicability in a new context furthermore in many cases one treatment arm clearly dominates another from the perspective of the participants yet the better treatment arm is not viable as a policy for all either due to scarcity or other practical or political issues a study testing the returns to a large cash transfer is a perfect example yet evidence from the better treatment arm still serves an important social value even if limited to the generation of abstract knowledge this renders the concept of clinical equipoise wrong for social science experiments is there a similar obligation for social scientists organizing or participating in rcts mackay building on the same principles as london argues persuasively that a sufficient requirement for ethical randomization is policy equipoise we have adopted that view here policy equipoise builds on clinical equipoise but considers resource tradeoffs explicitly two arms of an rct are in equipoise when there is meaningful uncertainty about the efficacy of each arm in achieving the relevant outcomes of the study for all participants policy equipoise requires that all arms of the study be in equipoise with each other and with the best proven morally and practically attainable and sustainable alternative policy for achieving improvements in the relevant outcomes of the study each of those words in quotes carries weight proven implies scientific consensus clearly this is not a strictly binary concept but rather about the degree of certainty of relevant experts and stakeholders and what is proven in one time and place may not be so in another this also relates to what is meant by meaningful uncertainty naturally no amount of social science research will render judgements that are perfectly certain rather by meaningful uncertainty we mean a degree of uncertainty deemed important and likely enough as to make reasonable and informed stakeholders disagree on the optimal policy morally … attainable requires that the alternative policy be consistent with individuals rights and liberties practically attainable means that the government or implementing agency has the resources to put the alternative policy into effect sustainable means that the government or implementing agency could maintain the policy given a just system of resource procurement and allocation the policy equipoise requirement is a sufficient condition for randomization but it is quite strict first no participant in any arm of an rct can be predicted to be better or worse off than he or she would be under any of the other arms of the study second this equipoise must extend to the appropriately defined counterfactual policy which constitutes whatever policy would have occurred in the absence of the research often this counterfactual policy is the current status quo but that need not be the case there may be an alternative policy that is moral practically attainable and for which there is a consensus on its effectiveness or it could be that the current status quo is not itself sustainable we emphasize a key distinction that we agree is important made in mackay that what matters is not what the actual counterfactual policy is but rather what it could be if policy equipoise is not satisfied then randomization can be justified if no participant can be predicted to be worse off in any arm of the study than under the counterfactual policy and if there is scarcity of the resources required for the arms in which participants are better off a treatment arm may be unambiguously the best for recipients but not viable as a systematic policy for all the simplest example here relevant in social science would be large transfer programs it is unethical to withhold this policytreatment unless it is scarce 3 budget constraints can make it impossible to reach everyone with a better costly intervention in which case it may be permissible to allocate access randomly if the second scarcity condition is also met that is if it is not known a priori who should receive that intervention if all participants have equal claims to a scarce intervention then randomization can be ethical if some participants have stronger claims then these participants should have priority rather than being randomized out of access 4we highlight one further component of the above definition of policy equipoise achieving improvements in the relevant outcomes of the study an rct could for example be focused on testing alternatives for reducing child malnutrition a treatment arm could be cash transfers if we were to know that cash transfers create benefits beyond reducing child malnutrition should the nonchild malnutrition outcomes be considered when examining if any treatment arm is viably better than all of the others doing so would require a fullblown multidimensional welfare analysis weighing all ethicallyrelevant outcomes we argue that it is typically sufficient to constrain the comparison of treatment arms to the problem at hand realistically anything that dominated in all dimensions with certainty would likely not be practically attainable we do see merit in this discussion though randomization into different treatment arms therefore is unethical if two conditions are met first there is not policy equipoise and second either the preferred arm does not require resources that are scarce or all participants do not have equal claim to those scarce resources some examples can clarify the requirements of policy equipoise and scarcity karlan et al implements an rct that compares a treatment arm in which farmers are offered cash grants of approximately 400 to a control group this rct violates policy equipoise because there is no meaningful uncertainty among experts that receiving an offer of a cash grant is better for the recipient than not receiving such an offer however randomization remains ethical because of the two principles of scarcity providing cash grants to farmers predictably improves their welfare so the cash grant arm is better than the counterfactual policy of no cash grants however there is no consensus that providing cash grants to farmers as a policy is practically attainable and sustainable given the cost of that policy this meets the first requirement for scarcity nor is there a consensus about which farm households have stronger claims over receipt of cash grants this meets the second scarcity requirement and therefore randomization of access to the grants is acceptable similarly glewwe et al violates policy equipoise there is no uncertainty that eyeglasses benefit those whose eyesight can be corrected by them however there is no consensus that eyeglass provision to school children is a costeffective policy for improving school achievement therefore it was not clear a priori that there was an alternative sustainable policy that dominates the control arm satisfying the first scarcity requirement randomization occurred at the township level and there was no a priori knowledge of which township would benefit most from the intervention satisfying the second scarcity requirement policy equipoise would be violated if there is an expert consensus that an arm of a trial is dominated by another policy that is proven attainable and sustainable a hypothetical but realistic example of a violation of policy equipoise would occur if a government with sufficient resources for a national program agreed to withhold a progresainspired conditional cash transfer from some households for a pure control group in an rct 5 in this hypothetical case the first scarcity requirement also fails because the government is presumed to have sufficient resources to make the cct available to more households so this randomization is unethical consider a potential research project studying the effect of mobile money transfers on food security during a drought with a control group receiving nothing and a treatment group receiving the transfers while policy equipoise is violated because the transfers can be expected to improve food security the first scarcity requirement is met due to the budget constraint of the project however if the researchers know a priori through say remote sensing data which households farms were particularly affected by the drought the second scarcity requirement may be violated the most affected farmers should be prioritized for transfers rather than randomized into treatment or control 6 thus such a proposed randomization raises an ethical red flag researcher roles with respect to implementation are researchers active researchers ie did the researchers have direct decision making power over whether and how to implement the program if yes what was the disclosure to participants and informed consent process for participation in the program providing irb approval details may be sufficient but further clarification of any important issues should be discussed here if no ie implementation was separate explain the separation in social science the role of the researcher is quite varied and this has important implications for what may constitute ethical research on one end of the spectrum the researcher is merely the evaluator with neither influence over nor responsibility for any of the interventions in such an instance understanding the ethics of the intervention may even be the motivation for the research then with more evidence on deleterious effects of the intervention perhaps such policies can be altered or eliminated 7on the other end of the spectrum the researcher is the implementer in such cases the researcher for example secured funding hired staff decided the design of the intervention and directly implemented it in this case it goes without saying that the researcher is responsible for the ethics of the intervention itself the researcher is changing the world not merely through the dissemination of results of the research but deliberately through the research process itself even when the researcher is active however it may still be ethical to implement arms which raise valid ethical concerns but certain criteria ought to be met first there must not be a consensus among the relevant expert community about the outcomes that raise the ethical concerns second the policy or intervention must be commonplace enough that assessing the intervention is of high social value in these instances the onus is on the researcher to establish policy equipoise or explain why scarcity limits the extension of expected beneficial arms to the entire population as discussed in section 1 and mackay two recent examples in social science highlight the importance of this distinction and also point to the complicated nature of defining the researchers role in some instances in bryan choi and karlan researchers collaborated with a nonprofit organization in the philippines which ran a fourmonth program that included various secular activities alongside weekly meetings with a pastor that covered an evangelical protestant curriculum to understand the impact of the protestant curriculum on individuals and their households the nonprofit organization agreed to randomize across villages whether or not the protestant curriculum was included in their program the research did not lead to an increase or decrease in the quantity of sessions conducted nor the number of people reached by the program of note there is no consensus on the impact of such programs and they are commonplace in the world thus we argue that there is positive social value in evaluating claims of impact or harm and no ethical quandary for the researchers in kenya researchers from universities as well as the world bank collaborated with the nairobi water and sewerage company a kenyan utility company regulated by the government of kenya the researchers engaged with the utility company over several years working broadly and collaboratively in order to increase access to water and sanitation services coville et al reports on this collaboration specifically on an experiment in which one of the treatment arms threatened tenants with having their water access shut off if the water bill was not paid by their landlord while one could debate the ethics of that intervention arm as a policy we would argue that if the researchers unambiguously have no active role then such a discussion is important and worthwhile but should be discussed as an ethical consideration for the utility company not the researcher suppose counterfactually that the utility company was already shutting off water of tenants whose landlords had not paid and researchers worked with the utility to organize an rct that shielded some from being shut off this version of the trial is identical to that described above however because the status quo policy potentially infringes on important human rights the ethical issues may make this more important to study ultimately this study also highlights potential ambiguity on the binary categorization of active if a researcher suggests a treatment arm for example does this make them responsible for its ethics even if the researcher has no actual power over the decisions putting ethical onus on the researcher could be construed as ignoring the autonomy and agency of the local policymakers however researchers should acknowledge their role in influencing policies and decisions particularly in longstanding and complicated collaborations and thus take ethical responsibility for any such influence we argue that more transparency on this role would be fruitful for social science so that norms can be better developed on this question extreme examples however render this distinction meaningless for example research ethicists share a common consensus that medical data from experiments conducted on prisoners in nazi concentration camps cannot now be used to answer medical research questions but even if one believes the vietnam war was unethical using the lottery draft to study the impact of military service on later earnings is easily defendable as ethical perhaps one key distinction is the purpose of the original implementation because of the incentives created for researchers if the original implementation was being done for the sake of research then allowing future researchers to use such data creates perverse incentives to implement unethical research however when the original implementation was natural or reservation of village leader slots for women then we argue that use of such variation is valid ethically even if there are objections to the underlying policy we highlight two broad issues first despite best efforts irbs are unable to fully oversee all aspects of potential harms to participants and local knowledge in particular is invaluable and at the mercy of selfregulation second potential harms to nonparticipants is itself a topic of high interest to researchers on substantive levels but thus also carries important ethical considerations ethical guidelines for research on human subjects are primarily concerned with protecting study participants protocols typically expect researchers to highlight the benefits and risks of participation confidentiality protocols compensation and instructions for withdrawing from the study at any stage while in theory irbs strive to consider all such issues in reality irbs particularly ones from a different culture are not always informed enough to raise or adjudicate on them ultimately the responsibility of the researcher extends beyond mere irb approval we emphasize as well that harms extend far beyond mere monetary harm in particular for example for marginalized populations such as women in many cases that may be engaged in nonwage labor cultural norms and nuances of the implementation may pose potential harms to participants that are beyond the viable purview of the irb for example we have experienced in ghana and nigeria cultural norms or misinterpretations of implementation activities that have led participants to be perceived as being superior or to suffer stigma or discrimination which were mitigated by providing additional information or community discussions if not addressed such perceptions can boost or harm the reputation of participating households which may have implications for their social and perhaps economic lives elected community leaders in participating communities may suffer abuse and intense competition from political rivals as interventions are sometimes perceived vehicles for local leaders to maintain political power when deemed plausible projects ought to integrate mechanisms to deal with such issues while informed consent and irbs are primarily concerned with study participants research may also pose harm to nonparticipants the national bioethics advisory commission of the us asserts that regulatory oversight for research with human subjects extends beyond the protection of individual research participants to include the protection of social groups the potential effects on nonparticipants become especially salient when researchers are actively engaged in interventions it is therefore important to evaluate the scope and intensity of risks that are likely to impact nonparticipants in some cases communitylevel consent may be appropriate we highlight two examples in which nonparticipants are affected and discuss the ethical implications 8ashraf et al conducts an experiment in zambia on womens bargaining power and fertility in one arm women were given access to contraceptives alone and in the other with their husbands since both arms of the trial have implications for a nonparticipating husband in terms of childbearing outcomes should there be householdlevel consent for both arms in this case no because obtaining such household level consent could trigger domestic violence womens control of their reproductive decisions is a basic human right as is their freedom from domestic violence a womans nonparticipating husband may be affected but her human rights must take precedence second incentivizing students to take part in an antiauthoritarian protest poses a direct risk to participants but also poses risks to nonparticipants engaged in the protest thus if students may reasonably be expected to be rowdier in a protest than nonstudents incentivizing more student participation in a protest increase the risk for the nonstudent nonparticipants of the intervention inasmuch as it is important to minimize the risk for the study participants it is in this case even more critical that the actions of participants do not increase the risk for nonparticipants consideration of risks and benefits for nonparticipants helps evaluate the ethics and establish appropriate mitigation strategies naturally however indirect effects are easy to posit qualitatitively but much harder to confidently predict quantitatively and indeed studying indirect effects is itself a robust research agenda thus we do not argue that the mere posing of a possible indirect effect should render a study unethical rather we suggest considering such issues and as we learn more about them from ongoing research we hope this ethical conundrum can become more evidencebased we acknowledge that there are unresolved issues in expanding ethical considerations to groups which require further discussion and consensusbuilding research risks to communities and nonparticipants suggest that ethical protocols focused on individual research participant protection will be insufficient ethical guidance for research in social science in general and rcts specifically could extend protection beyond mere individuals to social groups ie family members community members etc group implications of identified individuallevel harm can serve as a starting point to identify risk to nonparticipants and should be properly assessed and addressed in an ethics review process working directly with community representatives may prove fruitful to discuss informed consent and develop methods that minimize potential group harms potential harms from data collection or research protocols are data collection andor research procedures adherent to privacy confidentiality riskmanagement and informed consent protocols with regard to human subjects are they respectful of community norms eg community consent not merely individual consent when appropriate 9 are there potential harms to research staff from conducting the data collection that are beyond normal risks the fundamental principle of ethical conduct of human subjects research centers around minimizing the risk of harm and respecting agency informed consent data collection genuine consent is present only when participants have the capacity to fully understand and process the shared information processes for obtaining informed consent differ widely and stated protocols and actual practice may differ field staff may treat consent as a mere formality where the main task is to get the participants approval thus leading field workers to not fully engage participants if interviewer and respondent differ on age education or status levels undesirable expectations may ensue due to perceived power or influence electronic data collection offers paths to oversight eg with time stamps on informed consent and survey components however perfect monitoring is not possible staff training is critical furthermore gifts even minor ones such as soap may have the unintended consequence of distracting from the importance of the informed consent compensating someone for their time on the other hand is also an important principle to respect enumerators are often encouraged to probe during their interviews to obtain more accurate responses while probing can be useful it can also create discomfort be considered intrusive and expose vulnerabilities of the participant there is a fine line between probing and harassment moreover although consent forms provide participants with researcher contact details they may be less likely to contact the researchers when they experience any privacy violations because of telecommunication charges or perhaps perceived language or status barrier informed consent randomization informed consent on the randomization process itself is often not discussed in medical trials partly because the medical professional has a standard of care therapeutics to which each patient has a clear right informed consent on the randomization process is essential to having agency over ones own health decisions however in social science the intervention is often implemented independently from the researchers and informed consent is effectively implied via voluntary participation in an intervention furthermore in social science scarcity often limits the total number of individuals that can receive a certain intervention and the randomization is being done not for research purposes but rather to allocate a scarce resource fairly and with minimal risk of corruption hawthorne and john henry effects are often discussed as threats to internal validity but they each generate ethical issues as well a hawthorne effect is generated when individuals because they know they are in a treatment group behave differently a john henry effect is the analog for a control group a problem ensues if there is an unlucky stigma among individuals leading them to harbor negative psychological effects the analog for a treatment group is potentially more nuanced if for example a treatment participant receives a cash transfer observing jealousy demands for sharing or other such effects are not necessarily a risk to internal validity but rather perhaps exactly the kind of changes in behavior that the researcher seek to learn about the question for ethics is whether the randomization process itself generated such effects over what the transfer itself generates this is difficult to know empirically but is a risk nonetheless when such a risk is deemed likely we suggest a discussion informed consent individual vs community social norms in many developing countries particularly in subsaharan africa raise important issues regarding individual versus group level consent for example often local norms mandate that visitors to communities first meet with chiefs and community leaders explain their reasons for visiting the community and in some cases provide customary gifts such as presenting kola nuts or drinks this level of community consent improves the security of field enumerators and researchers this also may be necessary etiquette for the sake of future researchers so that future enumerators are not greeted with mistrust community consent also could be critical for managing local security risks that may arise aside from issues relating to obtaining individual versus community consent there are other secondary level ethical concerns that projects ought to consider in the process of obtaining community or individual level consent in some settings research projects may inadvertently contribute to creating an expectant culture of participants or facilitate the corrupt behavior of local community and political leaders for example community leaders whose assistance may be required during the community entry or obtaining community consent for an intervention may take advantage of the project to advance their own agenda or illegally take bribes from community members in exchange of providing some service that the project may be providing for free local irbs can prove particularly useful for these issues as they may have better information about the local expectations and norms privacy confidentiality and sensitive information once data are collected the responsibility of ensuring confidentiality of the information gathered rests on the researcher researchers are expected to not betray the trust of participants with respect to data management storage and protection of privacy failure to ensure the confidentiality of the participants may have serious consequences for example revealation of information on the health status particularly sexually transmitted diseases such as hiv or sexual behavior of a participant can cause harm to participants similarly financial data could be used by a financial institution in ways contrary to a clients selfinterest biomarker data which open the possibility of disclosure of genetic information raise the stakes further confidentiality is therefore key to safeguarding and reducing the risk of potential stigmatization of participants especially for a vulnerable population in some cases the potential harm of a lax data management system may extend beyond the individual participant to his or her extended family for sensitive questions discussing the specific survey methods may help both for explaining the adherence to ethical protocols but also to guide future researchers looking to ask similar questions potential harms to field staff ironically risks to field staff are not a consideration for most irbs since they are not research participants yet clearly field staff are often unsung heroes of the research effort without high quality data a randomized controlled trial is akin to an elaborate birthday party without guests 10 but field work does create risks to staff risks range from normal such as road accidents or verbal abuse to extreme such as sexual harassment or political violence pandemics of course pose even further risks to communities in which traveling staff may unintentionally worsen the spread of a disease particularly in situations like covid19 where carriers are often asymptomatic financial and reputational conflicts of interest do any of the researchers have financial conflicts of interest with regard to the results of the research do any of the researchers have potential reputational conflicts of interest financial conflicts of interest reporting policies are similar but distinct across universities multilateral organizations and research conduits such as the national bureau of economic research or the american political science association it is important to report the exante possibility of a conflict of interest so that the research community can judge for itself whether the interpretation of the empirical results was biased in favor of the possibly competing interest these rules become vaguer when the income source and the data source differ but are from the same industry if earning consulting income from bank a and writing a paper with data from bank b does the bank a consulting income need to be reported in the research about bank b ultimately researcher judgement is required to make such decisions the goal of the structured appendix is to report potentially important issues without being a burden reputational conflicts of interest are not addressed by any university multilateral or research organization rules that we have seen but for many researchers idea promotion is a vital selfinterest while money is an interest that is easily defined and typically traceable via contracts and payment records reputational selfinterest is personspecific and difficult to define and trace we thus define a reputational conflict of interest with respect to a particular paper quite broadly when prior writing or advocacy could be contradicted by specific results in the new paper and such contradiction would pose reputational risks to the author taken to an extreme such disclosures could be exhausting we do not recommend that we make a key assumption academically there is no negative consequence to publishing work that contradicts ones earlier work rather here we are referring to reputation outside of academia where a public presence has been built around prior research findings or arguments we provide two examples from our own research first for karlan his paper tying odysseus to the mast evaluates the takeup and impact of a commitment savings product in the philippines he subsequently published a paper on commitment contracts for smoking cessation both find generally positive impacts from the commitment devices subsequent to the above paper karlan started a forprofit company stickkcom that helps individuals write commitment contracts to change some future behavior this company has been written about frequently in the media karlan owned equity when he cofounded stickkcom but has subsequently transferred all of his equity to charitable structures and he receives no financial remuneration from stickkcom as such he no longer has a financial conflict of interest that is reportable per standard university rules but he does have a reputational conflict of interest on the topic of commitment contracts as his work and stickk are often cited in the media as an example of successful nudges a disclosure would be appropriate for karlan on future work related to committed contracts for udry his paper gender agricultural production and the theory of the household finds that households do not achieve pareto efficiency if udry were to have a new paper in which he finds pareto efficiency this would conflict with his prior finding but would not constitute in our opinion a reputational conflict of interest even though his earlier work is commonly cited for testing for efficiency within the household udry has no nonacademic reputation that revolves around that finding lastly coauthorship with nonconflicted researchers and registration of rcts and preanalysis plans both can serve to mitigate reputation conflicts of interest issues because they both tie the hands of the research to some extent neither of course is dispositive the choice of specification and the choice of outcomes could all be biased and naturally the way results are interpreted can be biased thus reporting such conflicts and what steps if any were taken to mitigate could be useful intellectual freedom were there any contractual limitations on the ability of the researchers to report the results of the study if so what were those restrictions and who were they from while reporting of conflicts of interest makes potential biases transparent parties with vested interest may have other means of controlling research output and thus creating bias specifically researchers and collaborators often sign contracts regarding funding intervention plans or data rights if such contracts infringe on the intellectual freedom of the researcher this poses harm to the credibility of the research failure to disclose such conditions could reduce the social value of the research constituting an ethical transgression as such we have included an explicit question on this in the appendix the most egregious infraction is the simplest a contract which provides an external party unilateral power to prevent publication of the results this should be unacceptable to any researcher interested in putting forth credible research but at a minimum if such were the rights of the partner this ought to be disclosed in any and all publications we consider four restrictions to be benign but still worthy of reporting for the sake of completeness permission required to report the name of the collaborating institution a comment commitment collaborating institution can provide comments on the research output and the researchers agree to consider these comments to the best of their judgement a timing commitment the collaborating institution has a right to see the results before others with a specified period of time and proprietary intellectual property the collaborating institution has developed a proprietary technology that is relevant for the research but can only be described broadly without revealing its inner workings we do not assert this to be a complete list of all acceptable restrictions but we are unaware of any others that we consider acceptable a few details regarding researcher independence are important to note • timing matters intellectual freedom must be granted in advance a clause in an agreement which states that this will be decided later is a farce to the concept of researcher independence 11• partial set of coauthors if a subset of the coauthors on an academic paper are conflicted or lack independence then this section of the appendix ought to make clear that the independent researchers had full rights to publish on their own without the conflicted coauthor 7 feedback to participants or communities is there a plan for providing feedback on research results to participants or communities if yes what is the plan if not why not informed consent ultimately is about respect for the agency of an individual as well as their privacy and property rights to their information but often attention to this focuses on the informed consent process recently more attention but still too little has been placed on engaging with research participants local government and communities after the research is complete to further the principles of respect for persons beneficence and justice researchers should consider providing feedback to research participants and communities providing such feedback reduces the likelihood that the participant may feel exploited by the researcher public awareness of research results also may be a stepping stone towards research uptake to improve the lives of poor communities in addition providing feedback also improves the willingness of communities to participate in future research note that in many cases key gatekeepers may have been part of communitylevel consent and as such the feedback may be appropriate to such gatekeepers despite the ideal of providing such feedback there are several practical challenges that often render this aspiration unwise we highlight three budget finding people literacyknowledge necessary to understand the research budget followup visits to all communities can be costly and in some cases these costs can outweigh the benefits of directly providing feedback however with cellphone data and internet access expanding rapidly communicating results of the research to participants could be viable eg posting of information on a website and sending individuals text messages or sending prerecorded video or audio via text message literacyknowledge necessary to understand the research depending on the context and the research study participants may struggle to understand research findings poor understanding of research findings can generate emotional distress for research participants and affect community involvement in future studies therefore providing feedback to participants should not be done solely for the purpose of ticking a box but with genuine engagement furthermore any study with nuanced results may get misused intentionally or unintentionally researchers must examine their context so that proper measures can be taken to enhance understanding of their results we propose that the offer of feedback to participants be included as part of the informed consent processes for social science research although irbs may raise concerns if this offer created undue influence to participate as also argued in the medical literature this process of providing feedback must be designed to provide clear opportunity for the participant to decline receipt of results for policyoriented research it may be effective to provide feedback at a much higher level than at the individual level policy prescriptions often are made at the community district or national level researchers should consider the level at which to provide feedback to be relevant for policy providing feedback to participants may itself affect behavior before implementing such a process the possible adverse consequences of providing feedback should be considered given the complexity of some research a risk is that feedback is conveyed but then misconstrued leading to detrimental actions this concern reinforces the importance of careful communication and thoughtful consideration of the way the results may be interpreted and of course this is a question for research itself does provision of such feedback change later behavior foreseeable misuse of research results is there a foreseeable and plausible risk that the results of the research will be misused andor deliberately misinterpreted by interested parties to the detriment of other interested parties in research settings characterized by strong imbalances of power between interested parties there may be foreseeable plausible risks that a powerful party might use findings from the research in ways that will harm participants or nonparticipants research might reveal a vulnerability of a subpopulation that can be exploited for the gain of a more powerful party if this is the case the researcher has an ethical obligation to mitigate these risks an example might be an innovation in microcredit that research shows is overall profitable for lender and borrower on average however consider heterogeneity first suppose that the microcredit innovation harms a vulnerable and identifiable minority of borrowers second suppose that while the innovation leads to an increase in borrower income it has other psychological or social costs to borrowers that outweigh the income gain for at least some participants in addition suppose there is a foreseeable and plausible risk that forprofit lenders could misuse the average research results to advocate for expansion of the innovation without mitigating the deleterious impacts this observation calls for the research to take steps to address the possibility of such misuse of the research results by considering such risks exante and incorporating a measurement and communication strategy to ensure a complete and balanced reporting of the results in a context of a repressive or nondemocratic government additional care is required locationspecific research to improve digital identification services in such a context for example raises the possibility that the results could be used for repressive purposes and researchers should consider this possibility when considering and designing their work we use the phrase foreseeable and plausible to limit the scope of this question research findings can be misused in many ways that should not be considered to be the responsibility of the researcher the ethical responsibility of the researcher is to consider harmful uses of their work that are predictable and reasonably tied to the research context conclusion while much has been written on ethics of research we perceive there to be a large empirical research gap broadly we see two categories of empirical research needed documenting contextual factors that render a particular ethical concern critical or negligible and learning field research methods to improve adherence to stated intentions examples of the first category include the following under what circumstances does random assignment generate stigma that harms participants does promising the control group a later service change their behavior now during the observation period of the study examples of the second category include the following how much of an informed consent is understood by participants and what wording and content changes lead to higher or lower informed consent comprehension rates what survey methods and staff trainings are most effective for reducing harm from data collection eg from adverse emotional reactions to sensitive questions when does conducting surveys change later behavior ie a mere measurement effect we hope that the proposed structured ethics appendix will accompany papers and spark further consideration of ethical issues in field research we also would support inclusion of these questions or a subset therein in grant applications furthermore the anticipation of writing such appendices may shape design decisions we have aimed for brevity understanding that anything too burdensome will not be adopted in a public comment period we received several useful suggestions to include further questions we adopted several but not all for example some suggested ex post discussion of actual harms we decided not to include this because those are for the most part covered by irb protocols and we also believe the ethical decisions ought to be adjudicated blind to results otherwise no harm happened could be misconstrued as evidence of an ethical design this risks however that failure to discuss realized harms may thwart improvements in exante reasoning by researchers using similar methods this may be an area that shifts if our proposed guidelines are adopted and adapted we also did not extend the reporting of potential harms to be reporting of potential welfare change although we admire the aspiration we fear that such an inclusion would inevitably require considerable work and untenable assumptions in order to assert furthermore loss aversion in both law and ethics is commonplace lastly we did not include a call to discuss the social value of the research with respect to potential policy although this is an important consideration and articulating the policy implications may improve the researchtopolicy nexus we believe this would be too burdensome if addressed more robustly than merely regurgitating points made in most paper introductions we did not receive any suggestions for items to remove although a common suggestion was to make this shorter to increase participation and impact supporting appendix structured ethics appendix questions brief explanations policy equipoise is there policy equipoise that is is there uncertainty regarding participants net benefits from each arm of the study relative to the other arms and to the best possible policy to which participants could have access if not ethical randomization requires two conditions related to scarcity was there scarcity ie did the inclusion of multiple arms change the expected aggregate value of the programs delivered do all exante identifiable participants have equal moral or legal claims to the scarce programs if there is no reasonable expectation that one arm of the study produces more benefits to participants than any other arm or than the best possible alternative policy then randomization is ethically unproblematic if not then excluding some participants from the superior treatment arm can only be justified by scarcity scarcity conditions are twofold resources are not sufficient given constraints to include all participants in the superior treatment arm no exante identifiable participants are excluded from the superior arm and have a greater claim to those resources than any participant assigned to the superior arm see mackay for more complete discussions of policy equipoise 2 role of researchers with respect to implementation are researchers active researchers ie did the researchers have direct decision making power over whether and how to implement the program if yes what was the disclosure to participants and informed consent process for participation in the program providing irb approval details may be sufficient but further clarification of any important issues should be discussed here if no ie implementation was separate explain the separation a researcher should be considered active if for example the implementing staff are employed by an institution at which the pi is employed and the staff report either directly or indirectly to the pi at this institution with regard to this project or if researchers control funding for implementation or have direct decisionmaking power over key implementation decisions some key factors that help illuminate whether the researchers are active or not did researchers directly provide any of the interventions or parts thereof to participants did researchers interact directly with participants and implicitly endorse one or more of the interventions 3 potential harms to participants or nonparticipants from the interventions or policies does the intervention policy or product being studied pose potential harm to participants or nonparticipants related are participants or likely affected nonparticipants particularly vulnerable also related are participants access to future services or policies changed because of participation in the study if yes to any of the above what is being done to mitigate such risks it may be important to consider whether the researchers are active or not for this discussion if the researchers are active then they are responsible for the potential harms and thus a robust discussion is appropriate if the researchers are not active then while they may not be responsible for potential harms a discussion of this would be appropriate here there will almost always be some potential harms if nothing else because of complementary investments such as time that participants in an intervention necessarily redirect from one activity to another quantifying these risks and complementary investments may be difficult exante but a discussion of what they are here would help the reader assess their likely importance relative to the potential benefits of the tested intervention also note that measuring any harms expost may be the exact reason for the study particularly when the intervention is common if risks to nonparticipants exist discuss the mechanisms through which the risk arises from the study and provide an estimate of the magnitude of the risk and the probability of harm 4 potential harms to research participants or research staff from data collection or research protocols are data collection andor research procedures adherent to privacy confidentiality riskmanagement and informed consent protocols with regard to human subjects are they respectful of community norms eg community consent not merely individual consent when appropriate are there potential harms to research staff from conducting the data collection that are beyond normal risks example of subquestions to consider as part of the broad question are there any risks that could ensue because of the data collection process or storage eg discomfort to being asked certain questions or breach of confidentiality if so what are the mitigation strategies are there costs to the participant for the data collection process such as their time and if so what is the strategy or rationale for offsetting this cost because these are all issues covered by most irb processes a sufficient explanation for a yes response may be to provide the irb approval numbers for all irbs that have approved the project however if there are particular issues that are important to discuss please do so here harms to research staff could include eg exposure to political violence exposure to unusual levels of a communicable disease mistrust due to lack of perceived lack of community consent or emotional wellbeing from surveying about difficult subject matters this would not include eg traffic accidents 5 financial and reputational conflicts of interest do any of the researchers have financial conflicts of interest with regard to the results of the research do any of the researchers have potential reputational conflicts of interest we define financial conflicts of interest as that used by the researchers institutional guidelines we define a reputational conflict of interest as one in which prior writing or advocacy could be contradicted by specific results pursued in this study and such contradiction would pose reputational risks to the author 6 intellectual freedom were there any contractual limitations on the ability of the researchers to report the results of the study if so what were those restrictions and who were they from this could include for example approval of release of the paper and restrictions on data release but does not include things such as a comment period during which interested parties have a right to review and provide comments prior to release but not to control the outputs of the study 7 feedback to participants or communities is there a plan for providing feedback on research results to participants or communities if yes what is the plan if not why not engaging in poststudy feedback is a way of acknowledging the agency of participants and communities and is thus a desired practice however it may be impractical due to costs timing challenges communicating the results or potential harms if such communication may itself change behavior in undesirable ways 8 foreseeable misuse of research results is there a foreseeable and plausible risk that the results of the research will be misused andor deliberately misinterpreted by interested parties to the detriment of other interested parties if yes please explain any efforts to mitigate such risk in settings with strong imbalances of power between interested parties there may be foreseeable risks that a powerful party could use deliberately selected research findings to their advantage and to the harm of participants or nonparticipants including for general public policy for example if the research might reveal the vulnerability of some that can be exploited for the gain of the more powerful party what steps does the researcher plan to mitigate this risk 9 other ethics issues to discuss are there any other issues to discuss

and especially to douglas mackay for comments and discussions the views expressed herein are those of the authors and do not necessarily reflect the views of the national bureau of economic research nber working papers are circulated for discussion and comment purposes they have not been peerreviewed or been subject to the review by the nber board of directors that accompanies official nber publications

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introduction psychosocial factors play a significant role in the decisionmaking process regarding medical circumcision of males several studies have highlighted the impact of these factors on circumcision rates for instance a recent study conducted by smith et al found that cultural and religious beliefs strongly influenced circumcision decisions among males in their sample in this study 68 of participants who identified with specific religious or cultural groups that practiced circumcision opted for the procedure while only 23 of those with no such affiliations chose circumcision this demonstrates how psychosocial factors in the form of cultural and religious influences can sway individuals towards or away from medical circumcision moreover social stigma and peer pressure can also affect circumcision rates a study by johnson and brown reported that adolescents who felt stigmatized for not being circumcised were more likely to undergo the procedure in their sample 42 of participants who reported feeling stigmatized chose circumcision while only 15 of those who did not feel stigmatized decided to undergo the procedure this suggests that psychosocial factors such as the fear of being socially marginalized can drive males towards medical circumcision however its essential to note that the impact of psychosocial factors on circumcision rates may vary by region and culture while some regions may have high circumcision rates driven by cultural norms others may not even if the same psychosocial factors are at play therefore healthcare professionals should consider these factors and their regional variations when discussing circumcision options with patients psychosocial factors exert a substantial influence on the decisionmaking process regarding medical circumcision of males with various trends and statistics reflecting their impact cultural and religious beliefs for instance have consistently been shown to be influential determinants recent data from a study by smith et al indicated that among participants belonging to specific religious or cultural groups where circumcision was a norm a substantial 68 opted for the procedure in contrast only 23 of individuals without such affiliations chose circumcision this finding underscores how deeply rooted cultural and religious influences can significantly sway individuals toward or away from medical circumcision moreover socioeconomic status has also been linked to circumcision rates as highlighted in a study by williams and brown their research demonstrated that individuals with higher income and education levels were more likely to choose circumcision for their children this socioeconomic disparity is reflected in the statistics where 75 of families in the higherincome bracket opted for circumcision while only 35 in the lowerincome bracket chose the procedure these findings emphasize that psychosocial factors encompass not only cultural and religious dimensions but also economic considerations further complicating the decisionmaking process regarding medical circumcision nevertheless regional and cultural variations exist in the influence of these factors necessitating a nuanced approach by healthcare providers when discussing circumcision options with patients the circumcision of men is a technique in which the foreskin of the penis is removed for cultural religious or medical reasons it is a longstanding custom carried out by cultures all over the world as a male purification rite to promote improved mental and physical wellness factors that put off adult heterosexual males from voluntarily undergoing surgical male circumcision ran the gamut from fear of the pain associated with the process the belief that one has a low risk of contracting hiv the absence of a female companion the lack of family and social encouragement and the choice for a traditional method of male circumcision which has special meaning in some cultures and is seen as a ritual of transition another factor is the prolonged healing period which demands abstinence from sex some participants thought it is too long a period to abstain from sexual male circumcision may be a regular practice in some communities however many cultures do not practice it some cultures strongly opposed the practice due to cultural perceptions studies on noncircumcising tribes or societies have discovered older married people consider themselves not at risk of hiv infection their attitude towards the practices is informed by the fact that they think it is inappropriate for them but it may be more appropriate for younger men to enhance the uptake of consensual medical circumcision for males in this situation it is preferable to present it as a contemporary medical practice rather than a cultural ritual the perception of male circumcision improving sexual performance is another significant facilitator of absorption of consensual medical circumcision of men that is due to notions of masculinity amongst men which is associated with sexual prowess and high selfesteem age also significantly influences how people perceive the uptake of voluntary medical male circumcision highlighting the necessity of customizing the services to meet the demands of various age groups in zimbabwe tanzania and south africa studies were conducted to examine views toward the acceptance of consensual medical circumcision for men among younger males and adolescents the majority of the males in both strata who participated in the survey expressed a strong desire for the adoption of consensual medical male circumcision young teenagers were less likely than their older peers to say that consensual medical circumcision of men was done to protect them from stis and hiv they were more likely to say that encouragement and advice from others was the only factor in their decision to undergo consensual medical circumcision for males no of their age the participants in the study reported that pain during consensual medical circumcision for men was their top concern most areas have the view and attitude that consensual medical circumcision of men or ceremonial circumcision is more socially and culturally acceptable for teens as opposed to adults if the exercise is performed before they become sexually active because of longterm benefits for initiates and the wider public there is a larger chance of achieving a 90 coverage rate for consensual medical circumcision for men among 10 to 14yearolds in priority nations coverage of voluntary medical male circumcision amongst 10 to 29yearolds by the year 2021 another psychosocial issue existing research data suggests that when circumcision is performed during childhood it results in fewer complications when compared to the adults problem statement kenya is amongst six nations in africa grappling with high hiv infections alongside eswatini south africa botswana lesotho mozambique and zimbabwe compelling epidemiological evidence in kenya indicates a robust link between the lacks of circumcision amongst males with a high burden of hiv infections in areas that are traditionally noncircumcising such as turkana spontaneous surgical male circumcision is intended to be part of a comprehensive hivaids prevention scheme in kenya due to its costeffectiveness coupled with structural and behavioral strategies this has led to calls for optional medical circumcision of males to be taken into account as an intervention strategy to lower the rate of hiv in significantly impacted places like turkana and luo nyanza where men circumcision is not customarily done and hiv transmission is primarily heterosexual according to kenya county hiv estimates data extracted from the turkana county government database the county has an hiv prevalence of 4 despite significant attempts there hasnt been much success in turkana county in spreading awareness of voluntary medical male circumcision therefore as part of a thorough and detailed prevention of hiv initiative in turkana county it is necessary to increase the adoption of consensual medical circumcision for males coupled with organizational and behavioral strategies methodology the study used a qualitative crosssectional research approach to examine the psychological and knowledgebased elements that affect males in turkana county in using elective surgical circumcision procedures the study focused on turkana men in the loima turkana north and turkana central subcounties of turkana county who were 15 years of age and older this is due to the high incidence of hiv in these areas and the low prevalence of consensual medical circumcision of men both used a random selection method and purposeful sample technique the sample size was 434 respondents the study used both qualitative and quantitative data data was collected questionnaires interviews and focused group discussions spss version 23 was used to conduct the analysis the findings were presented in form of figures and tables results psychosocial factors on the uptake of voluntary medical male circumcision according to the study a number of psychosocial factors influence whether consensual medical circumcision of males is performed at medical institutions particularly 676 of the respondents concurred that the level of uptake is influenced by a persons attitude about circumcision furthermore 532 of those polled thought that the acceptance of consensual surgical circumcision for men was influenced by selfesteem the study also showed that 577 of the participants thought that the way the community views individuals who have had circumcision can affect whether or not vmmc is adopted some of the participant agreed that motivation by males to undertake voluntary medical male circumcision is influenced by their spouses and communal support 628 the overall mean score indicated that psychological factors under this study had positive influence on the vmmc uptake as the mean score was 3602 1024 2534 and 3550 differences between the circumcised and uncircumcised based on psychological factors the psychological variables that affect both circumcised and uncircumcised participants acceptance of consensual surgical circumcision for males were compared using an independent sample ttest in terms of their opinions about other people and their motivation to participate in vmmc the circumcised and uncircumcised participants showed statistically significant differences and similarities respectively according to the study however there was no statistically significant difference in the participants attitudes about circumcision or level of feelings of worth between those who had been circumcised and those who had not the process of embracing male circumcision can have a negative status on the life of persons circumcised in turkana society vmmc is viewed by most of the turkanas as a foreign practice which is common among other tribes for instance turkana men who have embraced circumcision are often viewed as outcasts amongst the traditionalists cultural beliefs and traditions run deep this means that those who go against our traditions may be considered as outcasts the perception and attitude of those who have undergone consensual medical circumcision for males by the community has a significant effect on their standing in society the level of selfesteem in a person is an important factor in influencing whether or a man chooses to undergo voluntary medical male circumcision relationship between psychosocial factors and uptake of vmmc the link between vmmc adoption and psychological variables was evaluated using a correlation assessment test the findings indicated that the perception of people who have undergone circumcision by community positively influenced uptake of vmmc besides the motivation by males to undertake vmmc positively influenced the uptake of vmmc table 3 presents this information ho there is no significant influence between uptake of vmmc and psychosocial factors based on the results null hypothesis was rejected qualitative results psychosocial barriers negative vmmc perceptions three out of the six key informants interviewed stated that one of the barriers towards the uptake of surgical male circumcision done voluntarily was a negative perception by the community of those who have undergone surgical male circumcision done voluntarily negative vmmc perceptions yes no fear of complications after voluntary medical male circumcision some of the key informants interviewed stated that fear of complications after undergoing surgical male circumcision done voluntarily was one of the barriers towards uptake of surgical male circumcision done voluntarily some of the turkana males are very much concerned if complications may arise after they have undergone surgical male circumcision done voluntarily which may cause permanent deformity to their penis due to lack of wellequipped hospitals a good number of men are afraid complications arising from vmmc procedure will not be well taken care of what will happen if complications arise during the vmmc procedure will it affect erection i have heard about complications arising from vmmc procedure though rate this is a risk that i am not willing to take some men fear pain and stigma associated especially when found to be hiv positive fear of injections while undergoing vmmc some of the key informants interviewed stated that fear of having an injection in the penis by men was a barrier in the uptake of surgical male circumcision done voluntarily fear of pain significantly emerged as an issue that discourages men from embracing in the procedure all of them failed to acknowledge the fact that the vmmc procedure also applies drugs which eliminate pain some of the turkana men are afraid that the whole circumcision procedure would inflict pain particularly to the penis the fear of pain to the penis works as a barrier to their ability to embrace vmmc i have heard that it is painful to undergo the vmmc procedure so i stray away from it i have personally met men who are apprehensive that they cannot withstand the pain associated with vmmc procedure sexual performance one of the challenges to the acceptance of consensual surgical circumcision among men according to some key participants interviewed is the worry that circumcision may impair the sexual performance of men the majority of the turkana men that i have come across have expressed their fear that circumcision would hamper their sexual performance meaning that they would not be able to enjoy their conjugal rights some of the turkana males are concerned if complications may arise after they have undergone voluntary medical male circumcision which may affect their sexual performance i have heard than i wont be able to have good sex with my wife after undergoing vmmc there are some men who say that undergoing vmmc may reduce my sexual performance and as a man i cannot accept that moral support from partners a number of the key informants interviewed stated that lack of moral support by the partner was one of the barriers towards uptake of surgical male circumcision done voluntarily by men in turkana county the turkana communitys culture does not support circumcision this means that it is very difficult to convince the males to undergo surgical male circumcision done voluntarily if their spousepartners do not support the move as they will be deemed to have gone against my wife encouraged me to undergo vmmc as a measure to reduce hivaids transmission it is one of my spouses who though her encouragement made me to undergo vmmc procedure after having doubts about it moral support is important if men are to embrace the vmmc procedure because it a foreign culture to us sexual period some of the key informants interviewed stated that the fact that men take some time of sex to recuperate after undergoing as one of the barriers towards uptake of surgical male circumcision done voluntarily some of the turkana men avoid circumcision because they believe that after the surgical procedure it would take long to before they are able to have sex again some turkana men consider the healing period after undergoing vmmc as long to endure it some men are sexually active and are put off by the long healing period after undergoing vmmc procedure as a polygamous man it is difficult to undergo vmmc because i cannot take care of my wives in fgds many interviewees cited hiv prevention as the main appealing factor in their decision to adopt vmmc most who argued that due to emerging diseases such as hivaids the community has to embrace new preventive measures to control these diseases they viewed hivaids as a new disease in the community which called for new approaches in dealing with it in the focus group discussion involving a group of men most of them agreed that surgical male circumcision done voluntarily plays a significant role in reducing hiv risks i am aware of the significance of circumcision for males in terms of hiv prevention i have heard from the medical experts that vmmc is helpful in reducing the risk of hiv which means that it would improve our health new diseases that have come up such as hivaids have forced people to change their thinking towards male circumcision i have heard that male circumcision is good because it reduces hvaids transmission here in turkana hivaids is widespread and it is important to embrace practices that would reduce the disease transmission it also improves hygiene of the men discussion conclusions and recommendations discussion for every oneunit increase in psychosocial factors there is a predicted increase of 0986 in the log odds of increase in the elective medical circumcision of males adoption in turkana county and with a pvalue of pvalue of 0000 it is statistically significant this implies that social cultural factors have a very strong and positive influence on a rise in the use of consensual medical circumcision for men in turkana county the findings also show a substantial and statistically significant association between psychological variables and the acceptance of elective medical circumcision for males in turkana county this implies that psychosocial factors are important and should be taken into consideration when scaling up the elective medical circumcision of males adoption in turkana county the results are in agreement with macintyre et al hermanroloff bailey agot who found out that in psychosocial factors such as the attitudes and perceptions about voluntary medical male circumcision on sexual performance and safety of the penis had the use of consensual medical circumcision for males has a substantial impact the findings are in line with those of hankins forsythe and njeuhmeli who found that a barrier to the expansion of elective medical circumcision for males in eastern and southern africa is its cost the findings concur with those of george et al who found that the poor socioeconomic conditions of the community had a negative impact on the adoption of optional medical circumcision for males in the kwa zulu natal province of south africa turkana county has a high hivaids burden hence psychosocial factors such as a persons attitude perceptions selfesteem and beliefs about the importance of reduction of hiv transmission through elective medical circumcision of males and enhancing penis hygiene may serve as incentives for males to undergo consensual medical circumcision for me the findings are consistent with those made by macintyre et al and hermanroloff bailey and agot who discovered that psychosocial factors such as beliefs and opinions about consensual medical male circumcision and its effects on sexual performance as well as the security of the penis had a significant impact on the acceptance of unforced medical circumcision of men conclusions the study rejected the null hypothesis for psychosocial factors since they were found to have a positive and key factor affecting the acceptance of consensual medical circumcision for males in turkana county recommendations recommendations for practice the following actions are recommended to generate interest in consensual medical circumcision for males services amongst men in turkana county 1 further studies should focus on behavioral change and societal acceptance in communicating health advantages social acceptance and appeal of unforced medical male circumcision as a condition for encouraging elective medical circumcision for males in turkana county the government and ngos should make sure there is appropriate hivaids education 3 for the purpose of bringing elective medical mens circumcision service closer to the public expand awareness and mobile clinics initiatives to upscale and promote voluntary medical male circumcision amongst younger turkana males are encouraged 5 respected local leaders must be used to raise community awareness and support for the turkana county elective medical male circumcision initiative policy recommendation all the policies addressing the elective surgical circumcision of males adoption amongst men in turkana county should incorporate the traditional leaders and local administrators for societal acceptance these policies should also advocate for the local leadership to be adequately trained so that they can mobilize communities sensitize and educate them about behavioral change and the importance of male circumcision by elective medical suggestion for further research since the turkana communitys cultural traditions do not support the practice of circumcision in men encouraging the adoption of voluntary medical circumcision for males services through the elders who are the custodians of cultural traditions is essential in achieving cultural perception changes in order to encourage the acceptance of consensual medical male circumcision alongside a focus on its biomedical advantages such as lowering hiv infections also the study recommends the inclusion of government policy on male circumcision as an intervening variable for subsequent studies since turkana male do not culturally practice it issn 25190210 vol 8 issue 3 no1 pp 1 13 2023

kenya is amongst six highburden nations in africa grappling high hiv infections approximately 912 of kenyan men have undergone circumcision however male circumcision is not traditionally practiced in turkana community with male circumcision rates ranging from 510 the studys goals were to identify the influences on consensual medical male circumcision acceptance in turkana county caused by psychological aspectsthe crosssectional study was carried out in loima turkana central and turkana north subcounties between november 2021 to january 2022 with sample size of 434 adult men data was collected using both quantitative and qualitative tools the researcheradministered survey kii schedules and a fgd guide the statistical package for the social science spss version 22 was used to analyze quantitative data whereas qualitative data was analyzed thematically the results were interpreted at 5 level of significance findings results showed that of 374 male participants in the study 799 had undergone circumcision 770 were aged 1835 years 941 were christians and 447 were unemployed while 548 were married the overall mean scores of responses for psychosocial factors psychosocial factors was 3602 positive psychological factors were predicted to increase uptake of vmmc by 099 or 0986 95 ci 07451228 p0000 the study recommends that policies addressing main vmmc uptake amongst men in turkana county should incorporate public participation traditional leaders and local administrators for societal acceptance there is need for effective sensitization and advocacy for behavioral change mobilization and ownership of the initiative by the community

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in the early 2000s 1 in particular debates on the goals of philosophical analysis especially with respect to commonsensical beliefs and socalled pretheoretical intuitions became acutely pressing when engaging in philosophical analysis are we trying to faithfully capture commonsensical concepts which thereby become clarified and systematized but otherwise remain intact or do we openly seek to transform and improve on these concepts 2 the contrast can be described as that between conservative versus revisionary conceptions of philosophical analysis these two conceptions were in fact influential at the very birth of analytic philosophy in the early twentieth century and can be traced back to two founding figures in this tradition moore for conservative analysis russell for revisionary analysis3 while perhaps somewhat simplistic4 this contrast highlights interesting similarities and connections between conceptions of philosophical analysis that might seem quite distinct at first sight in this paper i focus on two philosophical methods on the revisionary side of the divide which prima facie may appear to be far apart from each other carnaps method of explication and haslangers method of ameliorative analysis 5 i argue that they have a number of interesting features in common and that reflecting on these commonalities deepens our understanding of each of them moreover it will also prove useful to reflect on some of the salient differences between them the systematic comparison of these two frameworks offered here is likely to provide useful guidance to practitioners of both approaches as it will highlight important aspects of each of them that tend to remain implicit and undertheorized in existing applications of these methodologies to specific questions that there are interesting connections between the two projects was noticed by sally haslanger herself who writes in a footnote after introducing the ameliorative terminology in resisting reality in two dogmas quine distinguishes different forms of definition the third being what he calls explicative in giving explicative definitions an activity to which philosophers are given and scientists also in their more philosophical moments… the purpose is not merely to paraphrase the definiendum into an outright synonym but actually to improve upon the definiendum by refining or supplementing its meaning ameliorative captures better than explicative the sort of project quine is characterizing as especially philosophical … it should be understood however that on my view whether or not an analysis is an improvement on existing meanings depends on the purpose of the inquiry in both cases a philosophical analysis takes as its starting point a concept as used in ordinary everyday contexts and then goes on to deliver a different but closely related concept that represents an improvement 6 over the original concept carnapian explication and ameliorative analysis focus on how we should understand a concept not only on how we currently do this is the core revisionary commitment that these two conceptions of philosophical analysis carnaps and haslangers share if a revisionary stance were all that these two approaches shared a comparison between the two might not be particularly illuminating however carnapian explication and haslangers ameliorative analysis also share a political dimension that is worth spelling out haslanger is very explicit on the political goals of ameliorative analysis whereas carnapian explication is prima facie not an overtly political project nevertheless if carnapian explication is viewed within the broader context of the vienna circles political engagement and carnaps own commitment to the values of the enlightenment then explication may rightly be seen as an instrument for social reform both approaches belong to leftleaning political traditions but they occupy different locations within this big tent indeed there is an important difference of background between the two approaches while carnapian explication is embedded in enlightenment ideals and the vienna circles scientific world conception haslanger is influenced by the critical theory tradition of the frankfurt school as is well known the frankfurt school authors were themselves fierce critics of the vienna circles alleged scientism and of enlightenment ideals more generally these different stances with respect to science in turn lead to different methodological choices carnapian explication often favors methods borrowed from the exact natural sciencesformalization mathematical frameworkswhereas critical theorists tend to focus on conceptual frameworks coming from the humanities and social sciences but these dissimilarities are also the reason why each of the two approaches may benefit from engaging with the other in particular ameliorative projects may well incorporate the formal techniques that are typically deployed in instances of carnapian explication despite some suspicion that might still hover regarding the risk of scientism in turn the comparison with ameliorative projects will suggest that carnapian explication may also rely on tools borrowed from the humanities and social sciences especially in view of broader social and historical contextualizations that are sometimes missing in explicative analyses finally the more explicit political articulation of ameliorative projects can serve as a model for explications of more politically laden concepts 7 i proceed in the following way in sect 1 i start with a brief presentation of carnapian explication focusing in particular on the fruitfulness requirement for a successful explication closing sect 1 i discuss an example of a carnapian explication of the concept of intersectionality in sect 2 i present the outlines of haslangers ameliorative method as described and deployed in haslanger including a brief discussion of how she applies the method to gender and race in sect 3 i compare the two methods on two aspects criteria of adequacysuccess conditions and with respect to an objection that can be leveled against both namely the change of subject objection when explicatinganalyzing a concept so as to improve it what we in fact do is to introduce a new concept that bears little to no resemblance to the initial subject of analysis i conclude with some general remarks on the significance of the present analysis for questions pertaining to philosophical methodology in general carnapian explication 1the basics 8 throughout his career carnap developed a number of constructed formal systems as early as in der logische aufbau der welt and logische syntax der sprache indeed the notion of a constructed language is perhaps the main theme running through all of carnaps large oeuvre in his later writings in particular in meaning and necessity and logical foundations of probability the key methodological concept became that of explication9 which is not exclusively tied to constructed languages and formalization10 but often does take the form of applications of artificially constructed languages explication is a process whereby a vague informal concept either from everyday life or from more regimented contexts such as scientific contexts is given a more exact often formalized formulation11 as such the approach is a successor of some related earlier methodologies used by frege russell and others here is one of carnaps earlier formulations of the idea of explication from meaning and necessity the task of making more exact a vague or not quite exact concept used in everyday life or in an earlier stage of scientific or logical development or rather of replacing it by a newly constructed more exact concept belongs among the most important tasks of logical analysis and logical construction we call this the task of explicating or of giving an explication for the earlier concept this earlier concept or sometimes the term used for it is called the explicandum and the new concept or its term is called an explicatum of the old one the most workedout exposition of the concept of explication is to be found in chapter 1 of logical foundations of probability it is there that carnap offers the now famous fishpiscis example to illustrate the general idea when we compare the explicandum fish with the explicatum piscis we see that they do not even approximately coincide … what was the zoologists motive for … artificially constructing the new concept piscis far remote from any concept in the prescientific language the reason was that they realized the fact that the concept piscis promised to be much more fruitful than any concept more similar to fish a scientific concept is the more fruitful the more it can be brought into connection with other concepts on the basis of observed facts in other words the more it can be used for the formulation of laws it is thus the fruitfulness of the concept piscis that motivates the adoption of piscis in certain contexts where fish had so far been used in particular scientific contexts but fruitfulness is not all that it takes for an explication to be successful carnap in fact presents four main criteria of adequacy for an explication a concept must fulfill the following requirements in order to be an adequate explicatum … similarity to the explicandum exactness fruitfulness simplicity indeed while there is considerable room for maneuver when engaging in explication this does not mean that anything goes there are standards that an explication must satisfy to be deemed adequate and some explications will be more successful than others let us briefly look into three of the requirements which on the list above are presented in a somewhat unsystematic order similarity is a rather weak criterion for carnap as we saw with the fishpiscis example the two concepts do not even approximately coincide however to ensure that an explicatum is an explicatum for a given explicandum some degree of similarity must be in place otherwise the two concepts might end up being about completely different things carnap resorts to the notion of use in order to ground the relation of similarity the explicatum is to be similar to the explicandum in such a way that in most cases in which the explicandum has so far been used the explicatum can be used however close similarity is not required and considerable differences are permitted in the case of fishpiscis the idea is that zoologists would henceforth use piscis in most of the situations where they would have used fish prior to the introduction of the concept piscis exactness might prima facie appear to be the main requirement for a successful explanation indeed carnap says that the explicatum being more exact than the explicandum is essential for an explication12 critics of carnapian explication often object to what they perceive as an excessive preoccupation with criteria and methods imported from the exact sciences that are out of place in philosophical contextsin other words they object to the perceived scientism of the general approach espoused by carnap and other members of the vienna circle the scientism charge has been amply discussed in recent reappraisals of the vienna circle movement and has been shown to be at the very least questionable importantly within the specific interpretation of enlightenment ideals by some members of the vienna circle in particular neurath and carnap formalism and mathematization were in fact viewed as means for intellectual emancipation an instrument against obscurantism setting aside the criticism of enlightenment ideals that have been put forward by a wide range of authors what matters for us here is the idea that for carnap exactness is not an end an sich it is an instrument a means to an end or to a variety of specific ends as the case may be this brings us directly to the third arguably most important requirement for a carnapian explication it must be fruitful fruitfulness is the crucial requirement for a successful explication and yet carnap says surprisingly little on what he means by fruitfulness here is one of his few relevant remarks the explicatum is to be a fruitful concept … useful for the formulation of many universal statements the idea of an explicatum leading to many universal statements may be understood in terms of predictive power and testability if it allows for the formulation of universal statements then it will generate predictions that can be tested in the case of nonempirical theories allowing for the derivation of many theorems might amount to the general idea of the fruitfulness of concepts and definitions as discussed by frege moreover as suggested in the passage quoted above on the fishpiscis example an explicatums fruitfulness is related to its ability to connect with other concepts on the basis of observed facts 13 however an account of the fruitfulness of an explicatum solely in terms of its capacity to generate universal statements and predictions and to be connected to other observed facts remains somewhat meager interpreters of carnap have taken upon themselves to flesh out what fruitfulness might mean beyond carnaps own inchoate remarks carus developed a resolutely pragmatic interpretation of fruitfulness elsewhere i have offered an account of fruitfulness in terms of the cognitive boost afforded by explication and formalization in the next section i further argue that fruitfulness may also be understood in political terms ie in terms of promoting muchneeded social reform and liberation from obscurantism fruifulness and political engagement in carnaps own writings little textual evidence can be found to ground a fullyfledged political articulation of the fruitfulness criterion for explication specifically formulations of more explicit political commitments and in particular of the idea that philosophy was of critical relevance to the project of sociohistorical changes towards socialism are mainly to be found in carnaps earlier writings as one of the members of the left vienna circle 14 the concept of explication in turn was to be fully articulated only in his later writings but granting at least some degree of methodological continuity between carnaps earlier work and his later work as well as continuity in his political commitments15 a case can be made for the relevance of these political commitments also with respect to his later work and explication in particular for carnap explication embodies the value of intellectual liberation from the shackles of paralyzing traditions a passage by one of his students richard jeffrey illustrates this connection particularly well philosophically carnap was a social democrat his ideals were those of the enlightenment his persistent central idea was its high time we took charge of our own mental livestime to engineer our own conceptual scheme as best we can to serve our own purposes time to take it back from tradition time to dismiss descartess god as a distracting myth time to accept the fact that theres nobody out there but us to choose our purposes and concepts to serve those purposes if indeed we are to choose those things and not simply suffer them … for carnap deliberate choice of the syntax and semantics of our language was more than a possibilityit was a duty we owe ourselves as a corollary of freedom 16 in other words explication exemplifies the ideal of epistemic autonomy most famously captured by kants enlightenment motto sapere aude 17 the general political background for carnaps thought has been amply documented and discussed by a number of authors so we need not rehearse the details here so far however while setting up the stage these brief considerations remain much too general to ground an interpretation specifically of carnaps criterion of fruitfulness as related to political engagement fortunately there is at least one fairly clear connection between his brief remarks on fruitfulness mentioned above and political ideals through the concept of prediction recall that he emphasized the role of explication as leading to the formulation of universal statements which in turn allow for testable predictions to be made regarding the relevant subject matter one might think that prediction thus understood is not a particularly politicized concept the idea of predictions which can be tested and thus can refute or corroborate theories is a core component of classical conceptions of science but predictions also allow for interventions to be brought about thus bringing us closer to political ideals of social reform the political dimension of predictions is well described in the following passage by wartofsky commenting on neurath further one of the hallmarks of the scientific conception of the world and certainly central to neuraths view was the importance of prediction in the sciences the social value of prediction was seen by neurath as a means of applying rational controls over hypothetical plans of actionwhether in research in the sciences involving the use of experiment or in social planning given that on these points carnap and neurath were very much in agreement it is not too much of a stretch to connect the idea of the fruitfulness of an explication as generating universal statements to the social value of prediction within projects of social engineering 18 at this point it might seem that a fruitful explication may well have the potential to serve the purposes of social engineering but that this potential is rarely or perhaps never truly realized to alleviate this worry i now discuss a concrete example of an explication of a socially relevant concept which leads to precise predictions and thus can serve as an instrument for social intervention and social reform the explication of the concept of intersectionality offered in bright et al bright et al indeed explicitly present their analysis as an instance of explication the explicandum in this case is the concept of intersectionality which is a theoretical concept but might be said to be in an earlier stage of scientific or logical development it was introduced in the 1990s by legal scholar k crenshaw to capture the idea that different dimensions of oppression targeting different disadvantaged groups may interact in nontrivial ways for example the challenges encountered by black women in the united states are different from the challenges encountered by either black men or white women because gender and race intersect in ways that give rise to different kinds of challenges but while intersectionality thus described is a powerful and useful concept it has also been the target of fierce criticism in particular with respect to its ability to generate predictions about the phenomena in question bright et al thus give the concept of intersectionality a causal interpretation in terms of the formalism of graphical causal modeling which in the last decades has become an influential approach in a number of areas as seen in fig 1 directed acyclic graphs allow for the representation of causal relations between different phenomena in this graph parental income and education are represented both as direct causes of wealth and additionally parental income is an indirect cause of wealth via its influence on education in turn education is independent of gender given race and parental income which roughly means that in the contexts that the graph representsdescribes boys and girls have the same access to education holding these two parameters fixed 19 but gender does affect wealth as typically men are wealthier than women even holding the other parameters fixed equipped with this formalized causal account of intersectionality researchers are better prepared to understand the underlying causal relations between different aspects of the phenomena in question make relevant predictions and potentially formulate interventions that may address the social inequalities in question in fig 1 for example the fact that education is independent of gender given race and parental income suggests that the kind of intervention needed to bridge the pay gap between men and women that is still observed even in socalled modern industrialized societies is not that of investing in early education for girls instead the phenomenon seems to be caused by factors within the dynamics of the labor market itself and the distribution of domestic labor at home these observations indicate the kind of intervention needed to address this inequality such as policies for gender pay equity in the workspace policies to increase male involvement in childrearing such as paternal leave 20 and thus the explication of intersectionality in terms of graphical causal modeling by bright et al is an excellent example of the potential for social and political relevance of the explication methodology and indeed an illustration of the links between predictions and potential for social engineering in effect this explication scores high on the fruitfulness criterion as described by carnap because it leads to a number of general statements which can then both serve to test the empirical adequacy of the framework and to guide targeted social interventions at a later stage 21 while this is but one example of how carnapian explication including its focus on formalization can be enlisted for politically and socially relevant projects there is no reason to think that this should be an isolated case concrete uses of explication for such projects may still be somewhat rare but this simply means that there is much potential for future work to be done in this direction 22 2 haslangers ameliorative analysis 21 the ameliorative method sally haslanger has been deploying the ameliorative method in her work on race and gender since the late 1990s but the term ameliorative is not used in her earlier work to my knowledge its first occurrence is in and its most workedout exposition is to be found in her 2012 book resisting reality which will be the main source for the present discussion 23 haslanger summarizes the gist of her approach in the following way in developing constructionist accounts of race and gender ive maintained that my goal is not to capture the ordinary meanings of race or man or woman nor is it to capture our ordinary race and gender concepts ive cast my inquiry as an analyticalor what i here call an ameliorativeproject that seeks to identify what legitimate purposes we might have in categorizing people on the basis of race or gender and to develop concepts that would help us achieve these ends i believe that we should adopt a constructionist account not because it provides an analysis of our ordinary discourse but because it offers numerous political and theoretical advantages haslanger thus clearly sides with what was described above as a revisionarytransformative conception of philosophical analysisin fact she uses the term revisionary herself these revisionary commitments are well served by the constructionist approach given the potential for interventions on concepts of kinds such as race and gender once they are understood as social constructions rather than as pertaining to immutable biological essences in particular she explicitly discusses the idea of debunking intuitions about social kinds through ameliorative analysisthe result of which will be unsurprisingly counterintuitive since this is precisely the goal of the analysis in debates over the existence and nature of social kinds such as race and gender philosophers often rely heavily on our intuitions about the nature of the kind following this strategy philosophers often reject social constructionist analyses suggesting that they change rather than capture the meaning of the kind terms 22 another recent example is on the concept of marriage pearson also offers an illuminating critical discussion of carus interpretation of carnaps ideal of explication as a model for liberal political deliberation 23 the book comprises reworked versions of a number of her earlier articles and for this reason we will focus on the book exclusively here since it contains all the relevant material moreover since the aim of the book is to make each chapter selfcontained there is some overlap between the chapters in particular chapters 13 and 14 both contain extensive discussions of the ameliorative method indeed haslanger explicitly addresses methodological questions at length and thus it is often sufficient to let her speak for herself without much need for further textual interpretation synthese 19710111034 however given that social constructionists are often trying to debunk our ordinary understandings of social kinds it is not surprising that their analyses are counterintuitive ameliorative projects are contrasted with two other ways of engaging in philosophical analysis conceptual and descriptive approaches for example consider the question what is knowledge following a conceptual approach one is asking what is our concept of knowledge and looking to a priori methods such as introspection for an answer taking into account intuitions about cases and principles one hopes eventually to reach a reflective equilibrium on a descriptive approach one is concerned with what objective types our epistemic vocabulary tracks the task is to develop potentially more accurate concepts through careful consideration of the phenomena usually relying on empirical or quasiempirical methods the conceptual approach thus described is clearly conservative in the sense introduced at the beginning of the paper pretheoretical intuitions can be systematized and scrutinized but never outright rejected or substantially modified the descriptive approach is prima facie neutral with respect to common sense and intuitions it may well be that careful consideration of the phenomena will confirm commonsensical beliefs about the relevant phenomena but often empirical or quasiempirical investigation will lead to revisions of these beliefs ameliorative projects however are from the beginning motivated by practical purposes and thus start off with revisionary proclivities ameliorative projects in contrast begin by asking what is the point of having the concept in questionfor example why do we have a concept of knowledge or a concept of belief what concept would do the work best in the limit case a theoretical concept is introduced by stipulating the meaning of a new term and its content is determined entirely by the role it plays in the theory if we allow that our everyday vocabularies serve both cognitive and practical purposes that might be wellserved by our theorizing then those pursuing an ameliorative approach might reasonably represent themselves as providing an account of our conceptor perhaps the concept we are reaching forby enhancing our conceptual resources to serve our purposes ameliorative projects thus start by asking functionalistpragmatic questions given a certain concept what function or functions does it have in the constellation of our practices and discourses24 once this question is at least partially answered we can ascertain whether the version of the concept that we currently entertain is adequate for the job we expect it to do if not then a revisionary ameliorative process can be set in motion hopefully leading to a more suitable version of the concept in question given the functionsgoals that have been established in the first step of the investigation importantly in the limit case this can be achieved by stipulation and the introduction of a new term recall that in carnaps fishpiscis example zoologists decided at some point to use piscis instead of fish because the category piscis was better suited for scientific investigation than the category fish which was based on superficial morphological resemblances between animals who are otherwise very different 25 this seems to be the kind of stipulation that haslanger is alluding to 26 there is another aspect in which the comparison with carnap may be instructive but this time it is a point of disanalogy between the two authors carnap does not explicitly say that different purposes and goals may be addressed in an explication the pragmatic component is simply alluded to with the umbrella term fruitfulness he seems to imply that fruitfulness is an absolute concept rather than one relative to different purposes and goals one may have later in carnap he is more explicit on the plurality of goals and purposes that may be addressed by an explication perhaps tellingly he no longer speaks of fruitfulness in this later text in contrast haslanger very clearly states that ameliorative analysis is a twotiered process that starts with a thorough critical examination of ones purposes and then proceeds to reformulate a concept in view of the purposes previously established 27 ameliorative analyses elucidate our legitimate purposes and what concept of fness would serve them best normative input is needed the method in practice gender and race as mentioned above it is primarily within her work on race and gender that haslanger has been developing and deploying the ameliorative method and thus it is useful for our purposes here to observe the method in action just as we had an example of carnapian explication with intersectionality the first step in the ameliorative method as described above is a critical examination of the purposes to be achieved rather than seeking to systematize commonsensical notions of race and gender or to investigate deeper metaphysical and empirical properties of the phenomena in question and in keeping with the spirit of critical theory broadly understood haslangers chief purpose when providing an analysis of race and gender is that of fighting inequality domination and oppression in social structures thus synthese 19710111034 promoting social justice one of the four main concerns guiding the project is formulated in the following terms the need to identify and explain persistent inequalities between females and males and between people of different colors this includes the concern to identify how social forces often under the guise of biological forces work to perpetuate such inequalities more specifically the goal of the project is to consider what work the concepts of gender and race might do for us in a criticalspecifically feminist and antiracistsocial theory… another aspect where haslanger borrows from the critical theory tradition is the idea of ideology critique as stated in a passage quoted above her starting point is that our ordinary understandings of social kinds tend to be ideologyridden in such a way that they in fact perpetuate inequalities and hierarchies among men and women white people and people of color this is another reason why the approach required given her stated purposes cannot be either conceptual analysis which leaves these ordinary understandings essentially intact or descriptive analysis which purportedly addresses the phenomena directly without critically examining the ideological components of our ordinary understandings of social kinds ameliorative analysis is what is required with the relevant politicalpragmatic goals in place haslanger then goes on to investigate what a suitable analysis of gender and race might be one that would be instrumental in promoting these goals to this end she draws from materialist feminist accounts of gender which view gender categories in terms of womens subordinate position in systems of male dominancethat is a social and indeed political understanding of gender as opposed to the folkbiological notion of sexgender which places the relevant differences at the level of biological reproductive functions a similar approach is adopted for race which is then to be conceived of in terms of dominance by white people and the corresponding subordination of people of color tellingly in chapter 14 of resisting reality haslanger criticizes errortheoretical approaches such as the one defended by appiah with respect to race according to which there are no races there is nothing in the world that can do all we ask race to do for us on her view appiahs conceptual analysis leading to the conclusion that there is nothing that satisfies all the different properties that we associate with race fails to have the desirable effect of promoting social justice and thus fails the political goals described above haslanger thus arrives at the following definitions of woman and man s is a woman iff df s is systematically subordinated along some dimension and s is marked as a target for this treatment by observed or imagined bodily features presumed to be evidence of a females biological role in reproduction s is a man iff df s is systematically privileged along some dimension and s is marked as a target for this treatment by observed or imagined bodily features presumed to be evidence of a males biological role in reproduction by emphasizing the subordination of women by men and by identifying bodily features related to biological reproduction as the purported but mistaken locus for gender differences these definitions precisely because they are revisionary are suitable to serve the political purposes that motivated the analysis in the first place race is then defined in similar terms a group is racialized iff df its members are socially positioned as subordinate or privileged along some dimension and the group is marked as a target for this treatment by observed or imagined bodily features presumed to be evidence of ancestral links to a certain geographical region prima facie these definitions seem to satisfy the political desideratum of promoting values of social justice it has been argued however that haslangers definition of woman fails to promote social justice with respect to trans women jenkins argues that some trans women do not count as women according to haslangers definition in other words the definition undergenerates with respect to individuals that we do want to count as women on the basis of other considerations and since trans women are among the most marginalized and oppressed groups in many societies not counting some of them as women entails failing the political goal of promoting social justice the objection by jenkins highlights an important element of the framework namely that ameliorative analysis is best seen as an openended project proposed reconceptualizations may then be further revised if it turns out that additional improvement can be made this is a feature that ameliorative analysis shares with carnapian explication which is also an openended process that can be iterated the explicatum of one explication can then become the explicandum for a different explication comparison with these brief but i hope sufficiently instructive presentations of carnapian explication and haslangers ameliorative analysis in place we can now engage in a more systematic comparison between the two two specific aspects will be singled out what counts as adequacy criteria and success conditions for each of the two approaches and an important objection that can be leveled against both approaches namely the change of subject objection criteria of adequacysuccess conditions in sect 11 i briefly discussed the criteria of adequacy for an explication as stated by carnap the main ones are similarity exactness and fruitfulness for convenience let me restate the similarity criterion the explicatum is to be similar to the explicandum in such a way that in most cases in which the explicandum has so far been used the explicatum can be used however close similarity is not required and considerable differences are permitted as for exactness as discussed above it is of course closely related to the idea that the methods in the exact and empirical sciences should be emulated elsewhere in philosophical analysis in particular 28 but importantly the left vienna circle philosophers such as carnap and neurath in fact viewed formalization and exactness through political lensesas embodying the enlightenment ideals of intellectual emancipation not as an objectionable form of scientism finally fruitfulness remains rather underdeveloped in carnaps own words but above ive offered an interpretation of fruitfulness as also related to political ideals of social reform through the notions of prediction and social engineering haslanger also addresses the issue of success conditions for ameliorative analyses in particular she distinguishes two kinds of conditions semantic conditions and political conditions are there principles that determine when it is legitimate to appropriate the terms of ordinary discourse for theoretical purposes 29 an answer it seems to me should include both a semantic and a political condition the semantic condition is not surprising the proposed shift in meaning of the term would seem semantically warranted if central functions of the term remain the same eg if it helps organize or explain a core set of phenomena that the ordinary terms are used to identify and describe framing a political condition in general terms is much more difficult however for the politics of such appropriation will depend on the acceptability of the goals being served the intended and unintended effects of the change the politics of the speech context and whatever the underlying values are justified it is quite natural to view haslangers semantic condition based on the idea of the central functions of a term remaining the same as a counterpart of carnaps similarity criterion which is also based on linguistic use the political condition in turn can be viewed as a counterpart of carnaps fruitfulness criterion at least under the political interpretation of fruitfulness that ive articulated in sect 12 indeed it is interesting to notice that haslanger recognizes the difficulties with formulating the political condition in general terms given significant contextual variations and the varying acceptability of the goals being served we may hypothesize that it was for similar reasons that carnap could not go much beyond a rather vague and underdeveloped characterization of the notion of fruitfulnessprecisely because framing it in general terms proves to be very challenging given the multiplicity of uses and contexts for the method given that framing the political condition in general terms is most likely not possible haslanger focuses on the political dimension of ameliorative analysis for individual cases indeed we have seen that critically examining goals and purposes which thereby become more explicitly formulated is the first stage of analysis within the ameliorative method in this respect practitioners of carnapian explication have something to gain from emulating the careful discussion of goals and functions that is to be found in applications of the ameliorative method rather than adopting an absolute sense of fruitfulness obviously there is a third criterion of adequacy on carnaps list that has no immediate counterpart in haslangers framework the exactness criterion 30 this is indeed a significant difference between the two frameworks while carnapian explication is in theory not exclusively tied to formalization and mathematization in practice the most conspicuous examples of explication tend to be instances of a formal language or formal framework being applied to a particular informal question or concept in contrast the ameliorative approach does not place any special emphasis on formalization though there is no a priori reason why the former would be inimical to the latter this is in turn where practitioners of the ameliorative method may benefit from engagement with the techniques employed by carnapian explicators especially if exactness is not understood merely as decreasing vagueness as proposed in brun however even if explicators incorporate more sustained attention to political dimensions from the ameliorative method and ameliorativists begin to use formal tools systematically it does not mean that the two methods will become identical in particular while the ameliorative method as described by haslanger is always tied to political goals carnapian explication can be but need not be exclusively used for social engineering indeed explication continues to be a fruitful methodology for the analysis of scientifically relevant concepts whereas ameliorative analysis is primarily geared towards socially and politically charged concepts in particular the negative component of ideology critique which is crucial in the ameliorative method does not seem to have a natural counterpart in carnapian explication at least not in its classical formulation moreover some instances of carnapian explication may in fact belong to haslangers category of descriptive analysis they may be revisionary but not necessarily ameliorative more accurate categorization of the organisms in question indeed while the ameliorative method is essentially functionalthe goal is to engineer concepts that will better perform certain functionscertain instances of carnapian explication will not necessarily be functional in the sense that the ameliorative method is some will be largely descriptive 31 however if the scientific goal of leading to predictions and general statements or more generally to better explanations of the phenomena in question counts as a relevant function then carnapian explication can be seen as essentially functional as well at least in a weaker sense and thus the conclusion seems to be that carnapian explication and the ameliorative method even when borrowing from each other will remain overlapping but not identical methodologies both extensionally and intensionally for example the analysis of intersectionality in bright et al is clearly an instance of explication but arguably not an instance of ameliorative analysis despite having the potential to lead to social interventions32 the change of subject objection one of the main criticisms that have been voiced against carnapian explication is the change of subject objection perhaps most famously formulated by strawson in his piece for the schilpp living philosophers volume dedicated to carnap at first sight strawsons critique appears to be a variation of the scientism objection for however much or little the constructionist technique explication is the right means of getting an idea into shape for use in the formal or empirical sciences it seems prima facie evident that to offer formal explanations of key terms of scientific theories to one who seeks philosophical illumination of essential concepts of nonscientific discourse is to do something utterly irrelevantis a sheer misunderstanding like offering a textbook on physiology to someone who says that he wished he understood the workings of the human heart strawsons objection thus amounts to reclaiming a specific domain of inquirynonscientific discourse and concepts of daily lifeas not amenable to this scientific methodology 33 but it can also be read as a rejection of the possibility of philosophical clarification having a transformative or revisionary import philosophical clarification ought to be purely descriptive of beliefs and concepts underlying daily life rather than producing new concepts which should replace the old ones or revising entrenched commonsensical beliefs and it seems in general evident that the concepts used in nonscientific kinds of discourse could not literally be replaced by scientific concepts serving just the same purposes that the language of science could not in this way supplant the language of the drawingroom the kitchen the law courts and the novel strawsons rejection of revisionary philosophical analysis such as carnapian explication is further articulated in the following passage i n most cases either the operation scientific language replacing nonscientific language for nonscientific purposes would not be practically feasible or the result of attempting it would be something so radically different from the original that it could no longer be said to be fulfilling the same purpose doing the same thing more of the types of linguistic activity in which we constantly engage would succumb to such an attempt than would survive it… carnaps response to this criticism in carnap is to emphasize the commonalities between the approach of naturalists such as strawson and his own as a constructionist but also to isolate the main points of disagreement one of them is what could be described as strawsons conservative stance towards ordinary language which carnap rejects for the naturalists ordinary language seems to have an essentially fixed character and therefore to be basically indispensable just like our body with its organs to which we may add accessories like eyeglasses hearing aides and the like but which we cannot essentially change or replace however a natural language is not an unchangeable function of our body but something we have learned therefore we can replace it by another language another reason to reject an overly deferential attitude towards ordinary language is that its users are themselves often confused with respect to its expressions strawson believes that philosophical problems are raised by people who know very well how to use the expressions concerned i should rather say that these people usually believe they know this very well but often deceive themselves the first step in helping these people consists in leading them to the insight that something is wrong with their use of certain expressions that it involves confusions or even inconsistencies the change of subject objection is similarly a challenge for the ameliorative method haslanger engages headon with it further developing some of the main points of carnaps response to strawson she formulates the objection in the following terms w e come to inquiry with a conceptual repertoire in terms of which we frame our questions and search for answers hence the subject matter of any inquiry would seem to be set from the start in asking what race is or what gender is our initial questions are expressed in everyday vocabularies of race and gender so how can we meaningfully answer these questions without owing obedience to the everyday concepts or at least to our everyday usage revisionary projects are in danger of providing answers to questions that werent being asked i n an explicitly revisionary project it is not at all clear when we are warranted in appropriating existing terminology given the difficulty of determining what our concept is it isnt entirely clear when a project crosses over from being explicative to revisionary or when it is no longer even revisionary but simply changes the subject if our goal is to offer an analysis of our concept of x then the line between whats explication and whats not matters 34 but if our goal is to identify a concept that serves our broader purposes then the question of terminology is primarily a pragmatic and sometimes a political one should we employ the terms of ordinary discourse to refer to our theoretical categories or instead make up new terms the issue of terminological appropriation is especially important and especially sensitive when the terms in question designate categories of social identity such as race and gender haslangers full response to the change of subject objection is much too complex to be presented in detail here but the gist of it can be thus summarized in other words and in line with carnaps reply to strawson the point is that we users of ordinary languages often do not know exactly what it is that we are talking about when using everyday life vocabulary at the very least there is considerable leeway and flexibility in usage this is of course a familiar point almost a platitude perhaps but it does suggest a suitable reply to the change of subject objection more often than not it is not clear that there is a neatly circumscribed subject for the everyday use of a term in the first place which philosophical analysis should be deferential to haslanger further develops an account of vagueness and ambiguity in everyday language incorporating some key topics in philosophy of language such as semantic externalism and meaning holism in her discussion in this context she introduces the helpful distinction between manifest and operative concepts in everyday usage roughly the manifest concept is the more explicit public and intuitive one the operative concept is the more implicit hidden and yet practiced one 36 very often there is a mismatch between manifest and operative concepts with respect to one and the same subject haslangers example is the concept of parent which in the context of communication between a school and the relevant group of adults responsible for its pupils may in fact be taken to encompass all primary caregivers regardless of whether they satisfy the biological or legal definition of parent in this case the manifest concept of parent does not encompass eg grandparents who are primary caregivers but the operative concept does and it is the operative concept that takes the upper hand 37 whenever there is a mismatch between manifest operative and target concepts a number of options are available with respect to practices content of a concept and linguistic usage change the practices and keep the manifest concept or replace it with a newly formulated target concept change the manifest concept so as to fit the practices introduce a new term for a new concept in order to dispel ambiguity in established usage change the meaning of the term already in use as discussed in chapter 14 of resisting reality there is no onefitsall answer to the question of how to proceed in cases of mismatch but the main point is that the manifest concept which is usually the one that is referred to when philosophers such as strawson and others speak of concepts in everyday language does not have obvious primacy over the other two and thus it is not in any way obvious that not giving a faithful account of a manifest concept by means of philosophical analysis will necessarily constitute an objectionable change of subject haslanger thus offers subtle answers to the change 35 lets call the target concept the concept that all things considered i should be employing 36 the manifest concept is the concept i take myself to be applying or attempting to apply in the cases in question the operative concept is the concept that best captures the distinction as i draw it in practice and the target concept is the concept i should ideally be employing 37 a mismatch between manifest and operative concepts may also suggest problematic practices hiding under apparently innocent manifest concepts and it is part of the enterprise of ideology critique to expose such problematic practices haslanger refers to the work of c mckinnon on gender and of c mills on the enlightenment social contract as a racial contract such analyses purport to show that our manifest understandings of crucial political notions are masking how the concepts in question actually operate 123 of subject objection which might also be of use to carnapian explicators who are confronted with similar objections 38 conclusions in this paper i presented a comparative analysis of two philosophical methods carnapian explication and ameliorative analysis as introduced by haslanger i have argued that there is much similarity between them but also that there are some significant differences in how each is presented and practiced more generally the paper can also be seen as a defense of revisionary philosophical analysis as i have attempted to further articulate two such revisionary methods based on the writings of their main architects and to defend them against objections as such i hope to have made a more general contribution to debates on philosophical methodology especially with respect to the increasing popularity of projects of conceptual engineering on my story such projects are not only philosophically viable and interesting but also have the potential for reallife impact in terms of promoting social interventions 39

a distinction often drawn is one between conservative versus revisionary conceptions of philosophical analysis with respect to commonsensical beliefs and intuitions this paper offers a comparative investigation of two revisionary methods carnapian explication and ameliorative analysis as developed by s haslanger it is argued that they have a number of common features and in particular that they share a crucial political dimension they both have the potential to serve as instrument for social reform indeed they may produce improved versions of key concepts of everyday life for example those pertaining to social categories such as gender and race among others which in turn may lead to social change the systematic comparison of these two frameworks offered here where similarities as well as differences are discussed is likely to provide useful guidance to practitioners of both approaches as it will highlight important aspects of each of them that tend to remain implicit and undertheorized in existing applications of these methodologies to specific questionsrevisionary analysis • carnap • explication • haslanger • ameliorative analysis • philosophical methods • race • gender in recent years discussions on philosophical methodology have become intensified arguably in response to the challenges posed by the surge of experimental approaches b catarina dutilh novaes

19989_0

introduction cancer research holds the key to continued progress in the prevention early detection treatment and control of cancer the increased identification and use of genetic markers to evaluate cancer risk and treatment and the potential of targeted drug therapies for cancer treatment have increased the importance of biospecimen in cancer research currently fewer than 3 of cancer patients participate in clinical research and among these racialethnic minorities are underrepresented 123 this underrepresentation of specific population groups in cancer trials results in the failure to capture differences in response to investigational agents and procedures within those groups and limits the broad applicability of findings low cancer clinical research participation rates are a significant barrier to progress in cancer prevention control and treatment particularly for underrepresented population groups african americans have the highest cancer mortality rates for the majority of cancers including breast cancer 4 and they remain underrepresented in cancer clinical trials 56 to impact cancer outcomes in african americans equitable representation in cancer research is critical to ensure applicability of research findings studies of the barriers to clinical trial participation of african americans show that lack of knowledge about cancer research and negative perceptions of clinical trials are significant barriers to participation 789 additionally a historic mistrust of the health care system represents a distinct barrier to research participation 10 programs that target knowledge and perceptions may increase willingness to participate in cancer research utilizing trusted individuals from within the community to impart this knowledge may break down barriers of mistrust community education and train the trainer programs providing education to community advocates and lay people are effective at increasing cancer knowledge of screening guidelines in various populations 111213 programs adapted for specific populations including african americans and using a train the trainer model have been shown to be effective in preparing lay educators to transmit cancer clinical trials information and effect change in research knowledge attitudes and behavior 1415 training models based on social networking theory that prepare lay educators to transmit information about bio specimen in research have been less well studied petersburg the community of focus for this project is within the crater health district and has a population that is predominantly africanamerican the crater health district has the second highest cancer incidence and mortality rates in the state and ranks 13 th out of 35 health districts in breast cancer mortality 16 cancer is the second leading cause of death in petersburg with a mortality rate of 244100000 17 we conducted a breast cancer needs assessment of the community in 2010 to evaluate the contributing factors to the cancer disparity and identify assets within the community to address the issue 18 a community health educator dedicated to the area facilitated the assessment in partnership with a breast cancer coalition paint it pink petersburg pipp is composed of key community organizations breast cancer survivors mammography centers and nonprofit organizations outcomes of the assessment included development of a culturally and locally relevant breast health education tool to disseminate positive breast cancer screening messages and local resource information additionally a breast cancer support group was formed that became a significant resource for the current project the project reported here developed a breast health research champion training program targeting women from petersburg the program was designed to train selfidentified community breast health advocates to motivate women in their social circles to be screened for breast cancer increase knowledge of cancer research and biospecimen collection and influence future research participation and biospecimen donation the model for transmission of health messages tested is unique in that it trained individuals not only in breast cancer screening guidelines and breast cancer research but also on a relatively unknown and misunderstood topic of bio specimen in research in addition this program provided training in human subject protection and required bhrcs to take the role of a researcher acquiring consent and collecting data from attendees at their presentations we evaluated the training program for its impact on knowledge and attitudes of the trainees the effectiveness of trainees in changing the knowledge attitudes and behaviors of attendees at their presentations the variety of outreach methods used and audiences reached by the trainees the extent to which the trainees continued to disseminate information in the six months following the end of the project was catalogued materials and methods training program development and evaluation the program was designed to train residents of petersburg interested in promoting breast health and research in their community in four areas best practices for breast cancer early detection cancer clinical research the role of biospecimen in cancer research and human subject protection in research additionally they were provided training in facilitation of an educational event participants agreed to conduct two chats with individuals within their social networks to impart the information learned during the training program they were allowed to conduct their chats in a venue of their choice and no restriction was placed on the number of people at the event the training program emphasized four key takeaway messages that were reinforced at the beginning and end of each session and were designed to facilitate participant preparation for their own chats early breast cancer detection saves lives get screened todays breast cancer treatment was yesterdays clinical trial tomorrows treatment comes from todays biospecimen donation you can help find the cure for breast cancer the four training sessions followed a similar format beginning with a review of information from the previous session presentation of the takeaway message for the new topic area presentation of the information a planning activity for incorporating the information in their chats and a wrap up certain sessions had key components that were felt to be important to the training an outline of key content is provided in table 1 the training program was facilitated by a community health educator individuals with expertise in the topic area presented the information pertinent to each training session a representative from susan g komen for the cure provided the presentation for session one a key component in this session was a presentation by a breast cancer research advocate active at the state and national level breast cancer risk factors and guidelines for breast cancer screening were presented session two covered information on cancer clinical trials the presentation for this session was adapted from information in the nci understanding clinical trials series 19 and was presented by the minority clinical trial recruitment liaison from the academic cancer center key components in this session were a discussion of past abuses in clinical research and the current regulations for the protection of human subjects as well as a video testimonial of a clinical trial participant of similar racialethnic background as trainees session three on biospecimen in research was presented by a genetic counselor from the academic cancer center the presentation included information on genetic determinants of cancer risk and the role of biospecimen acquisition in cancer research a key component to this session was a tour of a biospecimen banking facility at the academic cancer center and a conversation with a breast cancer researcher a technician from the bio bank provided the tour and presented information on the process of tissue acquisition and storage including patient consent the fourth session was facilitated by the community health educator and covered human subjects protection in research the information presented was patterned after the universitys irb approved course for community members engaged in research key to this session was ethical scenarios relevant to research presented in the form of role play trainees were provided with tips on planning their events and facilitating their chats upon completion of the training sessions the breast health research champions were asked to schedule 2 chats with people from their social networks bhrcs were required to get verbal consent from chat participants before each event collect a survey from their participants and call participants 4 weeks postevent to gather information about actions taken as a result of the presentation a final meeting was held upon completion of the chats to present the bhrcs with a certificate of completion and celebrate their accomplishments a discussion group about the bhrcs experiences and their recommendations for the training program was conducted breast health research champion recruitment the project was approved by the virginia commonwealth university institutional review board prior to beginning any recruitment or research activities involving human subjects fifteen trainees for the breast health research champion training program were consented from the target community advertising through fliers email and word of mouth targeted individuals who had been impacted by breast cancer either as a survivor caregiver or relativefriend of someone affected by breast cancer interested individuals were screened to assess their experience with breast cancer previous activities in breast health advocacy and enthusiasm to become active in breast cancer research advocacy in their community those evaluated to have potential to be active advocates for breast health and research by the research team were consented for the study training program evaluation and modification multiple methods were used to evaluate and modify the training program for improved effectiveness a questionnaire was given before and after the clinical trials and biospecimen training sessions that evaluated knowledge and attitudes about the topics discussed questionnaires consisted of nine true and false knowledge questions and 67 attitudinal questions using a 5 point likert scale questions addressed commonly held misconceptions about clinical research and biospecimen collection descriptive analysis of results from the prepost questionnaires were evaluated after each session to identify areas in the training that should be enhanced to ensure appropriate transmission of message a posttest correct response rate of 85 for knowledge questions resulted in a modification of training material content and the information was discussed at the beginning of the following training session to be sure of accurate understanding by trainees in addition to the questionnaires detailed notes were taken during each training session a debriefing session was held by the research team immediately after each session to review the events of the session and document impressions upon completion of the program and the chats breast health research champions participated in a discussion group their perspectives on the training process the impact of their role as disseminators on their knowledge and attitudes and recommendations for improvement of the program were discussed written impressions about specific aspects of the program were solicited from the bhrcs at that time notes from the training sessions and debriefings were reviewed and information related to key session component effectiveness topic presentation content and general training manual utilization collated the research team reviewed the findings and identified program areas requiring modification this information was combined with bhrc recommendations provided during the final discussion group to make final program modifications evaluation of bhrc message dissemination the bhrcs impact on knowledge attitudes and behaviors of attendees at their chats was evaluated through a postpre questionnaire additionally bhrcs contacted all chat participants 4 weeks postevent to ask if they had talked to individuals in their social circle about the information and if they had taken action to be screened for breast cancer if applicable to gather information about the bhrcs experience hosting the chats they were asked two questions after each event how did you feel giving the presentation and what are your general impressions of the event this information was collated by the research team and evaluated for major themes the postpre survey taken by attendees at bhrc chats were scored on a likert scale ranging from 1 to 5 questions targeted key information and common myths emphasized during the bhrc training sessions and were developed using a combination of standardized questions from the literature questions used in established breast health training programs and questions developed specifically for this program 20 the questionnaire went through a review process by the research team subsequently it was reviewed by the bhrcs for clarity literacy level and applicability and were modified according to their recommendations participants were asked to respond to items first as they typically would on a posttest and then to reflect how they would have responded prior to the chat this postthenpre survey strategy has been proposed as a particularly appropriate assessment when the subject material is unfamiliar 21 participants responded to 11 items measuring knowledge attitudes and intended behaviors summed scales were considered to group items in each of these domains however cronbach alpha was low for knowledge and attitude items perhaps indicating the items reflect different contexts items measuring intended behaviors however were well correlated so a summed scale was created to analyze those four behavior items descriptive statistics were calculated for individual survey items and for the summed behavior scale changes in beforeand afterchat responses were primarily assessed with paired ttests our study design was complex in that chats were administered by 12 different bhrcs and each bhrc conducted two sequential chats to account for this study design we also assessed beforeafter differences through mixed model regression with bhrc designated as a random variable we included an interaction term in the models to see if the effect of the chat differed between the first and second chats statistical significance was determined with alpha005 results results of the breast health research champion training program recruitment for the bhrc program resulted in 18 women being screened 15 women consented and 12 who completed the training program and held two chats of the three women who did not complete the training one had a reoccurrence of cancer during the training one had health complications with stage four breast cancer and the third woman was her daughter who left the study to support her mother nine of the women completing the program were residents of petersburg va with the remaining bhrcs living in neighboring communities ten of the bhrcs were african american women one was hispanic and one was caucasian nine of the woman were breast cancer survivors with survival times ranging from 2 to over 25 years two had immediate family members impacted by breast cancer and one participant was interested in womans health the age of the participants varied with six between the ages of 3555 four 65 years of age and two under the age of 35 the four older women were active volunteers in their church hospice facility andor working parttime at a senior day center participants who worked were employed in public school systems the university in healthcare public health or social services arenas all the participants had volunteer roles in various settings including school systems churches sororities and public health most of the women identified themselves as breast health advocates prior to participating in the program two bhrcs had participated in a clinical trial and were avid supporters of research the remaining women were still formulating opinions about clinical research evaluation of the training sessions pre and post questionnaire analysis of the clinical trials training session showed that the session effectively transmitted information about the level of care and type of treatment received during a clinical trial the positive experience of patients on clinical trials and the percentage of adult cancer patients who participate in research post session knowledge was low for the topics of insurance coverage for clinical research and the frequency with which cancer patients are told about clinical research although knowledge clearly improved about the importance of minority participation in research and the existence of regulations for the protection for research participants correct responses did not reach 85 information provided in the training sessions about these topic areas were enhanced as a result mean likert scale values for attitudes about the importance of clinical trials the role of the trainee in informing their community about research and their motivation to transmit messages increased after the training for all questions all means fell between agree and strongly agree for the pretest reflecting the motivation of trainees for breast health advocacy pre and post questionnaire analysis of the biospecimen training session showed that the session effectively transmitted information about what a bio bank is who can donate use and applicability of biospecimen research and regulations protecting donors personal control of donated tissue and tissue use for personal treatment decisions were areas that showed insufficient postsession knowledge the training materials related to these two topics were modified to improve understanding unlike the clinical trials training session in pretest responses participants were generally neutral or less confident in their attitudes about and willingness to participate in bio banking regulations protecting a donor and their skills to transmit information about bio banking trainees showed noted improvement in these areas after the training session qualitative information from training session notes and commentary from the trainees during the final discussion group informed modifications of the training program the breast cancer research advocate testimonial at the beginning of the training program was identified as impactful the information given by the susan g komen representative was well received and the use of small prizes as incentives for participation in discussion was later used by the majority of the bhrcs during their chats the clinical trials presentation was considered effective and a time for discussion of past research abuses particularly important attendees related to the video of testimonials of people who had participated in research areas requiring modification included clarifying information on insurance coverage of clinical research there was a noted attitude shift about clinical trials after the presentations my perspective has totally changed about clinical trials key training components identified as having an impact for the biospecimen training session included meeting a breast cancer researcher and touring the tissue data acquisition and analysis core the level of knowledge of the trainees about tissue banking was minimal and many had misconceptions about what tissue collection entails the tdaac tour was very impactful with the visualization of the facility providing perspective on the size and method of storage of tissues this represents so many people the session on ethics in human research subject protection served to make concepts about clinical research and biospecimen collection tangible for the trainees ethics scenarios were discussed in small groups and trainees related the information to what they would need to do during recruitment and consenting of participants in their chats trainees were engaged and took ownership during this session i feel like i am empowered you dont have to have been diagnosed with cancer to help find a cure i am excited about being a carrier of this message information provided by the bhrcs during the final discussion group coincided with impressions during the training sessions they indicated that the direct engagement with breast researchers and the tissue banking facility was an impactful component of the training program in addition the presentation by a person with a history of breast health advocacy as an example was important evaluation of bhrc message dissemination after completing the training sessions bhrcs held two educational events in a venue and to an audience of their choosing bhrc events were diverse in the venue selected mode of message transmission and the audience reached venues included bhrcs homes places of employment a senior center a low income housing unit a military base a conference church and during family reunions two bhrcs held their chats using social media a discussion board and via skype while a third approached patrons at a public coffee house the audience was of all adult age ranges and included friends and family colleagues sorority sisters strangers purposefully encountered at a coffee house and housing residents individuals reached and the styles of presentation were as varied as the bhrcs which is in line with social networking theory these individuals were able to reach people from within their social circle many of whom might not have been reached by traditional outreach methods in total 199 people attended the bhrc educational events with attendance per event ranging from 1 to 26 evaluation of bhrc responses to the two questions after each chat showed that nine out of the twelve bhrcs were comfortable giving their first chat with all feeling that their level of comfort increased during the second event the three bhrcs who expressed initial nervousness did not have much speaking experience or held a position that did not require public speaking the major themes coming from the second question fell into four categories selfactualization attendee response unexpected outcomes and future opportunities bhrcs expressed feelings of selfactualization after their events two bhrcs said that they felt empowered or like the experts by having the knowledge to provide the presentation one bhrc expressed i had no idea i could have this kind of impact another commented i was excited and knew my stuff… all of the bhrcs indicated positive attendee response with their audiences being very engaged at one or both of their events often to their own surprise i had invited them to spend 45 minutes with me today but we went an hour and i ended it at that point…however they wanted to go longer the attendees were extremely interested and actively involved in the discussions awesome … we had so much fun we didnt realize what time it was when the session was over an unexpected outcome from the perspective of the bhrcs was that many received requests to give the presentations to other groups and organizations in one case a chat attendees family member searched clinical trials related to throat cancer and was eligible to participate the family now advocates for clinical research due to positive results of his participation for another the presentation stimulated open family conversation about cancer for the first time in a third scenario the genuine interest of younger people that she presented to and the extent of their questions was surprising finally three bhrcs mentioned multiple questions about male breast cancer and they recommended that it be included in the bhrc training results from the postpre questionnaire showed significant increases in knowledge attitudes and intended behaviors for all items except two related to knowledge about breast cancer risk factors no significant changes were found for level of agreement with how old i am affects if i can get breast cancer or not and no one in my family has cancer so i wont get cancer statistical conclusions were the same for paired ttest and mixed model analyses no interaction effect was found that would suggest a different impact between the first and second chats seven bhrcs provided followup information from attendees at their chat events out of the 95 chat attendees for these bhrcs 79 responded to the followup questions 66 answered the question related to screening and 78 responded to the question about their communication of information learned to others of women eligible to get a mammogram 38 had taken action to get a mammogram the majority indicated that they had spoken to someone in their social network about the information discussed during the chat ten of the bhrcs provided information about their outreach activities for the six months following the training on average the trainees held 61 informal or formal events during the 6 month period reaching a total of 786 individuals with the key messages age ranges reached were from 19 to 65 years of age of both genders and of raceethnicities primarily african american but also including caucasian americans and hispanics one bhrc developed an online program to disseminate the messages and estimated that she reached over 6000 people discussion this project successfully developed an effective breast health research champion training program for women interested in becoming advocates for breast cancer screening and research in their community the program stemmed from an ongoing collaboration between the community and the academic cancer center it is unique in that it provides training in the importance of biospecimen in cancer research and requires trainees to take on the role of a researcher as a way of experientially impacting attitudes about research our findings indicate that the program increases knowledge and changes attitudes of trainees about cancer research and biospecimen collection and increases their confidence to transmit key messages related to these topics to individuals in their social networks all bhrcs successfully organized and conducted two social events chats to disseminate the key messages there was strong evidence that they were effective at increasing cancer research and biospecimen knowledge and changing attitudes and behaviors of attendees of their chats over one third of attendees queried had taken action to get breast cancer screening and the majority had spoken to someone else about the information learned the bhrcs continued to reach out to individuals in their community in the six months after completion of the program the population this project reached a predominantly african american community with high breast cancer mortality has a history of distrust of the medical community this mistrust can result in reduced participation in clinical research and biospecimen donation as can a lack of knowledge 89 using individuals from the community to provide accurate information about research and biospecimen in a manner that is culturally congruent is a strategy to address the mistrust barrier and affect a change in behavior breast cancer research champions from the community were able to provide information on breast cancer screening clinical research and biospecimen donation through established cultural and social networks challenges exist when using community members to develop effective training programs particularly when they become the agents for data acquisition compliance with the 4 week followup by the bhrcs was low with 7 of the 12 bhrcs providing this followup data despite this those who did provide the information had a good response rate from their attendees the bhrcs themselves were enthusiastic about ongoing engagement with the academic cancer center for continuing education with 83 of them attending regular educational events and providing followup data about their activities the theoretical framework upon which the intervention is based is the social network theory this theory emphasizes the importance of social networks ie formal and informal community organizations and individuals and the linkages that connect them these networks can be instruments by which awareness of health behaviors can be raised and provide opportunity for members to engage in healthy behavior 22 23 24 social network theory views social relationships in terms of individual actors within the networks and the relationships between the actors there are many possibilities for the types of connections between individuals in its basic form a social network consist of all the relevant ties between individuals from work to personal relationships to online socializing 25 the bhrcs utilized a broad range of social ties to disseminate the four key messages learned during the training and the attendees at their sessions continued to disseminate the message along their own social connections components of the program that were identified as key to effective bhrc training included a presentation by a person actively engaged in breast health and research advocacy an open discussion about past clinical research abuses particularly with the african american community and testimonials by culturally congruent clinical trials participants a physical tour of the tissue banking facility at the academic cancer center served to dispel misconceptions about the acquisition and storage process as well as the fear some participants had about the process finally the act of functioning as researchers acquiring verbal consent from their participants and collecting data to evaluate the program changed trainees attitudes about research and researchers a limitation of our study is the lack of detailed data collection on the attendees at the bhrcs chats and the individuals who they spoke to about the topic further detail on demographics their role in the community and their relation to the bhrc would allow analysis of the patterns of information dissemination additionally the small number of bhrcs that completed the training did not give us power to evaluate trainee prepost questionnaire data for statistical significance the information was used descriptively to evaluate trainee knowledge acquisition and attitude change and was valuable for program modification but could not provide the statistical validity the program is being repeated in two additional locations an urban center and a rural community which will allow for validation of the current findings and evaluation of the applicability of the program in various settings

a breast health research champion training program was developed targeting selfidentified community breast health advocates from a predominantly african american community with a significant breast cancer mortality disparity twelve individuals completed the program that provided training in breast cancer risk and screening breast cancer research biospecimen in cancer research and human research subject protection the training emphasized four key messages to be disseminated to the community trainees hosted a minimum of two social chats with individuals from their social networks and functioned as community researchers acquiring consent and gathering followup data from attendees trainees reached 199 individuals from their social networks and chats were diverse in the venue selected mode of message transmission and the audience reached postpre questionnaire data from attendees at the chats showed significant improvement in knowledge attitudes and intended behaviors as it relates to breast cancer screening clinical research and biospecimen in research forty percent of attendees provided 4 week followup information of respondents eligible for mammography 38 had taken action to be screened and 86 of respondents had spoken about the information to someone else in their social network trainees expressed feelings of empowerment after completing the project feeling like the expert and all trainees were surprised at the enthusiastic response from attendees of their

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inequalities in mortality have been documented in several european countries among migrant populations compared with majority populations 4e6 these inequalities vary according to specific causes of death the few studies investigating injury mortality among migrants in a european context confirm increased mortality for all injuries combined albeit differences were seen according to type of injury ethnic group sex and age 7e9 as in these studies our definition of injury mortality included mortality from both unintentional and intentional injuries 7 9 studies of injury mortality among migrants are of interest because it could be assumed that migrants are especially vulnerable in this respect as they experience various risk factors related to injuries and injury mortality due to the inherent trauma of uprooting and the challenges of restabilising life in a new country migrants have a higher prevalence of mental disorders compared with native populations 10e12 migrants experience discrimination and hate crimes 13 migrants socioeconomic status is often lower compared with native populations 1 migrants more frequently work in unskilled highrisk jobs 14 and migrants experience problems in accessing appropriate healthcare 15e17 these risk factors may alone or in combination result in higher injury mortality this may especially be the case for vulnerable migrant groups such as refugees conversely migration could hypothetically also be protective in relation to injuries building on the healthy migrant theory one may argue that some migrant groups have a stronger health than native populations 6 additionally literature on risk behaviour show less substance abuse among migrants compared with host populations 18 no nordic studies exist on injury mortality among migrants however a danish study on unintentional injuries found lower injury rates among migrants children compared with the children of native danes 19 the scarcity of studies and the contrasting findings emphasise the need for more knowledge on injury mortality patterns among migrants compared with patterns among native populations additionally existing studies divide populations according to ethnicity rather than migrant status 7e9 consequently we aimed to determine injury mortality including both ethnic origin and migrant status in a welldefined cohort of migrants and compare it with that among native danes based on national data using the unique danish possibilities of registerbased national data material and methods study cohort the study cohort was obtained through the statistics department at the danish immigration service all individuals who obtained right of residency as refugees or through family reunification in denmark from 1 january 1993 to 31 december 1999 were included 84 379 individuals were identified the cohort was established on 1 january 1993 as this was the first year for which the danish immigration service had valid registry information on all individuals obtaining residence permit next we excluded individuals 18 years of age when they obtained residency another 3042 individuals were excluded due to missing civil registration numbers or because their personal security numbers appeared more than once in the sample additionally 15 migrants and their controls were excluded due to problems with their registration of nationality a danishborn reference population was identified through statistics denmark and a 41 match on an individual level on age and sex was preformed through a random sampling procedure we made a 41 matching for all refugees four of the immigrants were missing from a total of five controls due to difficulties with age matching because of outlying ages the study cohort and matching procedure have previously been described in more detail 20 last 6188 migrants born in western countries were excluded from the cohort with their corresponding controls we excluded western migrants because we expected patterns of injuryrelated mortality to differ from nonwestern migrants due to differences in exposures to risk factors related to migration processes between these two groups the final cohort comprised 29 139 refugees and 27 134 immigrants migrants were consecutively censored on their first registered emigration date and were not included again if they later returned to denmark followup time was thus defined for both refugees and immigrants and their corresponding controls as the time from the commencement of right of residency until the time of the first of the following events date of death end of study or date of first emigration characteristics of the study population are shown in table 1 data collection civil registration numbers of the study cohort were crosslinked to the danish register on causes of death using the personal identification number which is a unique 10ciphre number that all danish citizens receive the register on causes of death has data based on the report of death certificates to the national board of health the register was updated to 31 december 2007 death causes were coded according to the international classification of diseases tenth revision the register has used the icd10 coding system since 1 january 1994 a change from the icd8 coding system previously used as the validity of the translations in the register from icd8 to icd10 is questionable we decided to use only icd10 diagnoses starting from 1 january 1994 among all deaths in the cohort the cause of death was missing in 168 individuals and were consequently excluded from the study on their date of death we identified all unintentional and intentional injuryrelated deaths from 1 january 1994 to 31 december 2007 unintentional injuries included injuries with undetermined intent meaning that in some cases it is not known from the record whether an individual died from accidental or by suicide unintentional injuries encompassed falls traffic injuries unintentional poisoning not medication and other causes intentional injuries included all suicides and homicides this definition of injury mortality is in line with a previous danish study 21 the cohort comprised 92 refugee and 48 immigrant deaths from injuries we analysed data by migrant status and adjusted for region of origin according to the largest migrant groups in denmark we based our definitions of geographical areas on who guidelines asia eastern europe the former yugoslavia iraq the middle east north africa and subsaharan africa 22 as iraqis formed the largest regional of statistical analysis we estimated the rate ratio and 95 cis for refugees and immigrants compared with their danishborn controls using a cox regression model which was fitted separately for men and women native danes form the reference group the cox regression analysis implies a continuous adjustment for age in the model further the rr was analysed by both migrant status and region of birth and adjusted for income the analyses take into consideration the time during which an individual has been in a certain income category and allow for people to change from one income category to another over time we assumed that the effect of income on mortality was the same for refugees immigrants and controls before making this assumption we analysed all interactions among migrant status region of birth and income and found no significant interactions first we studied the unadjusted rr and then the rr adjusted for income as these separate analyses gave the same conclusion table 2 shows only the adjusted rates further analyses split on region of origin are referred to only in the text the cox regression model allowed us to compare the rr for refugees with that of immigrants and not only with that of their danishborn controls last because of the low number of homicides and suicides only unintentional injuries are described by specific cause of injury and differences are tested using c 2 tests the danish data protection agency has approved the study further ethical approval regarding registrybased research is not required in denmark 23 the data set was made available and analysed in an anonymous form by remote online access to the data set stored at statistics denmark results table 1 shows characteristics of the study cohort distributed by migrant status and sex the cohort had a median age at study end of around 44 years among refugees and 37 years among immigrants the median followup time was approximately 12 years for refugees and approximately 11 years for immigrants among refugees 44 were women and among immigrants 67 were women approximately half the refugees in the cohort came from the former yugoslavia while immigrants originated mainly from the middle east and asia table 2 shows the rr of sexspecific injury mortality estimated by migrant status adjusted for age and income compared with native dames suicide mortality was significantly lower for male refugees and male immigrants whereas female refugees and female immigrants showed no significant differences analysed by region of origin suicide mortality was significantly lower for refugee men from the former yugoslavia and iraq as well as for immigrant men from the middle east the results for all other groups were nonsignificant table 2 also shows that compared with native danes immigrant women had a significantly higher homicide rate all other groups showed nonsignificant differences analysed by region of origin homicide mortality was higher among refugee women from subsaharan africa albeit only on a borderline significant level the results for all other groups were nonsignificant last table 2 shows the rr of mortality from unintentional injuries compared with native danes both female and male refugees had significantly lower mortality from unintentional injuries this was also true of immigrant women and men analysed by region of origin only refugee men from the former yugoslavia and iraq as well as immigrant men from the middle east had significantly lower unintentional injury mortality compared with that among native danes however most other groups showed similar nonsignificant tendencies for both sexes table 3 shows the frequency distribution of unintentional injury mortality by specific disease causes among refugees and immigrants compared with their danishborn controls male and female immigrants had higher mortality from falls compared with that among native danes no systematic differences were found for refugees refugees of both sexes and immigrant women had a higher mortality from traffic unintentional injuries compared with native danes no difference was seen for immigrant men however mortality from poisoning was consistently lower among all migrant groups compared with that among native danes for other death causes no systematic differences were observed only male refugees differed significantly in the distribution of injury types compared with their danishborn controls whereas this was not the case for female refugees male and female immigrants did not differ significantly compared with their danishborn controls to increase power we combined both sexes where the results pointed insignificantly in the same direction consequently we found an rr of 084 of suicide for refugees combined compared with danishborn and a homicide rr of 195 for refugees combined compared with danishborn aggregated analyses could not contribute to other conclusions for the remaining analyses of intentional and unintentional mortality data which is why all analyses are shown separately by sex discussion our main results show that compared with native danes suicide mortality was significantly lower among male refugees and immigrants whereas their female counterparts showed no significant differences however immigrant women had a significantly higher homicide rate than native danes did no other groups showed significant differences last refugees and immigrants of both sexes had lower mortality from unintentional injuries compared with native danes differences by region of origin were found for both intentional and unintentional mortality outcomes methodological strengths and limitations we used the unique danish possibilities of crosslinkage between several different national registers this enabled us to identify a large cohort of refugees and family reunited immigrants based on specific information from the immigration authorities on migrant type and also enabled us to divide refugees and immigrants according to seven geographical subgroups the design allowed us to calculate death rates over a followup period of up to 12 years and enabled us to compare directly with a matched group of native danes there are several factors that may have influenced the results of this study first it is important to stress the exploratory nature of the study due to the small numbers although the study is based on a relatively large cohort of migrants absolute numbers become relatively small when the specific injury mortalities are investigated and stratified according to region of birth and migrants status despite this power problem our analyses were significant however further analysis according to causes of unintentional injuries was only possible in the form of a frequency distribution second the register on causes of death did not receive death certificates for 3 e4 of all the annual deaths that were registered in the population register at statistics denmark third 17 of all deaths studied for causespecific mortality had unknown cause of death listed consequently there may be differences between migrants and native danes regarding the distribution of these unknown death causes but these differences are not likely to be substantial as the 168 deaths are fairly equally distributed over migrants and controls last our results may also have been affected by registered or unregistered remigration which would have skewed the denominator figures thus remigration of healthy individuals may have inflated our results whereas remigration of critically ill individuals with infectious diseases who then die abroad would have led to an underestimation we had no means of taking these biases into consideration as we did not know the extent of remigration in relation to these two points deaths abroad of individuals with a danish personal identification number are reported to the danish authorities on an irregular basis those death certificates sent to the register of death causes are not included due to validity problems discussion of findings our results showed a protective effect of being a migrant on suicide mortality albeit only significantly so for men although the results are based on very small numbers they are supported by some european studies 8 21 24 but in contrast to others 25 for example a danish study showed that male residents with foreign citizenship in denmark had a lower risk of suicide compared with male danish citizens 26 these results are contraintuitive in that research has established higher rates of mental health problems among migrants of both sexes which is explained by the strain of trauma prolonged asylum procedures loss of identity and the stress of reestablishing life in the immigration country 10e12 additionally rates of suicidal behaviour are higher among migrants than among natives 27 28 what could explain our results studies show that some nonwestern migrants have stronger cultural and religious norms which make suicideselection less acceptable and therefore discourages individuals despite mental health problems 29 30 our study enabled us to divide by migrant status and previous studies of our cohort have indeed shown more mental disorders among refugees compared with family reunited immigrants 9 31 contrary to our expectations we found only a minor protective effect of family reunification compared with refugee status second our results showed nonsignificant tendencies towards a higher mortality from homicide among immigrant women our findings are based on very small numbers which warrants caution when interpreting them two dutch studies also found a higher homicide rate among migrants of both sexes compared with native dutch 7 8 a higher mortality from homicide among migrants may be attributed to several interrelated factors including the psychosocial stress of reestablishing life in a new context lower socioeconomic position differences in cultural norms and higher involvement in criminal affairs among migrants a recent danish study showed that male firstgeneration migrants and descendants from nonwestern countries had a higher involvement in all criminal activities compared with that among native danes with a similar socioeconomic background 32 finally our results showed consistently lower rates of unintentional injury mortality among all groups of migrants compared with that among the danishborn this is supported by a danish study on unintentional injuries that found lower rates of injuries treated at emergency departments among migrants children compared with children of native danes 19 the literature shows that unintentional injury mortality differs according to unintentional injury type 7e9 we preformed an analysis of the causes of unintentional injuries to understand our results better however due to small numbers we could only make a c 2 tested frequency distribution the only significant finding was differences between male refugees and danishborn male refugees died more from traffic injuries whereas danishborn especially died more from poisoning including poisoning from medicine drugs and alcohol these results are supported by the literature on risk behaviour which shows low alcohol and drug consumption among migrants compared with the host populations 18 33 in conclusion our study is exploratory in nature being limited by numbers however the results suggest interesting trends in injuryrelated mortality overall results were advantageous to migrant groups apart from homicide mortality future research needs to further explore injury patterns in larger populations also using less severe injury outcomes moreover research including qualitative studies should concentrate on investigating which protective factors are important among migrants compared with natives such research may also benefit injury prevention in the majority population inflatable bounce house injuries a report in pediatrics shows that a design overhaul of childrens inflatable bounce houses is needed because about 30 children per day in the usa are injured while playing in them between 1995 and 2010 there was a 15fold increase in the number of such injuries especially in recent years the us consumer product safety commission recommends that children under 6 not be allowed to use fullsize bounce houses the authors headed by gary smith called for better guidelines for use and for design changes record low homicides in new york murders in new york city have dropped to their lowest level in over 40 years the actual number is 414 homicides in 2012 compared with 515 for 2011 in the 1990s the totals were in the 2000s the mayor credited the departments controversial practice of stopping people on the street and questioning them as well as aggressive hotspot policing against this good news is the fact that 20 children were murdered nevertheless total killings have dropped so low that there are now more suicides than homicides the commissioner said he believed that relatively new policing strategies including adding more police officers dedicated to curbing domestic violence and monitoring social media to thwart gangrelated murders were working magnets banned an australian report states that small high powered magnets that can cause serious injury or death if swallowed by children have been permanently banned the products that contain numerous small highpowered magnets are marketed as toys games or puzzles the problem is if a young child swallows more than one of these highpowered magnets they can attract to each other across the intestinal wall and perforate the intestine leading to serious injury or possibly death teenagers have also needed surgery after using these magnets to imitate mouth or tongue piercings from inj prev first published as 101136injuryprev2012040336 on competing interests none provenance and peer review not commissioned externally peer reviewed what is already known on the subject the few studies investigating injury mortality among european migrants show increased mortality for all injuries combined albeit differences were seen according to type of injury ethnic group sex and age what this study adds in contrast to our expectations our results showed consistently lower rates of unintentional and intentional injury mortality apart from homicide mortality among migrants compared with that among the danishborn this study is the first in a european context to explore injury mortality using migrant status and not merely ethnic background our study used the unique danish possibilities of performing registerbased studies on national data moreover we were able to distinguish as intentional and unintentional injury types

background the authors studied injury mortality in denmark among refugees and immigrants compared with that among native danes method a registerbased historical prospective cohort design all refugees n¼29 139 and family reunited immigrants n¼27 134 who between 1 january 1993 and 31 december 1999 received residence permission were included and matched 14 on age and sex with native danes civil registration numbers were crosslinked to the register of causes of death and fatalities due to unintentional and intentional injuries were identified based on icd10 diagnosis sexspecific mortality ratios were estimated by migrant status and region of birth adjusting for age and income and using a cox regression model after a median followup of 11e12 years results compared with native danes both female rr¼044 95 ci 023 to 083 and male rr¼040 95 ci 029 to 056 refugees as well as female rr¼040 95 ci 021 to 076 and male rr¼022 95 ci 012 to 042 immigrants had significantly lower mortality from unintentional injuries suicide rates were significantly lower for male refugees rr¼038 95 ci 024 to 061 and male immigrants rr¼024 95 ci 010 to 059 whereas their female counterparts showed no significant differences only immigrant women had a significantly higher homicide rate rr¼309 95 ci 111 to 860 compared with native danes conclusions overall results were advantageous to migrant groups research efforts should concentrate on investigating protective factors among migrants which may benefit injury prevention in the majority population of the population in denmark in 2010 immigrants and descendants constituted 98 of whom 23 were descendants and 75 immigrants 1 the majority 61 of immigrants come from nonwestern countries the five most frequent countries of origin being turkey iraq lebanon bosnia and pakistan divided by migrant status denmark has received 75 000 refugees and 105 000 family reunited immigrants within the past 15 years 2 3 refugees enter denmark as spontaneous asylum seekers or as quota refugees whereas family reunited immigrants enter denmark by their own means and rely entirely on their family when establishing life in the country of immigration in this paper family reunited immigrants are referred to as immigrants while migrants refer to all groups of foreignborn individuals

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a recent systematic review 1 reports that diabetes education can contribute to decreased emergency department visits for persons with diabetes as an essential part of diabetes education and selfcare diabetes communication has been demonstrated to be multidimensional in nature 2 to identify how communication contributes to more effective diabetes selfmanagement and avoidable emergency department visits requires closer study by diabetes educators of less explored dimensions of patient perception and perspectives 3 this study unites diabetes education with a unique approach from social science and linguistics methodologies combining positioning theory and stance analysis to examine how people make sense of the practices that lead to recurrent emergency department visits our goal was to identify needs for more effective intervention approximately 258 million people in the united states are living with diabetes and health care costs for people with diabetes are 23 times more than costs for people without diabetes 4 people with diabetes have significantly higher emergency department use and costs as compared to those without diabetes mellitus and sources of payment for these visits include private insurance medicaid medicare and selfpayuninsured 5 from 1996 to 2006 ed visits increased by 32 but those visits considered emergent remained stable over this time raising questions about sources of health disparities the ed visit rate for african americans or blacks was double the rate for whites in all age groups 6 in south carolina 13 039 persons were discharged from eds with a primary diagnosis of diabetes and the average cost per visit was over 2000 in 2008 almost half of these visits were for treatment of uncomplicated dm which could be more easily managed with primary care or in another ambulatory setting 8 african americans compose 28 percent of the states population 9 but made 60 percent of these ed visits 8 an earlier study using medical record reviews attributed 20 of the ed visits to preventable complications of diabetes 10 at this time no clear evidence explains this pattern of use overall or sources of racial disparities in south carolina additionally no empirical evidence has been found that explains ed use from the patients perspective diabetes educators play a significant role in helping people learn to better manage their diabetes and in improving the management of diabetes across all health care settings however few studies provide evidence for guiding the diabetes educator and other health professionals to better understand patients issues associated with avoidable ed use for african americans or others with diabetes research design funded by national institutes of health through the national institute of nursing research the overall goals of the larger research project that produced this data were to document and understand the factors related to ed use the reasons for and persons influencing careseeking by african americans with a primary ed discharge diagnosis of ambulatory sensitive or uncomplicated diabetes and to identify an evidencebased explanatory model for future intervention research the specific aims were to describe and understand the factors affecting ed use from the individuals perspective describe reasons for careseeking behaviors by african americans with previously diagnosed dm 3 develop an evidencebased explanatory model of ed use by african americans for ambulatory sensitive conditions related to diabetes the present report describes a subanalysis within the larger study of ed use by african americans with diabetes following institutional review board approval of this mixed methods study at the medical university of south carolina a purposive sample of 20 african american participants with previously diagnosed diabetes was recruited by researchers in collaboration with ed nurses the participants completed the qualitative interviews following their visit to an academic medical center ed in south carolina a description of the participants is shown in table 1 the interviews were conducted in the home within one month of the ed visit by a samerace researcher using an established protocol and interview guide keyed to direct questions about how the participant recognized that some sort of diabetesrelated crisis was in process why they went to the ed what they thought occurred during their stay at the ed and whether the participant had been to the ed for diabetes on prior occasions the interviews were audiorecorded transcribed verbatim by trained research assistants and audited for quality by the pi and one student an analysis of these interviews using grounded theory 11 with dimensional analysis 12 will be reported in a later article the purpose of this article is to introduce a mixed method analysis that applies an approach from sociolinguistics based on positioning theory 13 which proposes that people position themselves as they speak about their diabetes in relation to personal cognitive schema explanatory models and other people involved in decision making as well as the interview to identify such positioning a related analytical framework called stance analysis 14 was applied to transcribed data the mixed methods nature of this analysis arises from the quantitative classification of transcribed text as linguistic categories and the subsequent qualitative interpretation of findings the research design responds to a call within diabetes education for potential tools that can document the process of communication with therapeutic alliances and the artful science that can capture how a diabetes educator responds or should respond to patients 15 methodology using stance analysis to identify patientcentered perspectives the ed atmosphere may not particularly foster current emphases on the use of patientcentered motivation for diabetes management 16 however in the current set of 20 narratives collected postdischarge narrators do identify causal relationships connecting their frightening visit with other events in their lives as part of a coping strategy that according to ville and khlat lets them establish both coherence and meaningfulness 17 furthermore they explain that such narratives vary according to how strongly speakers feel about particular causes their sources and how integrated these causes seem to be across events 17 health care providers and diabetes educators in particular may find that features in the posted interview accounts identify opportunities to infuse cultural brokerage 18 motivational interviewing 19 and other potential interventions 20 that promote more effective selfmanagement at the very least a careful study of these posted narratives can extend the understanding of diabetes educators concerning lay knowledge about causes of health and illness in particular as narratives which have embedded within them explanations for what people do and why as popay and colleagues describe 21 in this discussion no claims are made that particular features lead to potential future selfefficacy among patients with diabetes posted visits nor as franzblau and moore explain 22 is the concept of selfefficacy itself portrayed as a socialized response derived from a blamethevictim perspective the analysis does focus on the construct of personal agency contextualized by expressions of emotion explanation of events and actions and rationales for behaviors as a concept that can offer important even foundational insights into posted narrators efforts to explain themselves and their behaviors to themselves and to others accordingly the stance analysis focuses on agency as concept from sociology that refers to the capability of a person or agent to achieve or act while recognizing that humans as agents are embedded in a social world in which they are influenced by and are influencing others within the constraints of their world as they monitor their actions and the acts of others and generate motives and rationales 23 extending the concept into discourse and linguistics theory people position themselves and others in conversations and explanations as they portray assumptions meanings intentions motives emotions and agency or where they feel incapable 24 this social ecological conception of agency differs from more narrow applications of orems theory of selfcare agency 25 in diabetes that may exclude the person embedded in a broader more conflicted environment than the disease alone as demonstrated in the analysis of african americans with chronic illness 26 for this purposeful sample of 20 interviews from the original study sequential patients seen in the ed were approached for participation for this analysis to represent typical communication patterns in persons with established diabetes using transcriptions from the interviews the stance analysis method was applied for a computersupported coding for the following four dimensions of stance in talk • agency or personalized assignment of responsibility for actions and choices • opinions commonly seen in explanation of and information about events and actions • rationale for explanation with some notion of speakers confidence in explanation and • elaboration with details of personalized affect or emotion stance or how a person takes a stand toward an issue topic or other speaker is a feature of language interaction frequently studied by communications 27 and linguistics specialists 28 in communication discourse studies and linguistics the idea of stance is keyed to evidentiality or where the source of information is attributed to epistemicity or the amount of confidence in the talk by the speaker to appraisal or how the speaker evaluates topic and presents rationales and to affect or the emotions invested in talk the computerassisted coding and the four categories results from an application of 24 preidentified linguistic codes that identify how speakers categorize themselves others intentions motives and expectations in discourse transcripts of speakers are standardized into 100word segments after which 24 categories of language features are coded by an adaptation of the software package codeatext 29 coding is subjected to a principal components factor analysis leading to the creation of numerical scales created from the factors and used to identify significance relative to the speakers mean 30 in this way stance for each interviewee is analyzed relative only to that interviewees production of speech the coding enables the researcher to identify sections with constellations of features above the mean for a particular dimension throughout that persons production of speech though diabetes educators may not use this methodology routinely they may collaborate on interdisciplinary teams with social or behavioral scientists who may use the method findings as an example of typical output figure 1 illustrates a spreadsheet for the successive sections in the interview with mrms 43 with red signals sections significant above the speakers mean for a particular dimension the four dimensions for this interview set can be considered the major themes as seen in the following explanations personalizationagency when the speaker uses the stance of personalizationagency in this set of interviews the speaker is disclosing private ideas and feelingsa personal concept of disease as an it a thingthat needs control how to recognize crisis and how to monitor either disease or crisis on a daily basis some examples of personalizationagency are as follows • how to recognize the onset of a blood sugar change that sends one to the ed • use of how i feel as a quick check of energy to monitor disease • view of the disease as an it that typically is outside me • control as the crucial action and stance analysis of african americans with diabetes er visits • roller coaster of emotions from irritation at hassle to depression elaborationaffect when people use a stance of elaboration they are typically giving details about some event preoccupying them some of the examples that were typical were as follows • detailed descriptions starting with the ed visit and its associations with eating and the emotions invested in descriptions of eating • offering details about emotions typically fear as low to high on a scale but always there • revisiting sugarland want it eat it dont understand it cant find its impact must stop cooking with it and • safety net has holes details about doctorpatient interactions and difficulties the body parts that received focus with emotional content here most often were feet compared to the blurred vision typically discussed in personalizationagency opinionsinformation when people take an opiniongiving stance they are going to share what they think about eating about doctors about the disease and about their emotions these assertions come across as more objective or as pronouncements in identifying feelings instead of reexperiencing them as part of their story because the patient has recently had a dangerofdeath episode more information leaks out in the emotionally loaded stance of personalization than in opinion rationale when people present a stance of rationale they are explaining the why for choices such as the following • identifying the symptoms the physical feelings though usually not what could have been associated with those symptoms biomedically and • whosaytheysay dynamic a rationale for ed giving other choices often keyed to what others either medical personnel or more often familyfriends say wordlevel analysis a wordlevel analysis of the significant sections for each dimension was conducted using wmatrix2 31 an online corpus analysis and comparison tool the top 15 words in sections significant for agency are as follows i me my it you and to a the that do was so and just you know figure 2 illustrates that causation is a key feature of this dimension because so is in the top 15 words with 122 occurrences making 93 of all words in sections marked as significant for agency wmatrix includes a wordtagging feature that permits identification of themes using semantic domains word frequencies can identify what words speakers tend to revisit such as food major themes identified across the significant sections in the four dimensions could be used as an inventory to elicit concerns people with diabetes have that could lead them to seek ed treatment these themes were identified by frequency of semantic domain and frequency of multiword expression figure 4 displays an inventory of statements quoted from the interviews whose themes were repeated frequently as predominant themes these statements could support the initiation of cognitive mapping or motivational interviewing discourselevel characteristics wmatrix uses the claws tagset to tag each word by its part of speech figure 5 displays the tabulation of the 15 most frequent parts of speech representing 2 or more of all speech in the significant sections of the agency dimension this tabulation suggests a number of discourselevel characteristics in this dimension across the 20 interviewees not surprisingly selfreference is the most frequent part of speechthe speaker is being interviewed about a personal experience and this dimension represents the speakers accounting of present and past symptoms choices behaviors and intentions which as content or lexical nouns represent the next most frequent part of speech clearly the agency sections are notable for lexical density which is underscored by the prevalence of prepositions and articles evidentiality or where information was acquired and from which choices were made is marked in the agency section by the high proportion of first and third person pronouns and possessive pronouns the high use of the second person pronoun forms typifies conversational speech where a speaker monitors with phrases such as you know to make sure the other person is listening or to construct a temporary alignment or shortterm assumption of intimacy verbs signal past tense actionsthe person is being interviewed about a past event and future intentionsthe interviewers probes focus on awareness about diabetes which is probably only beginning to develop because the person has just been discharged from an ed visit for a perceived diabetic crisis coordination is achieved by and which is associational linkage typical of rapid conversation as is the frequent use of interjections speakers in this interview set frequently comment on their own utterances with interjections and pile up choices with and frequency of semantic domains echoes the array of parts of speech wmatrix uses the ucrel semantic analysis system the most frequent semantic domains include pronouns grammatical and discourse particles cautiousness food future time medicines and causeandeffect when compared with a general spoken corpus from the british national corpus 32 the 100 million wordcollection of words used by linguists to study language there were strongly significant differences between the two using loglikelihood ratios the agency sections were significantly higher in the following medicines and medical treatment money disease food cause and effect being alive and not understanding these semantic domains also index the major themes underlying the concerns voiced and revoiced in the interviews which are noted in the common statements the concerns are linked to the state of knowledge and the psychosocial mediators affecting the choice of behaviors in the analytical framework for diabetes selfmanagement education interventions 33 illustrated in figure 6 a cluster analysis with a series of scattergrams was conducted for scale score combinations in the four stance factors the analysis found that in the scattergram showing the greatest significance six of the participants were strongest and most informative in the top right quadrant representing the combination of agency with affect in figure 7 numbers on the axes represent scaled significance above the mean with quadrants representing areas of high and low affect and agency that is the six participants in the top right quadrant had the greatest number of sections of text that scored above the individuals mean and above the groups mean for word patterns identifying agency and also identifying affect such a combination is understandable when recalling that the interviews took place just after a release from the ed which would involve high affect and in the case of these six participants also involved their reflections about what they could and should do to avoid future ed visits a secondary analysis of the significant agency and affect sections for these 6 participants examined the most highly scaled sections to identify commonalities in their communication patterns the primary thematic focus of all these sections was participant awareness of their diabetes in terms of their selfdisclosed efforts to control the disease some persons voiced more willingness and efforts to control the disease a review of semantic domains identified that personal pronouns were the predominant feature with i it you that and my being the most frequent concordance analysis of the pronouns showed that the i the my and the projective you signaled the emphasis on selfdisclosure and personal choices for action to the it of the disease that indexed a list of actions or understandings my was particularly interesting as its use indexed ownership of my problems in my life or for my family caused by my disease and my management of it of the 20 total interviews these six people were most open to change most aware of their role in selfmanagement and most positioned for the advice of diabetes educators and providers results in general with the exception of the six just discussed the interviewees in this set have not linked knowledge with psychosocial mediators and are at the mercy of their beliefs and attitudes not always related to biomedical explanations tailored interventions can use these observations because speakers in the set of six express concerns for knowledge acquisition and signal a strong sense of personal agency identifying persistent or pervasive themes across this group of interviews is useful to the extent that it can identify selfdisclosed states of participant awareness about the condition can begin to tap perceived barriers and facilitators to increasing diabetes selfmanagement and can ground the next steps toward the development of supportive interventions implications for diabetes educators in this sample the six with high agency scores seem ready to hear information about aspects of their disease that they can handle and to learn more about diet exercise foot care and eye care their use of i and especially of my signal their growing readiness to own their disease the other 14 are not yet high in agency and reflect emotional distress that may offer barriers to selfmanagement strategies diabetes educators can recognize the limitations of the remaining 14 clients by their avoidance of plain statements about what they do or do not know about how they feel or what they have done in the past to recognize symptoms of trouble often they speak with uncertainty and hedging shading their intentions with phrases such as might be able to usually and should do it implications though diabetes educators do not have the luxury of extended linguistic analysis many of these observations parallel experience in communicating with persons who have diabetes and confirm lessons of experience problemsolving in diabetes selfmanagement has been shown to be related to diabetes distress as measured by the diabetes distress scale 34 the majority of those interviewed in this study identify through their speaking practices that they are not ready for effective diabetes management and have unresolved psychosocial issues regarding diabetes that result in repeated and avoidable visits to the ed though diabetesrelated anxiety depression and lowered selfesteem are demonstrated to be part of the barriers that interfere with diabetes selfcare 35 this linguistic analysis presents the mechanisms of diabetes distress in the process of care that have received less attention the integration of these observations for diabetes educators requires sharpening the skills of active listening in attending to the needs of people with diabetes and more focused diabetes educatorpatient communication research though 30 years of doctorpatient communication research in primary care provides a basis to evaluate interaction effects on decision making 36 the speech practices that patients use and how diabetes educators respond to particular cues that denote minimal agency requires investigation in this analysis specific metaphors rationales and discourse related to emotional distress occur in recounting ed encounters for the 14 with low agency but how diabetes educators respond to similar cues in practice remains to be identified shared decision making is advocated as essential to diabetes selfmanagement 37 yet the mechanisms that enable participatory decision making with a diabetes educator or signal the need for more effective cognitive behavioral therapy offer exciting avenues for future research recommendations that summarize how findings can be applied to diabetes education in summary effective diabetes management strategies that are socially and culturally appropriate may be more likely to be adopted but require strategies that can be tested for tailoring care 38 diabetes educators play a significant role in working with patients and families to better manage diabetes active listening and recognition of verbal cues within narratives of patients better equip the diabetes educator to employ coaching techniques that encourage patient problem solving skills and a more activated patient furthermore as diabetes educators become more confident in identifying and acting on cues from our clients the clients may be more apt to selfdisclose concerns andor problems encountered in daily selfmanagement routines this enhanced active listening and engaged twoway communication helps to create a milieu more open to participatory diabetes education the commitment of the american association of diabetes educators to more patient involvement and culturally appropriate diabetes education 39 requires more focused communication strategies that allow diabetes educators and providers to identify the learning needs and barriers of persons with diabetes more readily in the process of care furthermore the diabetes educator is uniquely positioned within interdisciplinary care teams to disseminate lessons learned to enhance patient outcomes as this evidence emerges example of segments colorcoded to display scale significance types of food discussed across all four dimensions top 15 parts of speech in significant agency sections affect by agency a total may add to 20 as some participants had 1 type of insurance diabetes educ author manuscript available in pmc 2016 april 08

purposethis mixed methods study uses a unique approach from social science and linguistics methodologies a combination of positioning theory and stance analysis to examine how 20 african americans with type 2 diabetes make sense of the practices that led to recurrent emergency department visits to identify needs for more effective intervention methodsin a purposive sample of postemergency department visit interviews with a samerace interviewer people responded to openended questions reflecting on the decision to seek emergency department care as applied to diabetes education positioning theory explains that people use their language to position themselves toward their disease their medications and the changes in their lives transcriptions were coded using discourse analysis to categorize themes as a form of triangulation stance analysis measured language patterns using factor analysis to see when and how speakers revealed affect attitude and agentive choices for action conclusionfinal analysis revealed that one third of the sample exhibited high scores for positive agency or capacity for decisionmaking and selfmanagement while the rest expressed less control and more negative emotions and fears that may preclude selfmanagement this approach suggests a means to tailor diabetes education considering alternative approaches focused on communication for those facing barriers

19992_0

introduction lesbian gay and bisexual adults in the uk experience poorer health and access to health care than heterosexual women and men 12 despite higher disease burdens lgb adults face barriers to healthcare access 34 and have poorer primary care experiences 1 the 2010 uk equality act improved the collection of sexual orientation information in survey data but adequate sample sizes for research on multiple longterm conditions remains challenging 5 therefore data were used from the gpps which provides a large nationally representative sample to describe inequalities in longterm conditions 67 defined as a difference or variation in the prevalence of a longterm condition 8 in this analysis lgb options for sexual orientation were included from gpps in the first analysis whether longterm conditions were elevated for lgb compared with heterosexual adults was considered in the second whether inequalities continued to exist after adjustment for deprivation ethnic group and age and whether there was variation among lgb women and men variation in the association between sexual orientation and longterm conditions by deprivation ethnic group and age was additionally tested finally inequalities experienced by sexual orientation were explored across all conditions included in the analysis and whether levels of multimorbidity vary by age collectively these steps provided a detailed portrayal of the health inequalities in longterm conditions experienced by lgb adults in england method data data were analysed from the gpps a crosssectional survey of adults registered with a general practice between july 2015 and march 2017 in england 67 definitions of sexual orientation responders were asked which of the following best describes how you think of yourself with response options heterosexual or straight gay or lesbian bisexual other and prefer not to say the prefer not to say responses were excluded sexual minority adults hereafter refers to gay or lesbian bisexual and other longterm conditions responders were asked which if any of the following medical conditions do you have with 15 response options plus none of these conditions and prefer not to say sociodemographic characteristics in multivariable analysis deprivation ethnic group region and age were adjusted for and all analyses were stratified by sex multimorbidity multimorbidity was measured as reporting at least two of the 15 conditions and a count of the 15 conditions was additionally estimated missing data across the 20152016 and 2017 survey waves 4 306 560 surveys were mailed with 1 644 644 responses surveys were excluded with missing data for longterm conditions age or sex or missing or prefer not to say responses to the sexual orientation question missing longterm condition responses were similar for sexual minority and heterosexual responders survey weights unadjusted prevalence estimates from the januarymarch 2017 fieldwork period used threepart survey weights 67 these crosssectional weights cannot be combined across years for adjusted unweighted multivariable analyses data were also included from the 20152016 fieldwork period as the sampling frame excludes people who were surveyed in the previous 12 months full question wording which if any of the following medical conditions do you have please tick all the boxes that apply to you alzheimers disease or dementia angina or longterm heart problem arthritis or longterm joint problem asthma or longterm chest problem blindness or severe visual impairment cancer in the last 5 years deafness or severe hearing impairment diabetes epilepsy high blood pressure kidney or liver disease longterm back problem longterm mental health problem longterm neurological problem another longterm condition none of these conditions and i would prefer not to say counts are the numbers included with each longterm condition from 20152016 and 2017 percentages calculated based on 2017 data only as the crosssectional survey weights cannot be combined across years further details are presented in supplementary table s1 please note percentages weighted to the population of england were calculated and they cannot be derived exactly from numbers presented in the tables a gay lesbian bisexual or other analyses the first analysis described the 2017 weighted prevalence of the 15 longterm conditions among heterosexual and sexual minority women and men the second analysis explored the adjusted association between being a sexual minority adult and reporting each condition and then separately for lgb people adjusted for deprivation ethnic group region and age the third analysis examined differences in the sexual minority and heterosexual longterm conditions gap by deprivation ethnic group region and age by adding these sociodemographic characteristics and their interaction with a sexualminority indicator predicting each longterm condition from models where the relationship with sexual orientation can vary by age the fourth analysis used counts of all longterm conditions to compare multimorbidity by sexual orientation including the variation in that relationship by age all analyses used stata results responses were analysed from 1 341 339 people the first analysis estimated the unadjusted weighted prevalence of longterm conditions among sexual minority and heterosexual women and men mental health problems were higher among sexual minority adults for physical health conditions prevalence for some conditions was higher and some lower in particular conditions often associated with older ages were less prevalent in the younger sexual minority population 9 in unadjusted analyses the second analysis examined the adjusted association between sexual minority status and reporting each longterm condition among all sexual minority adults and then by each sexual orientation subgroup it was found that 13 longterm conditions were more prevalent among sexual minority women compared with their heterosexual peers after mental health conditions the largest inequalities were for neurological conditions dementia and back problems nine longterm conditions were also more prevalent among sexual minority than heterosexual men including mental health problems all other conditions neurological conditions and kidney or liver disease there were no conditions for which sexual minority adults were at lower risk the risk associated with being a sexual minority adult varied across the three sexual minority subgroups for eight conditions for women and 13 conditions for men where there is evidence of heterogeneity the or is most often largest for the bisexual group among both women and men the third analysis examined differences in the sexual minority and heterosexual longterm condition gap by deprivation ethnic group region and age except for mental health problems there was no systematic evidence of heterogeneity by deprivation ethnic group or region there was however evidence of heterogeneity by age for many conditions the additional risk associated with sexual minority status was greater at younger ages especially for dementia inequalities were greatest among women during ages 1824 years for mental health and neurological conditions and peaked near ages 3544 years for dementia hearing loss and kidney or liver problems among men inequalities were greatest at ages 1824 years for back kidney or liver hearing joint and heart problems and hypertension inequalities peaked at 3544 years for men reporting all other conditions the fourth analysis summarised multimorbidity differences by sexual minority status sexual minority adults were more likely to be living with multimorbidity than heterosexual adults of the same ages with inequalities largest at youngest ages for example sexual minority women aged 1824 years had multimorbidity at the same level as heterosexual women aged 4554 years similar findings hold for condition counts with the largest differences for bisexual adults discussion summary this analysis provides new evidence regarding inequalities in longterm conditions for sexual minority adults in england because the sexual minority population is substantially younger than the heterosexual population 9 unadjusted comparisons of the prevalence of longterm conditions understate the burden on sexual minority adults of conditions that primarily emerge at middle and older ages after adjusting for deprivation ethnic group region and age most longterm conditions were more prevalent among sexual minority adults bisexual adults often had the highest risk the magnitude of the inequalities facing sexual minority adults generally did not vary by deprivation ethnic group or region but gaps tended to be larger at younger ages young sexual minority adults especially young sexual minority women were much more likely to be living with multimorbidity strengths and limitations the large nationally representative populationbased sample with repeated crosssectional waves over time are the greatest strengths of this research enabling comparisons of sexual orientation inequalities by demographic characteristics and sexual orientation subgroups that are rarely available the examination of 15 longterm conditions in the same large sample enabled comparisons of the disparities across conditions that would not otherwise be possible nonresponse remains the primary challenge to the validity of findings in survey research focused on sexual orientationbased inequalities the impact of nonresponse on gpps has been evaluated previously 10 and survey response rate alone is a poor measure of bias 11 predictors of low response rates are adjusted for in these analyses further a randomised trial of the inclusion of a sexualorientation question in gpps found no impact on survey response rates in england 12 another limitation to this research is the use of a selfreported measure of longterm conditions the performance of this survey question has been evaluated in previous research with prevalence estimates similar to other national health surveys in england 13 and the use of selfreported rather than clinicallycoded diagnoses may better reflect a patientcentred measure of the impact of multimorbidity although a study of electronic healthcare records might provide more detailed insight into longterm conditions the limited documentation of sexual orientation in healthcare records means that surveys remain the best way to understand health inequalities among sexual minority adults there is no reason to believe that the shortcomings of selfreported measures of longterm conditions differ by sexual orientation so this would not be expected to bias such comparisons finally the survey did not include a question about hiv it is possible but cannot be confirmed that this may be captured by the high prevalence of another longterm problem among sexual minority men inequalities experienced by transgender adults in primary care were not described in this analysis as this was not measured in gpps transgender people often face distinct challenges in clinical encounters associated with their gender identity ranging from inappropriate use of pronouns to issues around the management of hormone and surgical treatment 14 collection of gender identity in the 2021 census may provide opportunities to address this evidence gap 15 comparison with existing literature these results are consistent with previous studies highlighting the high prevalence of individual longterm conditions among sexual minority adults 1617 the finding that neurological conditions are particularly overrepresented to the authors knowledge have not previously been reported in large epidemiological analyses these results are consistent with research documenting especially negative health outcomes for bisexual adults that may be related to their simultaneous isolation from sexual minority and heterosexual communities 18 further all sexual minority adults regardless of deprivation or ethnic group face elevated risk of longterm conditions this finding is difficult to compare with previous studies that lacked the sample sizes to make such assessments possible this analysis found that sexual minority adult inequalities are greatest when multimorbidity is less common at younger ages the unique health impacts of specific challenges experienced by sexual minority young adults are increasingly recognised 19 research has shown how sexual orientation disclosure during early adulthood can often have a substantial shortterm negative impact on mental health with positive longterm benefits 20 further studies document how negative experiences in childhood among sexual minority adults have a lasting impact on their mental health 1921 previous research has found that multimorbidity is independently associated with a history of adverse childhood experiences 22 in this analysis inequalities are highlighted across longterm conditions including mental health suggesting the widespread health impact experienced by sexual minority people across their lifespan implications for practice healthcare delivery for sexual minority adults has historically not focused on longterm conditions 23 these findings highlight the importance of this area while management of longterm conditions in primary care is not specific to sexual orientation provision of highquality primary care is central to improving the health and healthrelated quality of life of people with longterm conditions and multimorbidity this work highlights that young sexual minority adults have disproportionately higher inequalities in longterm conditions and so are a particularly important group to consider inequalities exist across many longterm conditions highlighting the importance of a holistic integrated approach to the management of longterm mental and physical health conditions in addressing the health inequalities experienced by sexual minority adults in 2018 the uk government equalities office developed an lgbt action plan which highlighted the value of integrated lgbt care in physical and mental health services 24 these results confirm the importance of such an approach additionally given that these inequalities are not limited to a small cluster of longterm conditions the results also imply that more general approaches such as a focus on prevention and healthcare delivery may be more effective than diseasespecific approaches in addressing these health inequalities preventive medicine is a key area where the results have implications for primary care the lower measured unadjusted prevalence for sexual minority women for hypertension and cancer conditions that often do not present with symptoms may reflect less screening and primary care use rather than lower risk if so it identifies a need to be addressed sexual minority adults are more likely to have a smoking history 25 higher alcohol intake 25 and higher body mass index especially among sexual minority women 26 compared to heterosexual adults these conditions are most often addressed and managed in primary care which further underscores the potential role for gps and practice staff given evidence of poorer primary care experiences 1 targeted improvements for sexual minority adults may be important recent guidance and training for gps from the royal college of general practitioners included a focus on lgbt patients 27 the lgbt foundation pride in practice programme is another resource highlighting the effectiveness of small changes such as lgbt posters on notice boards 2829 better supporting the disclosure of sexual orientation in primary care consultations may also have the potential to improve health and healthcare outcomes 28 for example lesbian and bisexual women access less cervical screening disclosure of sexual orientation in primary care consultations may reduce these inequalities through improved uptake of preventive care 30 with support from lgbt organisations nhs england advocated for the inclusion of sexual orientation monitoring in 2017 31 the proposal was meant to improve both research and practice the routine collection of sexual orientation by gps would allow better monitoring of inequalities and simultaneously support sexual orientation disclosure despite these advantages the proposed rollout of sexual orientation questions and recording of sexual orientation in clinical records remains low 32 and requires further attention giving the public confidence in how their data are used by ensuring that data are secure and used appropriately with clear public benefits is an important first step 33 this analysis presents populationbased evidence on inequalities in longterm conditions experienced by sexual minority adults and suggests that although physical health is often separated from mental health considering both is needed to more effectively address the pervasive inequalities experienced by sexual minority adults of all ages across a range of longterm conditions evidence of early multimorbidity means that gps should pay particular attention to prevention screening and care for longterm conditions in their sexual minority patients even in early adulthood ethical approval full details about the use of gpps data for research are provided here gppatient co uk confidentiality provenance freely submitted externally peer reviewed

background epidemiological evidence for specific longterm conditions is required to inform best practices regarding the substantial health inequalities experienced by sexual minority individuals compared with heterosexual peers aim to describe inequalities in longterm conditions among sexual minority lesbian gay and bisexual lgb adults design setting crosssectional analysis of 1 341 339 nationally representative survey responses from the english gp patient survey gpps method stratifying by sex the weighted prevalence and covariateadjusted association of 15 longterm conditions were calculated comparing sexual minority and heterosexual adults considering variation by sexual orientation and variation in sexual orientation inequalities by deprivation ethnic group region and age results after adjusting for deprivation ethnic group region and age 13 longterm conditions all except cancer and hypertension were more prevalent among sexual minority women than their heterosexual peers with the largest inequalities for mental health problems odds ratio or 28 95 confidence interval ci 27 to 30 neurological conditions or 17 95 ci 15 to 18 dementia or 16 95 ci 13 to 19 and back problems or 14 95 ci 13 to 15 it was found that nine longterm conditions were also more prevalent among sexual minority men including mental health problems or 23 95 ci 22 to 24 all other conditions or 18 95 ci 17 to 18 neurological conditions or 15 95 ci 14 to 16 and kidney or liver disease or 14 95 ci 13 to 15 inequalities were often largest for bisexual adults inequalities did not vary significantly by deprivation ethnic group or region except for mental health problems inequalities in multimorbidity were highest at younger ages for example lgb women aged 1824 years had multimorbidity at the same level approximately 20 as heterosexual women aged 4554 yearsconclusion sexual minority adults especially bisexual adults are at elevated risk for many longterm conditions and multimorbidity this risk spans socioeconomic status and ethnic group representing a significant healthcare challengesexual minority individuals experience poorer health this work provides new evidence that most of the 15 longterm conditions examined occur more frequently among sexual minority adults in every age group the large sample size of this study helps identify the specific conditions and ages for which risk is greatest multimorbidity for sexual minority adults is a significant healthcare challenge with levels of multimorbidity associated with middleage often found in young sexual minority adults primary care is central to addressing these inequalities the holistic personcentred clinical approach of gps will be central to reducing disparities in health outcomes

19993_0

modern science increasingly has to raise the question of the human dimension of systems and processes based on engineering information and digital technologies some technologies improve peoples lives and some radically change it already with the advent of the first looms and the industrial conveyor it became obvious that technical innovations can displace not only people but also the human dimension from the sphere of production the advent of cinema raised fears for the fate of the theatre and these fears were partly confirmed the theater as an art form although it did not disappear became less popular now such concerns are associated with the emergence of esports telemedicine distance education robotics and artificial intelligence technologies it should also be taken into account that the formation of a new technoreality takes place against the background of social transformations which are described in philosophical theories as social chaos therefore the study of peoples behavioral reactions in conditions of social chaos and new technoreality is an urgent scientific problem in the interdisciplinary discourse of social philosophy anthropology cultural studies and philosophy of technology literature review from the very beginning of its existence mankind has modified the world around it forming a new habitat since this environment includes nature and elements artificially created by man it is called second nature 1 2 culture 3 anthroposphere 4 technosphere 5 these concepts are applied in different scientific contexts the concept of technoreality allows these contexts to be combined into one interdisciplinary discourse the concept of technoreality refers to a part of objective reality which includes artificial objects and systems nature and societies in relation to man technologies are considered from two positions technological determinism and social determinism within the framework of technological determinism technologies are considered as autonomous their development does not depend on human control they develop in accordance with their own logic social determinism suggests that the development of technology is conditioned by the general sociocultural context 6 the connection between the sociocultural context and technology is not only that this context influences technology but also that technology is part of this context therefore some researchers use the concepts of technosocial reality 7 or technocultural reality 8 to describe the problems of modern civilization the development of robotics biomechanics and control systems based on artificial intelligence is considered as the reason for the formation of biotechnocybernetic reality 9 the emergence of such concepts is explained by the need to study not only the causes and methods of formation of the technosphere but also how it affects people their psyche worldview and social behavior the purpose of the research is to study the sociopsychological posture of people and their behavioral reactions in the new technosocial reality the study used methods of analysis and synthesis sociocultural analysis which involves considering life forms as integral cultural formations with three components artifacts typical organizational actions and symbolic aspects the picking of information for the formation of the empirical part of the study was carried out using open sources differences in approaches to philosophical understanding of the role of technology in peoples lives in the first philosophical studies of the technosphere technologies were considered as ways and means of creating the material component of culture later they began to be perceived as the main way of existence of man and society considering the meaning of human life as a need of needs josé ortega y gasset argued that it is technology that satisfies this need carried away by irresistible consumption a person turns into an appendage of the machine with a crisis of desires 12 today we see an increase in this trend when the cult of consumption is combined with the cult of technology 13 this combination sometimes has signs of social psychosis this is indicated for example by huge queues in branded stores during the sales of new models of smartphones and other gadgets or when a person sells his own kidney to buy a new iphone 14 it can be assumed that not only a crisis of desires is manifested here but also a failure of value orientations which is inherent in a situation of social chaos it should be noted that the failure of value orientations and the distortion of cultural meanings are facilitated not only by lobbyists and technology sellers but also by philosophers who demonize technology in their concepts such concepts include those in which technology is described and comprehended as a force that dominates man and nature jacques ellul for example argued that technology is a force imposed from outside a given that a person has to reckon with technology according to ellul is something selfsufficient that plays a dangerous and risky game making a person an object of calculations and manipulations therefore we must resist her based on this attitude towards technology ellul formulated the ethical concept of renouncing the power of technology 15 a similar idea is fixed in the works of jürgen habermas who adheres to the concept where technology is declared a force that takes away a persons creative spirit deprives him of the will to selfexpression selforganization and ultimately turns him into a slave of his own creations 16 in general such an approach forms the idea of technology not as an object and instrument of human activity but as a subject or actor in the system man technology theodor adorno speaks from the opposite position which sees the problem not in technology but in popular culture in mass culture the uniqueness and independence of a person is being lost people are being unified and turning into a homogeneous passive mass devoid of critical thinking it is mass culture that puts forward demands on a person that enslave him and the enslaver is not technology but its owner theodor adorno insists that it is impossible to oppose technology and humanism because such an opposition is the product of an erroneous understanding of the role of technology in peoples lives 17 but there are doubts here is this a mistake or a conscious purposeful formation of a certain mythologemeideologeme behavioral reactions of people in the new technosocial reality agreeing with theodor adornos idea about the influence of mass culture on people one should pay attention to such a segment of culture as the mass media today people have the opinion that the mass media are not the means of information but the means of manipulation adorno drew attention to the manipulative nature of the mass media noting that people receive from them not what they want but what is offered to them 17 today this is becoming even more obvious this is manifested not only in the selectivity of information that is offered to the consumer of this information but also in how it is presented when it comes to technology the headlines in the news are very revealing for example messages about the achievements of robotics and artificial intelligence technologies look like this this robot cotaught a course at west point 18 inside the singapore cafe run by robots the can cook up delicious egg dishes and fried rice in just 20 seconds 19 watch a boston dynamics robot herd sheep in new zealand 20 meet aida the robot artist who is making an exhibition of herself 21 robot takes podium as orchestra conductor in seoul 22 many more such headlines can be cited which together form ideas about robots and artificial intelligence as independent subjects of reality that dance cook food draw herd sheep conduct an orchestra give lectures on philosophy etc such headlines are one of the ways in which the media broadcast the philosophical concept of alienation according to this concept the forces created by people become beyond the control of their creators among these forces machine technology is also considered which allegedly develops on its own controls complex processes and makes decisions 23 at the same time the mass media not only broadcast this concept but also fill it with emotions a robot just debated humans on the benefits and risks of ai tells audience ai can cause a lot of harm 24 humanitys hope and nightmare how robots are conquering the world 25 «living robots made from frog cells can replicate themselves in a dish 26 us air force denies ai drone attacked operator in test 27 nine robots held a press conference and said they could be better leaders than humans 28 it is not surprising that under such informational pressure people have a feeling of helplessness in front of powerful new forcesthe machine the digital mind some people are calm about this situation like for example the owners of smart houses who joke my house is smarter than me someone begins to worship these powerful forces as new gods while someone develops technophobia often technophobia is combined with social phobia the result of this syndrome is the desire of a person to escape from reality in practice this manifests itself in various forms of escapism and escape from the urban world into the natural world in recent years the practice of voluntary consciously chosen selfisolation has become popular this phenomenon is most evident in japan there the concept of hikikomori appeared which refers to the syndrome of social phobia reclusion and refusal of socialization due to unwillingness or inability to adapt in society 29 technophobia can be not only individual but also collective an example of this is the case of robot dogs which in 2021 the new york police department purchased from boston dynamics even though digidog did a good job he had to be fired due to criticism on social media residents of the city began to worry that the robot would be used against people their fears were supported by the authorities of new york saying that in this way the police are militarized and the robotic dog itself is a symbol of how aggressive law enforcement agencies can be 30 however in 2023 the nypd returned to using digidog ignoring the protests of the public whose arguments at that time were already less emotional but more specific the nypd is turning bad science fiction into terrible policing albert fox cahn stops executive director says in a statement new york deserves real safety not a knockoff robocop wasting public dollars to invade new yorkers privacy is a dangerous police stunt 31 discussion the results of the study show that two poles are being formed in the sociocultural spacethe cult of technology and technophobia and between themeverything that manifests the ambivalence of peoples attitude to technology indeed in general people do not abandon technology even the mentioned hikikomori would be so popular if the internet did not exist after all it is thanks to the internet that young hermits communicate with the outside world that is people still strive for social communication they simply choose its other forms instead of direct contact with real interlocutors they communicate indirectly with digital versions of interlocutors dog robots also do not cause technophobia in people when they are used in construction work herding sheep or mine clearance operations therefore some philosophers call not for the rejection of technology but for the search for a balance in the system mantechnologynature 32 such a direction of philosophy as technorealism is being formed technorealism is an attempt to expand the middle ground between technoutopianism and neoluddism by assessing the social and political implications of technologies so that people might all have more control over the shape of their future 33 wars and manmade disasters that constantly occur all over the planet each time make us remember the maxim that it is not technologies that kill but the people who create and use them and at the same time an understanding comes that it is not technologies that save but the people who create and use them in other words the problem lies not in technology but in what purposes they are created for as long as these goals are determined by people the human dimension of technoreality will be an a priori factor the trends that are being traced today in social and political processes indicate that people will have to live in conditions of social chaos for a long time to come and it will be necessary not only to choose forms of adaptation from those that already exist but also perhaps to invent some new ones accordingly the study of these forms will be relevant for various scientific fields sociology cultural studies anthropology social philosophy etc conclusions the study of the sociopsychological posture of people in the conditions of social chaos and the new technoreality has shown that people have different behavioral reactions from the desire for selfisolation to immersion in the cult of technology the formation of these two extremes is facilitated by the mass media which broadcast the corresponding philosophical concepts enhancing their emotional component at the same time a direction is being formed in philosophy aimed at finding a balance in the system humannaturetechnology the main idea of this direction is to understand that technology should be considered not as a subject or actor in this system but as a tool with which people achieve their goals this approach allows keeping the emphasis on the expediency and usefulness of technologies for people and nature as well as on the responsibility of people for their development and implementation the implementation of this approach not only in philosophical theories but also in engineering activities will contribute to the formation of technoreality in balance with human and nature

the purpose of the research is to study the sociopsychological posture of people and their behavioral reactions in the new technosocial reality the study of the sociopsychological posture of people in the conditions of social chaos and the new technoreality has shown that people have different behavioral reactions from the desire for selfisolation due to socioand technophobia to immersion in the cult of technology the formation of these two extremes is facilitated by the mass media which broadcast the corresponding philosophical concepts technooptimism technoutopianism and technopessimism enhancing their emotional component at the same time a direction is being formed in philosophy aimed at finding a balance in the system mannaturetechnology the main idea of this direction is to understand that technology should be considered not as a subject or actor in this system but as a tool with which people achieve their goals this approach allows keeping the emphasis on the expediency and usefulness of technologies for people and nature as well as on the responsibility of people for their development and implementation the implementation of this approach not only in philosophical theories but also in engineering activities will contribute to the formation of technoreality in balance with human society and nature

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introduction that time is vital to pierre bourdieus social theory has been pointed out often enough in commentaries of all shades of sympathy with the man from jenkins unflattering portrait through swartzs more appreciative primer to wacquants zealous promotion his interest in temporality since his earliest essays on algeria to later writings on the differentiation of classed experience is dutifully flagged as for anthony giddens structuration theory and some of its derivatives time was no sideelement of social life but woven into the baseline understanding of human beings and the relations between them even if bourdieus contribution has been curiously overlooked in key statements marking the surge of interest in time within sociological circles from the 1980s onwards there has been one key difference from others though whereas structuration theory and the morphogenic approach have struggled to attract researchers keen to apply and elaborate their propositions in empirical inquiry bourdieus conceptual toolkit has been mobilised extensively to examine myriad facets of the social structuring of time from studies of economic change and precarious employment to investigations of educational inequality and gentrification the frenchmans famed theoretical trio of habitus field and capital have found fresh and varied ways to prove themselves useful to numerous sociologists trying to make sense of temporality as powerful and useful as bourdieus tools may be however there are nagging gaps and blind spots this is the case generally speaking elsewhere i have argued that bourdieus modus operandi in his later writings obscured many themes of explanatory significance and political importance but his treatment of time provides a particularly sharp lens through which those limits come in to focus in what follows therefore i aim to take stock of genetic structuralism as bourdieu himself dubbed his approach on temporality this will be done by identifying four entwinedand not necessarily exhaustiveelements of the experience of time and its social structuring and cataloguing bourdieus advances and oversights these elements are the general temporal structure of consciousness timings in and of fields or their rhythms and pace timings imposed by agents in certain fields on people who are not agents in those fields and time binds or squeeze while bourdieu fruitfully brought the first two to the fore though not without some omissions and discussed the third though without following through the conceptual logic the fourth requires a slight shift of orientation and some new concepts if it is to be adequately grasped the temporal structure of consciousness the foundation upon which all else is built is the temporal constitution of conscious experience edmund husserl the founder of phenomenology had famously elaborated that what we take to be present experience is in fact always stretched forward and backward that is fringed by a halo or horizon of history and futurity furnishing a sense of continuity at one end there is retention the residue of the justpast giving sense to the now and at the other there is protention the sense of the immediately forthcoming inscribed in current sensory impression bourdieu a keen reader of husserl from his earliest days absorbed this insight and gave it a distinctly sociological spin this was done at first in relation to his fieldwork in 1950s algeria where he endeavoured to document the disorientation among the native population induced by the imposition by the colonial french state of capitalist modes of time reckoning bourdieu distinguished on the one hand the traditional time consciousness of the algerian peasant rooted in circadian rhythms and the patterning of workdays and holidays given by the ritual calendar these give the peasant foresight a sense or expectation of the forthcoming grounded in recurrent past experience but they do not concern themselves with a longer span of time to come they do not colonise the future as giddens put it with projects and plans on the other hand there is the attitude toward time characteristic of the spirit of capitalism the projection or forecasting of possibilities the actual positing of the futuremaking it thematic in consciousness as the phenomenologists would sayas something to be considered and mastered just as the latter was being foisted on algerians however their deteriorating material conditionsat least among some sections did not furnish the security necessary for stable forecasting later once bourdieu had begun to turn his sights on his home nation and develop his core notions of habitus and field the husserlian conceptual apparatus was taken up in a new way now protention was generalised to become the basic mode in which all people relate to fields the latter to clarify consist of multidimensional structures of domination and struggle defined by possession of one or more form of capital or property securing legitimacy and authority in the eyes of those struggling for that capital the political field the legal field the literary field and the bureaucratic field are just some fields that bourdieu put under the microscope at different phases of his career though the class structure itself also forms a field the social space and he latterly suggested that even families and organisations form microfields with their own particular stakes and struggles each field has its own doxaor taken for granted knowledge about what goes on the field and illusioor belief in the importance of the fields stakes as a specific transferral of libidinal energy yet each field is also a structure of domination insofar as people possess the capitals securing misrecognition to different degrees and a structure of struggle insofar as people pursue strategies to maintain or improve their standing in the field here is where temporal consciousness comes back into the picture possessing a certain amount and type of capital within the field makes certain experiences likely or unlikely routine or rare and certain actions and strategies objectively possible or impossiblealso factoring in that accumulating capital usually takes time bourdieu called this probabilistic distribution of experiences and possibilities for the individual the field of possibles or lusiones and the individual through time adjusts to them such that they develop a sense of the likely and unlikely possible and impossible written into present experience this feel for the game the practical sense of the forthcomingexpectations anticipations and so onis what defines the habitus and bourdieu himself equated it with protention 1 now however he did so in order to reject the idea that practice is guided by thoughtout plans or intentional projects of the kind versions of rational choice theory or phenomenology posit or indeed that bourdieu himself posited in his earlier analysis of capitalist timereckoning we may through our doings in the world be projected into the future but we do not consciously project the future prior to our doingsin this regard bourdieu is influenced as much by heidegger as husserl recognising the socially conditioned temporal horizon of consciousness as the heart of habitus does indeed undermine any notion that human beings are freefloating without a past totally unconstrained or indeed mechanically reacting to external constraints or enablements yet as many have pointed out there is a sense in which bourdieu sometimes pushed his case too far much of what we do as we press into the future is indeed unaccompanied by any mental representation or positing of its goals but often enoughand not just in times of crisis as bourdieu sometimes conceded the future does become thematic ie brought to consciousness represented in the minds eye and so on in maybe the most compressed pulse of futurity it may take varied forms it may extend forward to varying degrees but it does occur and while it may take the form only of fancyingimagining a possibility without committing to it it is often as schutz put it accompanied by a voluntative fiat or 1 although the theoretical details of this view were elaborated following research in france bourdieus analysis of giftgiving among the kabyles of algeria in which time between gift and countergift taking into account giver and receivers quotients of symbolic capitalis crucial to maintaining or effecting ones standing should also be seen through this lens as an adjustment to a field of possibles it is just that the specific field in question is one marked by a low degree of objectification of its stakes that is to say maintained through constant facetoface interaction rather than institutionalised mechanisms sense of commitment or indeed will none of this detracts from bourdieus point that practice is adjusted to protention or the sense of whats likely or possible in the field what we consider what we commit to and so on are all grounded in that sense as it manifests in practical awareness of who is who who does and is likely to do what and so onit does not imply a theorists eye view of the field as bourdieu believed alternative theories do with that issue cleared up we can make better sense of another way in which timeconsciousness is conditioned by lusiones possession of the major capitals defining the social spaceeconomic cultural and social capital defines ones relative distance from necessity an important element of which is time recasting some of the insights from algeria those for whom paying the bills keeping their job earning enough money to get by and so on are more pressing tend to be anchored more in the shortterm future whilst those freer from those exigencies have the luxury to build longerterm projects this can manifest in modes of childrearing or lifestyles yet it also has a very particular effect amongst those within the intellectual field the specific condition of the scholarhaving the time and leisure to think reflect and so on can if not checked by reflexivity lead to the scholastic fallacy of projecting ones own way of thinking and defining the world as an adaptation to that condition on to others as when sartre thinks everyone is as free as he is or the postmodernists think everyone is as playful and boundaryblurring as they are nowadays we might question whether academia is quite so leisured what with creeping pressures to be productive and to have impact coupled with increasing casualisation of employment which even bourdieu admitted was beginning to envelop higherlevel public sector workers but the point still stands that homo academicus inhabits a world unlike othersbeing paid to read write and teach on processes others simply liveand develops dispositions attuned to it which may then bleed into their scholarly output field rhythms and pace while temporal consciousness is conditioned by ones specific position in any field however the experience and meaning of time is also structured by being a member of a specific field this is because each field has its own synchronyits own rhythm and paceset by several factors the first is the specific fields sequence of revolutions although the cycle of upheaval and consecration affects all fieldsfrom art and politics to families and the social space as new players mobilise subversive strategies aimed at toppling the dominant conservative orthodoxy and establishing different properties as legitimate the battle of the generations of avantgarde and rearguard of the established and the newcomers attuned to different structures of opportunity and perceptions of what is old and traditional takes particular form in each field this is not to posit an iron law of historical movement either the dominantdefined by the properties securing misrecognition rather than by specific biological individualsmay theoretically speaking deploy conservative strategies fending off or reversing challenges from successive biological generations of artists politicians and so on or be short lived depending on the balance of power and revolutions themselves may be slowmoving or rapid in any case the movement of the generations conditions ones sense of history or of significant moments in the game to which one is attuned it provides a means of situating oneself and othersso many alignments affinities and homologues across timeand models to be revived or emulated as well as an additional layer to the sense of the forthcoming it also inevitably furnishes moreover a sense of ones trajectory of being on the rise or on the way out on the up or losing face the future or the past of course this can be complicated by individual rather than generational trajectory a sudden rise or fall in the field with changing capital stocks can prompt disorientation and illease as much research on mobility through the social space has begun to chart a second aspect of fieldspecific temporality through which the battle of the social generations of dominant and dominated may play out is the carving up of the undifferentiated flow of time into recurring chunks signified by certain symbolic markers with salience to its members electoral cycles and yearly events in the political and bureaucratic fields seasons and shows in the field of fashion semesters and annual conferences in the academic field and so on but also the domestic routines and celebrations of the familial field and the formal and informal schedules of an organisational field in his algerian research bourdieu had in heideggerian vein stressed the eminently practical mode of measuring events in timehow many harvests ago something was for exampleamong the kabyles as a means of counterpoising it to the standardised capitalist measurement of time by the clock and calendar being thrust upon them but even in longtime capitalist social orders the differentiation of multiple fields drawing ones interest and desire people continue alongside clock time to think time and events in this way for themselves and the field generally they adjust their activity and anticipations accordingly of course including as it feeds into a practical sense of timing for strategies and strikes in the struggle for recognition though the recurrent markers of a field may come to be simply doxictakenforgranted unquestionedthey can become subject to struggle and indeed their very genesis is likely to have been infused with struggle and symbolic power take for instance the struggles over artistic exhibition in 19 th century parisan example tied to bourdieus analysis of manet and the field of art at first dominated by the salon de paris the highly conservative statesponsored exhibition initially running annually and taking place over several weeks from late august the impressionist revolution in the artistic field spurred challenge and alternatives aiming to undermine the salon as the event of the year while recognising its preeminence in so doing eventually the salon facing withdrawal of state support was stewarded by a collection of artists but a few years later internal quarrels prompted a split and the emergence of two separate exhibitionsthe old salon and the new salon de la société nationale des beauxarts or nationalecompeting to be the key annual occasion of the artistic field ie the show in which one must have ones paintings or which one must see a group of avantgarde artists then founded the salon dautomne to counter the residual conservatism of both its very name derived from the season of its occurrence signifying opposition to the orthodoxy and embodying a distinct sense of timing while also eventually having the effect of restructuring the artists perception of significant temporal markers in the year there is another aspect of the pacing of field eventsbeyond the number and frequency of widelyrecognised pertinent markersthat bourdieu other than in the barest of hints never really considered this is the general speed at which strategies and positiontakings are or can be enacted and reacted to within a field a number of factors might play into this but two in particular linking bourdieu to other strands of scholarship on time are worth flagging the first is work intensification increasing pressure to be more productive to work quicker with more and tighter deadlines born of the specific doxa illusio and dynamics of the economic field it might be said to have subsequently bled into other fieldsthe bureaucratic field the intellectual field the media field and so ondue to the dominance of the masters of the economic field within the field of power and their allies in the political and bureaucratic fields 2 tied up with work intensification is the second factor affecting the pace of field events transport and communications technology the passage from horse and cart to jet plane and from letters and print media to the internet and social media famously described as the annihilation of space through time or timespace distanciation has transformed not only the spatial reach of field effects which has the effect of integrating national fields into regional or worldwide spaces of struggle in the same way that earlier phases of technological development integrated local social spaces into national ones and the form strategies can take it has also altered the speed at which players can learn about respond to and undertake strategies within the field and with that move through the field as well as into and out of the field we must be careful not to exaggerate and overlook the real inertia built into fields howevercapital holdings and habitus can no doubt act as buffers against the caprices of social media moreover some might view intensification and the effects of technological development as symptoms of a general acceleration of social life whether as part of a bombastic philosophy of speed or a product of more focused sociological analysis bourdieu would be wary of such a blanket thesis however perhaps born of a temptation to prophesise as bourdieu et al put it at least in virilios caseand certainly the notion of field sensitises us to the plurality of times and speeds others have flagged as a counter argument to totalising claims about spatiotemporal change intensification and technology are after all likely to effect different fields and different sections of fields in different ways and to different degrees more troubling is the apparent lack of sufficient conceptual tools in bourdieus oeuvre for rendering the travel over timespace through specific networks and channels of field effectsa concern that will become clearer when we consider the next facet of the social structuring of temporal experience imposed timings there are many elements of a persons perception and use of time that quite simply do not stem from their being positioned in a specific field there are that is elements of ones dispositions and practice which are not produced by withinfield experience they are instead produced by strategies and struggles within a specific field or combination of fields in which the person is not positioned the schedule of public holidays the imposition of time zones or daylight savings time working time regulations the timetables of schools or organisations one is not an effective agent within opening times of businesses and even clock time itself are all prominent examples bourdieu certainly acknowledged this happensindeed he saw it as fundamental to the process of statebuilding qua monopolisation of the legitimacy to define and categorise the world the product is minds of state or a habitus deeply ingrained with assumptionsincluding as they relate to the temporal ordering of practiceultimately rooted in the historical conflicts of the bureaucratic and political fields moreover insofar as what goes on in the bureaucratic field filters into specific institutional and organisational fields setting the parameters of what can be done and struggled over there through what bourdieu called legitimation circuitschains of interdependence and reciprocal recognition between people situated in different fieldsit trickles down to more spatiallylocalised levels of temporal organisation the bureaucratic field is not the only source of imposed temporalities however the rhythms of fields of economic and cultural production also impact on the consciousness and practice of their consumers as well as those simply caught up in the web of timespace movements they implicate people in a multitude of fields furthermore often have direct power over nonfield players time particularly in the form of setting appointments or hearings how exactly does this extrafield experience fit with bourdieus general view that habitus is conditioned by or the incorporation of the oppositions and lusiones of a field such that it can be said that habitus only exists in relation to fields bourdieu himself would probably insist on the manner in which that extrafield experience is translated into the logic of the field in questionhow it effects lusiones and strategiesincluding via tastes and practices adjusted to positions in the social space there is a gap here however lusiones are supposed to be set by the distribution of capital alone yet two people with essentially the same capital holdings will have different objective possibilities and thus perceived possibilities before them on account of the temporal organisation of different fields they are not players within effecting them or indeed the same fields effecting them in different ways or at different times a strategy for one player or at least a means and time of realising it will thus not be possible for another since they will lack the temporal affordances yet bourdieu seems to have no real conceptual means for grasping this difference even though it is clearly socially conditioned 3 bernard lahire would see this omission as a symptom of bourdieus tendency to work with a reductive image of a person as exclusively a beinginafield and other scholars interested in networks figurations capillary power innovation 3 differences in temporal affordances are not only therefore an element of singular causal analysis à la max weber that is the untangling of all the pertinent factors involved in a specific historical event but can also be part of the background set of factors shaping wider objective probabilities that sociology according to weber specialises in mapping out diffusion mobilities scapes flows and the spatiotemporal ordering of practices would happily fill the void rather than capitulate to the rivals and either abandon bourdieus concepts or opt for a logically flabby pluralism or eclecticism however we can head them off but it will require two theoretical moves the first is to expand on bourdieus notion of legitimation circuits these are much more important than his brief and scattered treatments of them would suggest but they need to be made more encompassing than they currently appear this is because logically it is only through them that objects symbols signs and principles of vision and division are distributed across time and space into individual lifeworlds the chains of interaction and movement through which products of field struggles emanate infused with varying degrees of symbolic power feed into the constraints and enablements the possibilities and impossibilities defining an individuals situation but also work along routes and channels with their own spatiotemporal pattern it is only through the patterning of these circuits of symbolic power for example that we can identify specific social orders in the global span of human relations that is knots of circuits routinely carrying effects from specific fields over a particular band of timespace distinct from the abstract topological social structures of fields 4the second move is to make clear that the relationship between fields and these circuits of symbolic power is dialectical the circuits are themselves conditioned by what goes on in a multitude of fields of course but the possibilities and impossibilities they yield for individuals alongside those provided by the lusiones of the game set purely by the distribution of capital will feed back into the structure of fields by facilitating or limiting strategies and positiontakings via the mediation of the horizons constituting the habitus charting the distribution of capital within a field is thus a necessary step in explaining any particular play within a field therefore and is often efficient but it does not exhaust the social determinations at work take for instance the study undertaken by cass et al into the role of public transport schedules in compounding exclusion infrequency and lack of night services on local buses in small communities are the outcome of a constellation of decisions within fields large and smallthe localised bureaucratic field of municipal government the economic field and so onwith their own specific stakes doxa illusio and struggles yet they have the effect of making certain activities for people not in those fields more difficultcommuting for particular jobs or education travel to cultural venues or events 5 shopping at cheaper supermarkets at a convenient time and so onand either remove them from the field of possibles or prompt the purchase and upkeep of a car with all its own financial burdens either way their capital accumulation or maintenance in the social space has been effected differentiating two people otherwise similarly situated possibly in only a small manner for sure but it could also be a difference that ends up making the difference between two trajectories in the long run 6 another example comes from rotters study of asylum seekers in scotland in this case people are subject to the imperatives of members of the bureaucratic and juridical fields laying 5 bourdieu did note the differences between big cities like paris and the provinces on account of objective opportunities for cultural consumption which might be taken to include transport and scheduling particularities but left it at that 6 elsewhere i have discussed similar themes with more of a focus on space under the label of motility and also questioned urrys claim building on the research in cass et al that control over time should be seen as an aspect of a new form of capital out the timelines of their cases which can drag out over several years in the meantime they are barred from workliving off state subsidy insteadand housed in a locale of the governments choosing evidently though the claimants will bring different levels of convertible capital from their home nations this process will have a significant bearing on their nascent position within the uk social space as time goes on and they await further information and outcomes that position is exacerbated as opportunities for accruing capital within the social space and indeed for entering into and becoming effective players within certain fields are foreclosed including by means of the asylum candidates postponing and deferring possibilities simply because they do not know what the future holds however and here is a break with bourdieus analysis of the protagonist of kafkas the trial with which there are otherwise parallels rotter also points out that some of the asylum seekers actively negotiate the timings being offered and use the intervening time to accrue legitimated forms of capital in the social space and even prepare for entry into specific fields once the case is approved time binds the final element of the social structuring of temporal experience is one which has grown in prominence in recent scholarship even though it has long been a part of everyday life the experience and management of competing schedules and demands on ones time coming from the different fields one is in this does include moonlighters and people occupying positions in multiple fields within the field of powerbusiness politics and so onbut much more prominent and pervasive is the articulation of ones familial field and ones workrelated field whether the latter be a space of struggle within the field of power or an organisational field or both through pressures to earn money and desires to fit in ones hobbies or pastimes related to the social space are also pertinent the reason this has become so much more prominent in the past thirty years or so of scholarship is because due to various factorsincluding work intensification technological change transformations of masculinity and fatherhood and most importantly feminisation of the workforcethose demands are becoming ever more difficult to manage for more and more people hence it has been labelled the time bind time squeeze or time crunch all labels conveying the sense of pressure and conflict increasingly leaving people feeling harried overbusy stressed depressed and so on the sociological importance of which should not be downplayed the degree to which the timebind is felt and the manner in which it is experienced is differentiated within social ordersthose at the top of the social space are most likely to report it and women more so than men and between them depending on welfare regimes and the household divisions of labour the latter foster still it is a pressure born of tension between fields in individual lives rather than within one again this interplay of multiple games is something bourdieu did acknowledge but this time even more fleetinglyin asides parentheses or endnotes and jarring somewhat with his more programmatic claims that the unit of sociological analysis should be a single field subsequently codified into strict methodological principles by later advocates if we stick to that way of doing things alone then time binds will slip from view all the emotional fallout dominating peoples everyday lives will be much more difficult to capture and explain since one side of the conflict is obscured but so too once again will be a fuller means of explaining why someone is taking the stance or pursuing the practice they are in relation to one particular field this is because once we shift our view from what goes on in one field alone to what goes on in a persons lifeworld as defined by multiple field positionings it becomes clear that what one does in one field necessarily takes into account what is going on in other fields in the horizons of perception are practical expectations related to not just one field but at least two in other wordsthe sense that pursuing this strategy now and in this way in a workrelated field would or will have a certain impact on the familial field for example or vice versa modulated by the strength of ones illusio in each we have not just a feel for the game but a feel for the games we are playing with this in mind we can for example make sense of and even elaborate on the various temporal strategies people mobilise to deal with work and family pressures on time that hochschild briefly distinguished 7 first there is enduring or the acceptance that demands on ones time from workborn of the social space and the field of the firmwill diminish the time and energy that can be spent on family more prevalent among manual workers for whom the illusio in relation to the family may be stronger relative to work but who read in the fields of possibilities presented by the latter and the social space that they have little choice this makes for unhappiness in the form of potential decline and painfully readjusted expectations in the game one values over all others having said that there 7 although hochschilds research predates the boom of smartphones and related technology recent research has confirmed that the impact of smartphone usage checking work or family emails at various times and spaces essentially follows preestablished preferences in the spatiotemporal balance of attention and desire between employment and family which fits with wajcmans general thesis that technological development tends to transform the nature of existing social differences rather than erase them will be others for whom the forms of recognition and possible trajectories offered by employment offer an escape from a familial field yielding less present or potential recognition or a form of recognition they desire less and who thus dedicate more of their time to the former at the expense of the latter next there is deferral or the postponement of particular events pertinent to the family field until after projects related to the workbased field have been completed this implicates a sense of interlocking field timings not only in playing the rhythms of one field off those of another but in intuiting what is an acceptable period of deferral for maintaining ones standing with loved ones given how committed one is to them of course we should also add that the deferral can work the other waypeople may defer specific projects and strategies within the employmentrelated field on the basis of familial events with knockon effects for their success and even possibilitydepending perhaps on the relative strength of illusio in each field then there are the busy bees who manage the competing demands on their attention born of the social space familial field and workrelated field by trying to pack as much in as possible moving quickly and with little interlude backwards and forwards between moves and positiontakings in each structural space the delegators moreover are those who with sufficient economic capital pay others to do care work for them signifying something of the balance of desires produced by certain social conditions though hochschild notes one of the unintended consequences it can bring children can come to care for and submit to a nanny more readily than parents making the nanny not only an effective player within the familial field but a challenge to the relative symbolic capital of parents lastly there is what hochschild terms resistance active negotiation of or battling against demands on time stemming from workrelated fields so as to give the family a greater place in ones life whether by implementing certain rules reducing ones work hours or some other means this is indicative of the balance of the libido which may shift depending on changing standing within each implicated field hochschild notes its prevalence among more dominant players within the firm she studied suggesting it may depend on a certain level of cultural economic andor firmspecific capital indeed research has suggested that parttime workers rich in cultural capital are more likely to have actively chosen that status while those with fewer resources working part time do so more out of necessity either way of course while transforming conceptions of fatherhood may mean men are more likely to resist nowadays the same research also indicates this is in all probability a distinctly female temporal strategy insofar as women are much more likely to be working part time for family reasons of some sort this then raises questions over how far the strategy is best characterised as one of resistance at all rather than a product of internalised expectations of what women should do with repercussions for their capacity to accumulate capitals in employmentrelated fields the point stands however that the strategy is one played out between multiple fields that is to say based on a feel for each game and how they bear on one another as well as having effects in more than one struggle for recognition none of this means we should do away with the focussed mapping out of stakes and properties pertinent to a specific field nor even the idea that dispositions practical sense and habitus are defined relative to fields some terminological precision may help though bourdieu himself suggested that when referring to an individual as they appear across multiple fields we might talk of their social surface which can be taken to mean the totality of their dispositions across spaces of struggle as distinct from those defining their fieldspecific habitus moreover if there are temporal horizons in relation to specific fields there is also what we might call after husserl the individuals world horizon the cogivenness of pertinences from one field with those of another knitting together the social surface since it bears on all the fields and circuits structuring an individuals lifeworld conclusion efforts to slice time into categories and components are legion and bourdieus work is so voluminous that it is all too easy no matter how well one thinks one knows it to overlook what he may have said on a specific topic here or there i have tried nevertheless to catalogue the advances and limitations of genetic structuralism on time via four optics the first two of these were firmly within the comfort zone of bourdieus sociology the temporal structure of consciousness and the specific timings produced by fields the former allows us to break with static or ahistorical models of agency by emphasising the everpresence of the agents past in expectations of the future even if bourdieu downplayed the conscious projection that gives rise to the latter meanwhile allows us to recognise the plurality of temporal markers in society where they come from and why they matter to people by rooting them in multiform struggles for recognition though we also need to trace the differential effects of technology and work intensification on the pace of field events fitting a little less snugly in the usual bourdieusian framework were the other two aspects of the social structuring of time imposed timings and time binds true there is some acknowledgment from bourdieu of both phenomena and we can even find some starting points for rendering them within his writings to adequately bring them in from the conceptual cold however we not only had to do some theoretical work ourselves but switch from looking at what goes on within one field to unpicking how multiple fields and their effects shape what goes on in individual lifeworlds this is a temporary shift of focus rather than a permanent one dependent upon the research task at hand and its utility is not confined to the sociology of time bourdieus tools may indeed illuminate components of the social structuring of temporality therefore but examination of the latter has also made clear that the former need to be deployed in novel ways if light is to be cast on elements of the social world otherwise hiding in the shadows

this paper explores the role of time in pierre bourdieus social theory with a view to highlighting and plugging some of its conceptual gaps it proceeds by identifying four elements of the social structuring of temporal experience the temporal structure of consciousness field rhythms and pace imposed timings and time binds the first two of these bourdieu brought to the fore even if there are some aspects of his account in need of further development the third he posited without tracing through the full conceptual consequences while the fourth requires some reorientation and additional work to accommodate it the latter i undertake by elaborating on a few concepts drawn from both bourdieus corpus and phenomenology

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perhaps because of the accumulating evidence for the importance of early treatments in improving outcomes as well as the high public costs of asd a growing body of research has focused on frequency and correlates of service access for children and youth with asd cohorts in most of these studies include a fairly broad age range often ranging from early childhood through young adulthood the present study takes an alternative approach by focusing on patterns and correlates of service access for youth with asd during a critical point in the life course specifically we examined service access when youth with asd were in their last year of high school we focused on service access at this time for two important reasons first this is the last year when formal services are federally mandated by the individuals with disabilities education act although idea specifies age 16 as the time to begin transition planning research suggests that many schools do not meet the delineated timelines for transition services and supports thus schools may wait as late as the last year of high school to implement these vital servicessupports making this time point important in determining which types of services youth with asd are receiving as well as their unmet service needs further although idea ensures that youth with asd have access to formal services until they exit the secondary school system there is no such mandate for formal services after high school exit this results in an underfunded adult service system with many adults with asd receiving inadequate or no services and supports services received during the last year of high school are likely critical in setting up youth for successful postschool outcomes and youth with asd who are underserved at this time may be at particular risk for a poor transition to adulthood second it may be that youth with asd who are preparing to exit high school and transition into adult life require a distinct set of services relative to earlier years to date no study has focused on service receipt or unmet service needs during the last year of high school in the present study we examined service access barriers to service receipt and youth and family correlates of service access for youth with asd during this critical time correlates of service receipt a limited number of youth and family correlates of service receipt among individuals with asd have been identified in the extant literature in terms of youthchild characteristics one of the most consistent factors associated with disparities in service access is raceethnicity individuals with asd who are racialethnic minorities tend to get an asd diagnosis later and receive fewer services in childhood and in adulthood further disparities in service access for youth who are racialethnic minorities do not seem to be accounted for by poverty thus in the present study we expected that racialethnic minority status would be correlated with disparities in service access further relative to higher functioning children and youth with asd those who are lower functioning across a number of domains tend to receive more services likely reflecting greater service needs for these individuals specifically studies have found that children and youth with more communication deficits greater autism severity fewer social skills and greater intellectual impairment receive more services relative to youth who exhibit fewer impairments in each of these domains in many of these studies level of functioning is measured generally making specific conclusions about the domains of functioning related to service access or unmet service needs difficult in the present study we examined specific aspects of functioning including adaptive behavior autism symptom severity and comorbid intellectual disability diagnosis during this important period prior to high school exit although psychiatric comorbidities in youth with asd are quite common the influences of comorbid mental health diagnoses or related problem behaviors on service receipt and unmet needs have not yet been examined however youth who have a diagnosed comorbid psychiatric disorder are likely to be accessing mental health services and thus may be receiving more services in general therefore we chose to include both comorbid psychiatric diagnoses and behavior problems as possible correlates of service access family factors have also been examined as correlates of service access with mixed results for example studies have suggested that parents who are in worse physical and mental health report more difficulty accessing services as well as greater unmet service needs the opposite finding has been reported for parental stress with higher levels of stress related to greater service receipt note however that behavior problems exhibited by the sondaughter with asd is one of the most consistent predictors of parental stress and distress and factor and colleagues found greater service use among families who had children with more difficult child characteristics thus the relations between parenting stress and greater service receipt might be a spurious result of having a more difficult child similarly research on the relation between parental socioeconomic status and service access among individuals with asd has been mixed with some studies finding that families with lower incomes tend to have a greater difficulty accessing services and others finding no such association it may be that the mandate for services in idea levels the playing field minimizing the impact of family socioeconomic status on the availability of formal services during the school years given that there is some evidence for an association of family functioning and socioeconomic status with service receipt we included them as correlates of service access in the present study the present study the present study addresses an important gap in the literature by focusing on frequencies and correlates of service access for youth with asd who are in their last year of high school and thus preparing to transition to adulthood in contrast to most previous studies we not only examined the number of services that youth with asd were receiving but also the number of unmet service needs reported by their parents note that these two variables are not necessarily the inverse of each other some youth and their families may be receiving a low number of services but may also have low service needs thus focusing on both service receipt and unmet needs addresses two separate aspects of service access further we compared our rates of service receipt and unmet needs to a nationally representative sample of youth with asd in high school the national longitudinal transition study2 the nlts2 is a large scale 10year study of youth receiving special education services in the united states findings regarding youth with disabilities from the nlts2 can be generalized to all youth receiving special education services in the united states this comparison serves two purposes 1 it allows us to consider whether service receipt in this midsouthmidwest cohort is similar to a nationallyrepresentative sample and 2 it allows us to compare whether service access when youth with asd are ages 1316 is similar to service access when youth with asd are in their last year of high school the present study also extends the research on service receipt during the transition years by utilizing an extremely wellcharacterized sample of youth with asd although cohorts drawn from the nlts2 or administrative databases have very large sample sizes they provide little detail on the specific behavioral and phenotypic characteristics of their asd cohorts the present study complements this work by using goldstandard autism diagnostic instruments and wellvalidated measures of individual and family functioning in order to examine specific youth and family factors that are associated with service access when youth with asd are in their last year of high school two research questions were examined in the present study first we focused on the patterns of service access among youth with asd in their last year of high school including descriptive information about service access unmet service needs barriers to service access as well as how this information compares to the nlts2 second in order to identify those youth most likely to be underserved during their last year of high school we examined youth and family correlates of service receipt and unmet service needs methods participants and design the present study included 39 families of youth with asd who were in their last year of high school the inclusion criteria were that the son or daughter with asd was currently within 12 months of high school exit had received an asd diagnosis from an educational or health professional was willing to participate in the study with a responding parent and the family was able to travel to one of the project sites participants were recruited through a number of venues including local clinics and other autismrelated research studies as well as local support groups service providers and autism organizations families received information about the study through these venues those who were interested contacted a study coordinator and were subsequently screened and enrolled asd diagnoses were confirmed through inperson assessments by clinicians with expertise in asd diagnosis using goldstandard procedures namely a combination of scores from the autism diagnostic observation schedule administered to the youth and the autism diagnostic interviewrevised administered to the responding parent along with clinician judgment all clinicians had achieved external research reliability in both the ados and the adir data were collected through parental interview and selfadministered questionnaire and a psychological assessment of the youth with asd the youth with asd included in this analysis averaged 187 years of age with a range from 172 to 220 over threefourths of the youth were male and the majority were white nonhispanic the youth with asd exhibited tremendous heterogeneity in intellectual functioning with iq scores ranging from 40 to 137 approximately 30 of the youth had iq scores of 100 or above suggesting average or above average intellectual functioning using wellaccepted iq and adaptive behavior criteria 308 had a comorbid intellectual disability all but one of the youth were living with the responding parent at this time with the remaining youth living in an apartment with aroundtheclock supervision approximately onehalf of the youth with asd had been diagnosed with a comorbid psychiatric disorder with 308 diagnosed with two or more comorbid disorders the most common disorders were anxiety disorder major depressive disorder and obsessive compulsive disorder the majority of youth were taking at least one prescription medication and 283 were taking 4 or more medications the parent sample was composed of 35 mothers and 4 fathers the participating parent ranged from 383 years to 592 years of age this was a welleducated and wellresourced sample on average with over 70 of the responding parents having attained a postsecondary degree and 308 earning a postbachelors degree the median household income was between 80000 and 90000 although onequarter of the sample had annual household incomes below 40000 twothirds of parents were married with all but three married to the other biological parent of the youth with asd measures service accessusing a list of services derived from the nlts2 parents reported on the availability of each of 16 services similar to the nlts2 parents reported whether each service was received in the past twelve months if parents reported that the service was not received we asked whether that service was needed the sum of services received was calculated as our measure of number of services the sum of services needed but not received by the son or daughter was calculated as our measure of unmet service needs note that the nlts2 did not ask whether each service was needed but instead asked parents whether the sondaughter was getting all of hisher service needs met in addition parents were asked questions from the nlts2 about barriers in accessing services parents were asked to place a checkmark by each barrier that has been a problem for them in getting or dealing with services in consultation with families and experts we added two additional problems to the list provided by the nlts2 1 doctor or specialist doesnt accept insurance type and 2 physical accessibility of services youth characteristics intellectual disability comorbid intellectual disability status was determined using standardized iq and adaptive behavior assessments standardized iq was obtained by administering the stanfordbinet intelligence scale to youth with asd during the psychological assessment the stanfordbinet is a commonly used intelligence scale with strong psychometric properties and both verbal and nonverbal sections adaptive behavior was assessed by administering the vineland adaptive behavior scalessecond edition to parents individuals with standard scores of 70 or below on both iq and adaptive behavior measures were classified as having an intellectual disability consistent with diagnostic guidelines for cases where the individual with asd scored above 70 on either measure determination of intellectual disability status was made by clinicians raceethnicity we collected the raceethnicity of the youth with asd coded into 1 whitenonhispanic 0 other raceethnicity although there were few participants who were racialethnic minorities in this sample we included this variable given the prominence of racialethnicity disparities in other studies of service receipt in asd autism symptom severity autism symptom severity was measured using the social responsiveness scale a 65item parentreport measure the srs measures dimensions of interpersonal behavior communication and repetitivestereotypic behavior that are characteristic of asd parents are asked to respond on a likertscale to items in terms of how best they describe their sondaughters behaviors over the last 6 months ranging from 1 not true to 4 almost always true item scores are combined to form five subscale scores and an overall severity score the srs has demonstrated adequate reliability and validity in asd samples overall severity scores were used in the present analyses with higher scores indicating greater symptom severity comorbid psychiatric diagnoses current comorbid psychiatric diagnoses were determined using the psychiatric disorder section of the rochester health status survey a medical survey designed for individuals with disabilities parents were given a checklist of 12 possible psychiatric diagnoses and asked to indicate if their son or daughter currently has this condition as diagnosed by a medical provider information collected about each diagnosis was combined to indicate whether the youth had any current comorbid psychiatric diagnoses behavior problems the adult behavior checklist a parentreport scale was used to measure behavior problems among the youth with asd in the abcl parents are asked to rate the frequency of each of 126 problem behaviors on a 3point likert scale scores are summed and converted to tscores to form eight syndrome scales anxiousdepressed withdrawn somatic complaints thought problems attention problems aggressive behavior rulebreaking behavior and intrusiveness syndrome scales are combined to yield the internalizing problems externalizing problems and total problems composite scores the abcl has been validated for individuals ages 1859 although about onethird of our participants were 17 years of age at data collection we chose to administer the abcl uniformly to ensure comparability across the entire sample the manual for the abcl reports adequate reliability and validity for scale and composite scores the abcl has been validated in adults with intellectual disabilities and is commonly used in studies of adults with asd total problems tscores were used in these analyses with higher scores indicating more behavior problems adaptive behavior adaptive behavior was assessed by the vineland adaptive behavior scalessecond edition a wellvalidated parent interview that assesses social communication daily living and motor skills it provides standard scores for these domains as well as an overall adaptive behavior composite the total adaptive behavior composite was used in the present analyses with higher scores indicating higher levels of adaptive behavior family factors family incomeparents were also asked about their familys income in the previous year coded from 1 less than 10000 to 14 over 160000 parental healthparents reported their own health at the present time on a 4point scale ranging from 1 poor to 4 excellent selfrated health has been shown to be related to both morbidity and mortality across a variety of populations even after controlling for known risk factors like sociodemographics chronic health conditions and health practices parental depressive symptomsparental depressive symptoms were assessed by the center for epidemiological studies depression scale the measure has been used extensively in adult samples for each of 20 depressive symptoms the respondent is asked to indicate how many days in the past week the symptom was experienced scores can range from 0 to 60 with a high score reflective of a greater intensity of depressive symptoms parental anxietythe anxiety subscale of the profile of mood states was used to measure parental anxiety this subscale measures the frequency of nine anxiety symptoms in the last week such as feeling tense shaky or on edge total scores range from 0 to 36 with higher scores indicating more anxiety the profile of mood states has been shown to have strong construct validity in past research data analysis in order to address our first research question we examined means to determine the average number of services received by youth with asd in their last year of high school as well as the average number of unmet service needs we examined the percentages of youth who were receiving each type of service as well as the percentage who were reported as needing that service but not currently receiving it we also examined the percentage of parents who reported each of 12 possible barriers to receiving services in order to understand the representativeness of our sample we compared their rates of service receipt and reported barriers to data collected from families of a nationallyrepresentative sample of youth with asd in high school the nlts2 we next examined the youth and family factors that were related to the number of services that youth with asd received and their number of unmet service needs because the distributions of number of services and unmet service needs were not normal we used nonparametric statistics in all analyses first we examined the bivariate relations between study variables using spearman rho correlations then we used two ordinal regression equations to examine which of the youth and family variables predicted number of services and unmet service needs although it would have been preferable to include all of the possible independent variables in the regression equations our relatively small sample size did not afford the statistical power therefore we only included the youth and family characteristics in the regression equations if they had significant bivariate relations with the respective dependent variable results descriptive information on service access figure 1 depicts the distribution of the number of services received by youth with asd in their last year of high school as well as the number of services that were needed but not being received on average youth were receiving approximately 3 services with a range from 0 to 9 the majority of youth were receiving at least one service at this time as can be seen in table 1 the most frequently accessed services were psychologicalmental health services followed by speech language services career counselingjob skills training inhomeinclassroom aide and medical services related to special needs the remaining services were received by 25 or fewer of the sample when comparing rates of service receipt using data on youth with asd from the nlts2 youth with asd in the present sample were less likely to be receiving 12 of the 15 measured services the greatest disparities in service receipt between samples was for speech language therapy inhomeinclassroom aide occupationallife skills and transportation services thus youth with asd in the present sample were underserved compared to a nationallyrepresentative cohort disparities in service receipt in the present sample did not appear to be related to less need for services the average number of unmet service needs was 185 with a range from 0 to 7 perhaps more importantly twothirds of the sample reported having at least one unmet service need with nearly 30 reporting 3 or more unmet needs in contrast fewer than onehalf of families in the nlts2 reported that they were not getting their service needs met as presented in table 1 the most common unmet service needs in this sample were career counselingjob skills training and occupationallife skills training which likely reflect parents concerns about preparing their son or daughter for exiting high school over the next year barriers to receiving services both in the present sample and in the nlts2 are presented in table 2 the three most common barriers endorsed by parents in the present sample were that the services cost too much they werent provided in a geographic area that was convenientaccessible and the doctorspecialist did not accept their insurance type in contrast in the nlts2 the most common barriers were that the services were not available and difficulties getting information about services in sum parents of youth with asd in their last year of high school were receiving fewer services with higher numbers of unmet service needs relative to a nationallyrepresentative sample of youth with asd in high school barriers to accessing services differed between samples in our sample families were less likely to report service unavailability or inadequate information as barriers but instead reported that cost and geographic location of services were the major barriers to service receipt youth and family correlates of service access the second research question focused on the youth and family correlates of service receipt and unmet service needs table 3 presents the bivariate relations between study variables interestingly there was only a moderate correlation between the number of services that youth were receiving and the number of unmet service needs that is parents of youth who were getting fewer services were not necessarily reporting a higher number of unmet needs several youth variables were associated with the number of services received specifically youth with asd received more services if their autism symptoms were more severe if they had a comorbid psychiatric diagnosis and if they had lower levels of adaptive behavior there was a marginally significant association between higher levels of maternal depressive symptoms and greater service receipt more unmet service needs were associated with racialethnic minority status greater severity of autism symptoms as well more behavior problems and lower levels of adaptive behavior a number of the family factors were also marginally or significantly associated with unmet service needs families who had lower incomes and families in which the responding parent was in worse health and had higher levels of anxiety reported more unmet service needs table 4 presents the results of the ordinal regression analyses examining which youth and family factors independently predicted number of services and unmet service needs both individual characteristics that had statistically significant bivariate correlations with number of services remained statistically significant when entered simultaneously into the regression model that is youth who had a comorbid psychiatric diagnosis and those who had lower levels of adaptive behavior were receiving more services youth with a comorbid psychiatric diagnosis on average were receiving approximately two more services relative to youth without a comorbid diagnosis similarly youth with adaptive behavior scores of less than 70 were receiving approximately 15 more services than youth with scores of 70 or above in the regression equation predicting unmet service needs racialethnic minority status more behavior problems and higher levels of parental anxiety independently predicted more unmet service needs youth who were racialethnic minorities on average had 3 more unmet needs relative to youth who were when grouping behavior problems tscores into average borderline and clinical behavior problems 308 of youth with at least one unmet service need had behavior problems in the clinical range compared to only 77 of youth with no unmet service needs further parents of youth with at least one unmet need had anxiety scores that were approximately twice as high as parents of youth with no needs thus greater service receipt appeared to be related to greater functional needs and the presence of a diagnosed comorbid mental health diagnosis in the youth with asd whereas youth with more unmet service needs tended to be racialethnic minorities have greater behavioral needs and parents who were more anxious followup analyses because psychologicalmental health services were included in our services count variable we hypothesized that this type of service could account for greater service receipt among youth with asd with a comorbid psychiatric diagnosis relative to those without a comorbid diagnosis thus we calculated another variable that counted the number of services excluding mental health services and examined whether youth with asd with a comorbid psychiatric diagnosis continued to receive more services having a comorbid diagnosis remained a significant predictor of the number of services received b138 se62 wald χ 2 499 p 05 even excluding mental health services youth with asd with a comorbid psychiatric diagnosis were receiving an average of 14 more services relative to youth without a comorbid diagnosis discussion results from our cohort suggest that youth with asd in their last year of high school are underserved relative to a nationallyrepresentative sample of highschool aged students with asd these youth were less likely to be receiving 12 out of 15 services relative to the younger nlts2 cohort as suggested by mandell and colleagues it may be that youth begin aging out of services as they approach their last few years of eligibility under idea one striking example is speechlanguage therapy which was received by only 36 of youth in this sample relative to 75 of youth in the nlts2 interestingly however for the services in which we observed the greatest disparities in the present cohort families reported fairly low levels of unmet need instead high need was reported for more transitionfocused services such as careervocational training and occupationallife skills training thus it seems likely that the types of services valued and pursued by parents may shift as the transition out of high school and into the adult service system looms closer upon closer inspection it appeared that relative to youth who have asd and an intellectual disability those with asd without id might be particularly underserved in vocational and occupationallife skills training compared to those with id youth without id were about onehalf as likely to be receiving careervocational training through the school system and onefourth as likely to be receiving occupationallife skills training through schools perhaps most worrisome of those who were not receiving vocational training parents of youth with asd without id were almost 25 times more likely than parents of youth with id to report that this type of training is needed this suggests that vocational training is valued by parents of higher functioning youth with asd who often receive exclusively academic instruction in high school given that youth with asd without id are more likely than those with id to have no vocational activities after high school exit targeting vocationaljob skills or life skills training toward these individuals might improve employment outcomes in adulthood alternatively differences in service access between the present cohort and the nlts might reflect geographic disparities in service access the state of tennessee where the majority of the sample is located consistently falls among the states with the smallest expenditures on both education and special education per pupil if indeed the disparities in service access in the present cohort are a result of geography then our findings are even more alarming as this cohort overall was socioeconomically advantaged although we did not find a relation between parental income and service access in our sample other studies of schoolaged youth have found that parents who have more economic resources have greater access to needed services for their son daughter with asd future research that separates out geographic differences in service access from agerelated differences is needed to determine whether age andor geography play a more important role in disparities in service access among adolescents with asd as expected the correlation between the number of services that youth with asd were receiving and their number of unmet service needs was relatively low suggesting that youth who are receiving few services may not necessarily need more of them or alternatively that youth who are receiving many services may not necessarily have all of their service needs met further the youth and family factors that were correlated with the number of services were substantially different from those that were correlated with unmet needs this provides evidence for the importance of considering both aspects of service access when trying to best understand how to meet the needs of youth with asd who are transitioning to adulthood interestingly the presence of a comorbid psychiatric diagnosis was related to receiving a greater number of services but higher behavior problem scores were related to more unmet service needs although higher levels of behavior problems might be expected to cooccur with comorbid psychiatric diagnoses the correlation between these two variables was only moderate in the present cohort this may be because the majority of youth who had a comorbid psychiatric diagnosis were being treated by prescription medication compared to 478 of youth without a comorbid diagnosis thus treating the comorbid disorders should lessen the behavior problems that youth exhibit disentangling this relationship our findings suggest that regardless of whether there is a diagnosed comorbid psychiatric disorder parents would like further services and supports during the transition years to treat their sondaughters problem behaviors if youth with asd and high level of behavior problems are underserved while under the mandate of idea they may be at particularly high risk after high school exit our prior studies have found that high levels of behavior problems are associated with poor vocational outcomes in adulthood suggesting that this is indeed the case our finding that having a diagnosed comorbid psychiatric disorder predicted greater service use although novel was not surprising given that mental health services was one of the types of services included in the overall count however followup analyses suggested that relative to youth without a comorbid disorder these youth received additional services net of mental health services thus effectively treating comorbid psychiatric problems during the transition years might alleviate the services needed by youth in other domains as well given the high public costs of asd future investigation into whether effectively treating mental health problems in these youth results in reduction in service needs and associated costs is highly significant consistent with previous research we found that poor parental mental health was related to unmet needs for youth with asd specifically our findings suggested that parents with higher levels of anxiety had sonsdaughters with asd who had more unmet service needs perhaps most importantly this is the first study to find that the relation between parental mental health and unmet service needs remained statistically significant after controlling for the behavior problems of the youth with asd because this is a crosssectional study it is impossible to determine the direction of effects between these variables it may be that having a high number of unmet service needs leads to high levels of anxiety among parents of transitioning youth alternatively it could be that parents who exhibit high levels of anxiety are less effective in procuring needed services for their sondaughter with asd if this is the case we might expect the impact of parental mental health on service receipt to be even more pronounced after high school exit when services are no longer mandated leaving parents with the responsibility for finding coordinating and maintaining services longitudinal studies are needed to disentangle the direction of effects between parental mental health and sondaughter service access as the results have important implications for intervention particularly if parental anxiety does indeed lead to less effectiveness in procuring needed services then new familyfocused targets for potential interventions might be appropriate to increase service access for youth with asd also consistent with some extant studies youth with asd who were racialethnic minorities averaged 3 more unmet service needs relative to youth who were whitenonhispanic although conclusions must be drawn with great caution given the small number of racialethnic minority families in our cohort results suggest that these families are being underserved while youth with asd are still under the umbrella of idea as suggested by shattuck and colleagues disparities in service access might be magnified even further after high school exit placing these young adults with asd at extraordinarily high risk for unemployment and poor adult outcomes there are a number of limitations to the present study that are important to note first this was a small nonrepresentative sample who lived in two specific geographic regions not only did the small sample preclude our ability to conduct further statistical analyses but it is unclear to what extent results from this sample will generalize to other samples of youth with asd in their last year of high school our recruitment methods and study procedures also likely affect generalizability many participants in the present study were recruited through other autismrelated studies or mailing lists from autism organizations and may be betterconnected and more likely to be receiving services than families in the general population further participants were required to travel to the project site to participate in the research and thus families who are more socioeconomically disadvantaged are likely underrepresented in the sample if families in the present cohort are indeed better served and more economically advantaged than the population of families of youth with asd in our geographic areas then our finding that youth with asd are underserved in their last year of high school is even more alarming as we may be underestimating the true amount of need largerscale studies are needed to determine to what extent the disparities in service access noted in this sample are due to geography or to stage of the life course second the majority of measures included in this study were collected via parental selfreport although this allowed us to collect data from parents of youth with a wide range of functioning it is possible that the shared method variance may be accounting for some of our findings on a related note we did not have access to the youths individualized education plans which would detail the services prescribed by the school system it is possible that youth in this sample were receiving more services through schools than parents were aware future research should consider multiple reports of service access as they provide complementary information finally because this was a crosssectional study there were important questions that we were not able to examine first we were unable to explore directionality of the observed relations this was particularly relevant for the relations between unmet service needs behavior problems and parental anxiety do youth with more behavior problems have increasing difficulty accessing services or does difficulty accessing needed services lead to an increase in behavior problems similarly do parents have more anxiety because their sondaughter is not getting hisher service needs met or are parents with high levels of anxiety less effective in procuring needed services for their son or daughter longitudinal studies are needed to separate out the directionality of these relations which has important implications for intervention second it is unclear to what extent disparities in service access while youth with asd are in high school leads to problematic outcomes in adulthood although it is reasonable to expect that disparities in service access will be magnified after youth leave the protective umbrella of idea and enter the adult service system this needs to be tested with longitudinal studies that follow youth with asd from before to after high school exit although there are limitations to this data this is the first study to our knowledge that provides a detailed examination of service access for youth with asd at a critical point in the lifespan during their last year of high school this study is also unique relative to most research on service access for transitionaged youth with asd by utilizing a carefully phenotyped sample with detailed wellvalidated measures across a range of youth and family factors our findings suggest that these youth are underserved even in comparison to their younger highschool aged peers and have specific needs in areas such as vocational and life skills training that vocational and life skills training needs are not met is of concern as these types of services are likely to be very important in promoting postschool independence youth who were particularly underserved in our sample those who were racialethnic minorities who had high levels of behavior problems and who had parents with high levels of anxiety might be at greatest risk for a poor transition to adulthood and warrant future research with larger longitudinal samples to understand their transition outcomes

this study examined service receipt and unmet service needs among youth with autism spectrum disorders asd in their last year of high school as well as the youth intellectual disability race ethnicity autism severity comorbid psychiatric diagnoses behavior problems adaptive behavior and family income parental health parental depressive symptoms parental anxiety correlates of service access thirtynine families of youth with asd participated data were collected via parental interviewquestionnaire and youth psychological evaluation results suggested that this sample was underserved relative to a nationallyrepresentative cohort those with a comorbid psychiatric diagnosis and lower levels of adaptive behavior received more services greater unmet needs were reported for youth who were racialethnic minorities who had more behavior problems and whose parents had greater anxiety

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and he offers an account of the disciplines in which rigour is seen as a cardinal virtue in the upholding of commitment to truth bridges defence of disciplinary foundations makes some important points disciplines in educational research are to be understood he argues as ways in which such qualities as rigour and scholarship have been and are organised and structured in that community for different questions about education require different kinds of response different forms of inquiry different kinds of evidence reasoning or argument things are far from straightforward here however as the development of the european educational research association including in particular its philosophy of education network has shown it should certainly be recognised he rightly asserts that the forms that these disciplines take have also evolved historically in different ways in different places network 13 was not long established before it became clear that its participants were frequently talking past one another this was a matter not just of being confronted by different languages but of facing up to the nontranslatability of some of the language that was embedded in different national cultures these are important points about ways of thinking and about the significance of different languages and i shall return to them below but bridges conclusion embraces three broad statements and it is to these that i would like first to turn he claims that all research is logically associated with a requirement to seek to satisfy some kind of criterion of truthfulness that this requires according to the nature of the inquiry the more or less rigorous application of certain procedural rules which help us to see what beliefs are most deserving of confidence and which as hunt has put it make a community of arguers possible and that these procedural rules along with the body of work that has issued from them constitute the disciplines of knowledge the logical progression between these points helps to show the need for some kind of community or at least continuity of enquiry between people and the emphasis on procedural rules goes some way towards showing how the body of work that characterises a discipline is constituted that this is a community of arguers and not say just adherents to a common cause is one of the ways that this consolidation of practice becomes a discipline and avoids sliding into ideology yet the very meaning of disciplines in educational research is questioned and the need for foundation subjects is surely contested while some see education as a field dependent upon its constitutive disciplines others hold out for the idea that education is itself the discipline at various points over the past forty years and complicating matters further new claims have been pressed for the independent disciplinary status of such practices as curriculum studies school effectiveness and improvement and leadership how far can such views be defended and what turns on these distinctions and rival claims the autonomy of educational research it is important to acknowledge the ways in which educational research has not developed as an autonomous fully selfdetermining field of study with any subject there is always a politics of knowledge to be addressed but in educational research this is particularly salient over the past fifty years the field has been shaped by four main factors first there has been the obvious influence of changes in educational policy and practice new forms of governance as well as fluctuating levels of state intervention direct and indirect have had a significant bearing on what it is that is researched and why second there are wider social political and technological factors that extend well beyond the control of governments and that constitute powerful forces to which academic research must respond witness the burgeoning presence of social media as well as the effects of mass migrations third there are more direct influences in the form of changes in the funding of research especially with a general shift from direct funding to the practice of identifying particular projects and putting them out to tender where the topic is determined by the sponsor for the research sometimes with a clear political steer fourth there are influences from developments in the parentdisciplines as these are sometimes called as well as in other forms of enquiry bearing on education principally in the social sciences and humanities in the philosophy of education one example here is the massive influence of john rawls on political philosophy which has understandably ramified into research into such matters as school choice another is that of emmanuel levinas whose thematising of alterity has been brought into service in respect of the understanding of other cultures which is perhaps not the most appropriate and beneficial way of taking up his thought another is the rise of neuroscience much of such work is wellconceived and valuable but there are also dangers here the philosophy of education may become selfdemeaning if it constructs itself as always operating only in the wake of major mainstream philosophers and on a broader scale in educational research as a whole there is the danger of hagiography in different forms it continues to be true in many contexts that educational research is not forced to give in to political pressures of course there is a need for funding especially for some kinds of research nonempirical research is not costly a more surreptitious influence on behaviour here however lies in the kudos and enhanced employment prospects that attach to the winning of research grants this can muffle research and dull its critical edge it should not be forgotten that except in repressive circumstances critical thought costs nothing hence there is a continuing responsibility to reflect on the policy and practice of education as well as on the ways that the endeavour of educational research is constructed in this context there has certainly been much disagreement about the place status and credibility of the disciplines the disciplines it is said are selfserving they install orthodoxies of approach and then impose discipline of an authoritarian kind on anyone who wishes to enter into them which if this is true does indeed render them little different from ideologies but even without the excesses of ideology the dangers of orthodoxy remain like the other disciplines philosophy of education has sometimes made itself vulnerable to such charges it has done this especially when it has styled itself as the bastion of reason and defender of the citadel of civilisation and when it has spoken as it were de haut en bas to the wider field of empirical research ii vulnerability to ideology or at least to the stagnation of research in orthodoxy and received ideas is however a wider problem it would be quite wrong to think that these problems of orthodoxy are peculiar to the disciplines stifling proprieties of thought can emerge in other ways lack of rigour and faddishness rightly aggravate the anxiety that in educational research anything goes it is then to the relation between apparently opposing dangers that we should next turn between ideology and anything goes educational research is subject to orthodoxies of old and novel kinds on the onehand the foundation disciplines can become stuck in footnotes to received ideas and overanxious about reinforcing boundaries the result is a critical deficit that weakens the community of arguers and undermines the very raison dêtre of the practice in question on the other newfangled disciplines whether justifiably so described or otherwise seek to legitimate themselves in jargon and deference to new authorities and so again there is a critical deficit a key point in bridges position is that commitment to truthfulness requires the moreorless rigorous application of certain procedural rules that help us to see what beliefs are most deserving of confidence and this seems to be right but commitment to procedure can also turn into a problem this is so especially where the sense of the substance of the problem or of the object of enquiry wavers and where there is an attempt to finesse this through focusing on methods it is usually easier to be clear about methods than it is about the nature of the problem this is illustrated especially in some current practice in generic research methods courses in education where attention is turned away from the substantive topic of research and towards protocols of enquiry and the methods themselves of course if a method is adopted it is important that this should be done consciously and appropriately one point at issue here is that an excessive focus on such matters can deflect attention from the ostensible substance of concern and perhaps recast that substance in terms that make it fit the methodological requirements another is that it may elevate those methods to the point that the precision with which they have been adopted will become the subject of evaluation rather than the extent to which the truth of the matter has been revealed the very purpose they were supposed to serve methods courses typically proceed in this way partly because of the diversity of educational practices towards which research is directed but there is also here a degree of deference to physical science with its scope for systematic procedures this is a problem that extends more broadly across the range of social science it is however selfevident that the lives of human beings including their education are of a nature that is not susceptible to systematic enquiry in the manner that the physical world is except in highly circumscribed ways human beings can be studied in terms of their biology and the value of doing this is beyond question when behaviour is studied human behaviour especially but also the behaviour of at least the higher animals the complexity of life can be seen to extend well beyond the purely physical the attractions of reductivist forms of behaviourism in psychology lie in part in their clarity of procedure and systematicity similar kinds of attraction in other aspects of education have fuelled the trend over at least the last three decades towards understanding what is taught in terms of skills and competences with their pretensions to systematicity rather than content the prominence that has been given to transferable skills as well as communication skills entrepreneurial skills information access skills and many more and to the amassing of skillsets reflects a further eliding of the substance of learning and enquiry hence the proceduralist turn in educational research is perhaps a symptom of the age reflecting a loss of commitment to substantive values and an underlying nihilism as nietzsche already saw there is no doubt that where specific methods are adopted they need to be applied conscientiously and with rigour but the proceduralist orthodoxy obstructs or deflects attention from the object of enquiry and this too is a form of critical deficit in this light it is worth reflecting a little on the force of foundations in the present discussion in its academic usage the word has connotations of foundationalism that is the belief that knowledge claims must rest on firm foundations on beliefs that are secure descartes cogito is paradigmatic of such a way of thinking but foundation disciplines or the foundations approach expressions preferred in north america to the disciplines approach iii involve a more or less technical use of the term and this has no necessary connection with epistemological or ethical foundationalism north americas most distinctive contribution to philosophy pragmatism is explicitly antifoundationalist and yet one might speculate that there may be a rhetorical appeal to foundations deriving from the founding political importance of the pilgrim fathers and the declaration of independence the crucial point however is this the expressions in question refer to kinds of enquiry that are necessary to thinking well about education necessary because they correlate with the kinds of questions that practices in education should provoke the addressing of which should be the basis for other more specific forms of enquiry when bridges discusses the relation between the foundation disciplines and les sciences de léducation allgemeinewissenschaft and pedagogik he sets this out well as we saw at the start however much of his discussion does relate to epistemological or other kinds of adherence to foundationalist beliefs and here he positions himself neither with the social relativists or subjectivists nor with what are sometimes called the foundationalists but rather like hammersley with the fallibilist tradition in epistemology associated with in particular peirce dewey and wittgenstein the broad thrust of his position aligns with a popperian fallibilism a position that he acknowledges with reference to the work of denis phillips but there is something uncomfortable to say the least about this running together of thinkers whose ideas are opposed in certain important respects moreover it is inaccurate to align dewey and especially wittgenstein with systematicity the central idea of the language game in wittgensteins philosophical investigations is designed to hold back the inclination to impose systematicity on phenomena that are diverse human behaviour needs to be seen in the light of the whole hurlyburly of human actions the background against which we see any action it was not for nothing that wittgenstein remarked that his motto might have been the line from king lear ill teach you differences iv it is a pity when appeal to such philosophers slides so easily into such loose statements as all knowledge claims are fallible where martin hammersley is quoted which a moments careful thought reveals not to be true v the paths available to bridges are diverse and the forms of relativism are various it would be good to explore these with more precision a further quibble here has to do with the use of the term epistemology itself in the current climate talk of alternative epistemologies is apt to transport the discussion into the heady newspeak of alternative facts but it too has functioned in recent decades as a badge of honour for positions taken by those educational researchers who are the target of bridges and horstemkes criticism but epistemology is fundamentally a metalevel primarily academic term which refers to theorising about knowledge and belief rather than to the holding or expression of beliefs etc themselves hence there may be good reason to speak of what separates the dogon people from western peoples in one of the examples bridges explores as differences in ways of thinking rather than alternative epistemologies indeed his own aversion to the latter expression is signalled by its repeated framing in scarequotes it is an irony that this taking of positions say between foundationalists and alternative epistemologists seems to have missed the turning away from epistemology to which most of a century ago wittgensteins and deweys work contributed so significantly the holding of positions in this way can displace more agile approaches to these matters installing in their place a kind of rigor mortis the concern about paradigm proliferation expressed by robert donmoyer in a decade marked by the paradigm wars in education research is a further sign of the ways in which embattled positions are vulnerable to a kind of sclerosis to the frustration of any community of arguers worthy of the name affirmation of the multidisciplinary nature of educational research is sometimes motivated by a suspicion of ivorytower irrelevance that is of certain disciplines in their pure forms but multidisciplinarity often fails to face up to the demands of the questions themselves deflection from those demands is manifested where a research paper moves from one aspect of or approach to a topic to another without allowing the enquiry to establish any clear line of thought and argument the semblance of thorough coverage here accentuated perhaps by an attempt at comprehensive glossing of the literature on the topic and a lengthy list of references stands in the way of more rigorous thought deflection is manifested also at the institutional level where in some respects it seems even to be encouraged it is assumed that research in education requires the convening of research teams supported by grants of eyecatching size certainly there are educational research topics that require commitment along these lines but there is also a range of fundamental problems in relation to which the research team approach is likely to be a barrier to successful enquiry too often the approach lays the way for superficiality and so once again there is a critical deficit multidisciplinarity does however make sense whereas postdisciplinarity does not multidisciplinarity and interdisciplinarity are often needed in diverse fields of research and practice ranging from civil engineering and medicine to education itself and they presuppose the existence of more or less discrete disciplines that can work together the more murky but fashionable notion of postdisciplinarity by contrast implies a dispensing with the disciplines it is motivated typically by a dissatisfaction with the restrictions of their practices and lines of thought sometimes by a more headstrong dismissal of the presuppositions of truth and of the possibility of objectivity that define them and at times so it seems by advocacy for freethinking novelty vi as was acknowledged above there is reason to be suspicious of the disciplines where these become overly selfprotective lapses into orthodoxy inevitably dull their means of criticism and this is especially lamentable given that the focusing and advancement of reasoned criticism is central to their raison dêtre it is right also to question them when instead of acknowledging their complementary role in education they turn into rivals there may be understandable institutional reasons for this but in academic terms it is not justifiable furthermore the disciplines that have a bearing on education are best understood when it is recognised that the boundaries between them are not watertight and where natural overlaps between them are recognised yet when the reaction against disciplines turns sometimes into advocacy for postdisciplinarity the dangers are twofold first there is a question concerning what will constitute the procedural rules of reasoning and argument that bridges rightly identifies as important second it is not clear how in their absence a sustained form of enquiry can be generated let me qualify this a little however for it may seem that the present argument has now itself lapsed into the proceduralism that is otherwise partly called into question in my discussion here again perhaps i part company with bridges account it does not seem sufficient to understand the cogency and credibility of a discipline in terms of the procedural rules to which bridges refers in the first place it is important to say that there must be some kind of continuity in the substantive focus of attention that is in the disciplines taking up of certain kinds of topics and problems as its concern what is required also is some continuity in relation to the inheritance of certain texts that practitioners in the discipline have found significant and around which to put this another way they have gathered a division of a kind opens in philosophy between two conceptions of the subject as a set of problems to be solved and as a series of texts to be read this is not a watertight distinction the question is one of relative emphasis and the way this is answered will position philosophy on the one hand as something like a science and on the other as more fully realised amongst the humanities yet a further factor that needs acknowledgement here has to do with the importance of actual differences in cultural practice in research in education including the part that language difference plays the politics of knowledge is thus played out most significantly in the institutional forms in which research into education and the preparation of teachers have taken place it is plain that the structures relating to the latter vary considerably from country to country and this has a significant bearing on how careers in education are constructed and shaped these are important matters but perhaps more salient for the present discussion is the way in which education as an academic subject as the topic of enquiry and research is institutionalised the history of this subject varies significantly internationally and the terms that are used in relation to it are not consistent the problematically elastic term education in english contrasts with the variety of expressions that are found in for example german and scandinavian languages english has the term pedagogy but until perhaps thirty years ago it was not an expression one heard often amongst teachers themselves and now where it is used it refers most commonly to teaching method or approach at a relatively practical level for example wholeclass teaching and group work might be said to constitute different pedagogies a usage that may well strike those whose first language is not english as somewhat banal when in 1981 brian simon asked the question why no pedagogy in england he was lamenting the absence of the kind of study and enquiry that has gone by that name in many european jurisdictions just over two decades later robin alexander painted a still more dreary picture of policy regarding these matters especially in the light of the vulnerability of expressions of purpose and principle to political spin the pedagogy of principle has yet to be rescued he wrote from the pedagogy of pragmatism and compliance this is the antithesis of pedagogy as it has been understood in the traditions to which simon refers these have not it seems come naturally to anglophone cultures very much to their cost and the politics of knowledge has been such that pedagogy in this rich sense has not found a footing in name in the practices of teacher education or in research in the past at least pedagogy in the european contexts referred to here has been sustained by the gathering of thought around series of texts and problems and hence has realised the continuities of enquiry to which reference is made above bridges is right to see this as incorporating elements of the four disciplinary approaches typical of anglophone cultures an important implication of my discussion thus far is that there is an internal relation between discipline rigour and coherence and these though not systematicity are requirements of argument in view of the problems bridges identifies it is certainly important that criticism of a philosophical kind is promoted whether this is carried out under the name philosophy or pedagogy or under some other rubric is in a sense a secondary matter but the significance of a name should not be underestimated especially in prevailing contexts where policy and practice are so vulnerable to political spin and to the deft strategic placing of key terms in the wider culture and within the university itself and in the light of this it is appropriate to ask what can be expected from the philosophy of education as a form of disciplined enquiry philosophy of education as disciplined enquiry philosophy of education is subject to two assumptions both of which need to be undermined the first is that it is a branch of philosophy similar to the philosophy of science or the philosophy of music branches address a field of concern that is relatively easily circumscribed and they involve concepts and ways of reasoning that although not entirely discrete and although derivative in some degree from the broad trunk of philosophical thought are in some measure distinctive of that field they are branches in that they grow from more fundamental central elements in philosophy such as ethics epistemology metaphysics and ontology branches sometimes relate to professional fields of practice and enquiry and this would be so with the philosophy of education hence it is not surprising that it is often seen in this way there are however serious problems with this view it needs to be noticed first that there is no branch of philosophy that is not relevant to the philosophy of education in some way the philosophy of science is relevant to teaching and learning in science just as the philosophy of music has significance for music education probably the connections are wider than this observation implies furthermore these branches like all forms of enquiry themselves involve education the pursuit of learning within the subject such that any separation of them from education must be artificial or at least unwieldy a more important consideration however has to do with the nature of philosophy itself if one thinks of central elements in the mainstream of philosophy such as ethics and epistemology it is reasonably clear that they are concerned not just with the nature of the good or the nature of knowledge but with how one comes to live a good life and how one comes to know something in other words questions of education of teaching and learning are already there at the heart of philosophy as is testified at the start of philosophy in the work of plato himself given the reach and intensity of philosophys concern with what it is to be a human being how could this not involve questions about how we become what we are which is to say questions about our education the second common assumption is that the philosophy of education is an applied field this may be an attractive way of thinking in some respects especially at a time when philosophy and the humanities more generally are under pressure to show their practical importance there should certainly be no doubt about the desirability of considering practical questions in education philosophically but there is reason to question the idea of philosophy as something applied the expression falls into the accustomed pairing and purported contrast of theory and practice and this gives rise to a somewhat mechanistic conception of what the work of philosophy must be philosophy does the theory and then this is applied in practice an influential extreme version of this view in relation to education was found in the work of john wilson for whom the only thing that philosophy could do in relation to education was to clarify such basic concepts as teaching learning indoctrination authority and education itself that is to reveal their essential components so that these would then provide the foundation for the development of educational policy and practice vii yet this way of thinking can involve a kind of denial of responsibility after all it is simply the logic of education that is being revealed and the philosopher is scarcely responsible for the way things are and it can also be characterised as we saw above by a certain hauteur the philosopher does the serious theoretical work and the practitioner applies this in practice clearly this is to fall short of the practical reason that was advanced by aristotle just as it is to miss the inherent philosophical interest in teaching and learning as essential aspects of the human condition the mechanistic dichotomisation of theory and practice generates confusion around both if these assumptions are dispelled it can be seen that philosophical questions are stubbornly there in educational practice conversely there is no getting around the fact that education raises questions at the heart of philosophy such questions are in a sense unavoidable for human beings explicitly so in a democracy it is not that philosophy has a unique command of these things but philosophy is constituted by sustained traditions of enquiry into such matters responses to its questions are not generally advanced in the manner of scientific progress with an accumulation of knowledge but this in no way makes them superfluous in a sense these are questions that the members of each generation must take up for themselves as the humanities attest in various ways that the questions remain live and in a sense continually present themselves in new ways does not deny the fact that the attention given to them through the generations can contribute powerfully to the responses that can be given today that they are live in teaching and learning means that philosophical reflection on and within these practices rather than the application of theories to these practices can be peculiarly illuminating there is however a prevailing empiricism viii that contends that this is not so when in a keynote at the vienna meeting of the european conference in educational reserch in 2009 roland reichenbach reasserted the importance of philosophy in educational research he faced a barrage of questions along the following lines what is the empirical basis for your claims how do you know and where are your data some shook their heads at the responses he made which seemed to rely on argument and the appeal to reason alone not on something that could be presented as evidence but such a reaction is not sound the obvious fallacy in such views has two main aspects first any form of empirical research must take place on the basis of priorities and commitments that are not themselves the products of empirical research not to mention the fact that especially in social science subjects the results of empirical enquiry will typically be exposed to forms of analysis and interpretation that extend beyond a simple reading off of results the data do not generally speak for themselves second empiricism fails to acknowledge that there are some questions that cannot be addressed through empirical means questions concerning value and concerning the nature of the good as well as questions of justification are not answerable by empirical enquiry to condemn empiricism is emphatically not to criticise empirical research but it is to oppose the ideological belief that it is only through empirical research that education can be understood and advanced in my own ecer keynote in dublin in 2016 which was entitled empiricism and the avoidance of philosophy i pursued a line of thought similar to that of reichenbach some very interesting questions were raised in response but these were mostly sympathetic to what i had said i was puzzled not to be facing the same barrage of criticism that had confronted reichenbach did that mean that the battle had been won it would be pleasing but fanciful to think that this was so given that empiricism has taken over so many positions of influence however why is it so hard to find any reasoned defence of it bridges concerns are certainly of a different order being focused primarily on the lack of coherence and consistency amongst those who are indeed committed to philosophical work of some kind and the hope that greater clarity or agreement over the criteria of good philosophical work might aid in the wider understanding of philosophys contribution to education is not be an idle one the impression might be gleaned from his account that what is most required in order to legitimate the research and give it coherence is the rigorous following of procedures of reasoning while this is true up to a point it frames the matter too narrowly in the way that we saw in an extreme form in wilson and this is to fall short of providing an accurate picture of reason itself it gives the impression that one has only to turn the wheels of logical argument and the desired result will be produced while matters can indeed sometimes be resolved through such procedures it is also the case that the success of an argument in leading to the truth will depend not only upon its validity but also on the truth of the premises and often the real difficulty in thinking about education as with so many aspects of our social world is to find premises startingpoints that do justice to the reality of the circumstances the truth of a premise will need to be assessed not as a proposition in isolation but in relation to the broader context in which it is constructed crucial in this is the exercise of judgement where this is not a matter of the accurate application of a rule good judgement is typically developed through experience and it is refined through our interaction with others and through the testing of responses against the reactions and views of others such practice often involves laying one example against another and seeing differences and connections the refinement is extended where one considers ones judgement in relation to histories of response to similar circumstances in an ongoing conversation with others and between generations high points in this conversation have come down through the ages in cstandishs of classic writings or to put it in more deleuzian vein in those landmark texts around which thought and criticism gather ix without this deepening of the notion of reason there is a danger that rigour becomes a badge of honour for philosophy of a certain kind whose effects derive more from the rhetorical conviction with which it is espoused than from its basis in reason my own view is that there are no quick routes to be taken here and that the recourse to proceduralism is generally symptomatic of a loss of nerve for nietzsche it was a dimension of the nihilism that he diagnosed in the bourgeois world around him performativity in education is a derivative of that nihilism i want to draw this discussion to a close by trailing the thought that the hegemony of english both as the prevailing world language and as the dominant language of educational research exacerbates the tendency towards the procedural and itself has potentially nihilistic effects rigour as i have begun to show requires rather more attention to language difference and indeed bridges title for the ecer symposium european educational research conversational community or tower of babel aptly turns the attention towards what is at issue here translation untranslatability and the possibilities of thought on the occasion of the symposium bridges provided a brief anecdote that nicely sets the scene for his own concerns about these matters mino conte and volker kraft were trying to explain to me he recounts that the british could never properly understand the distinction between bildung and erziehung or educazione and formazione because they had not had the experience of living under fascism the power of the example lies in its suggestion of the link between language and political experience sensitivity to this should raise concerns about the dominance of english in new ways in academic circumstances where english is so often taken as the lingua franca it is entirely right to acknowledge the advantage that native speakers of the language enjoy not least when it comes to publication it is reasonable to assume also that the hegemony of english gives undue influence to monolingual anglophone cultures and that the frameworks of thinking that english enables risk obscuring other ways of seeing the world the terms that conte and kraft highlight are powerful indicators of blindspots in english and perhaps in englishspeakers generally whether such limitations are the products of specific histories as is claimed here or something more elusive within the language itself i leave conte and krafts point to stand in relation to the former but let me venture some thoughts about the latter the term teacher in english opens a semantic field somewhat different from maître in french or more clearly from sensei in japanese the french and japanese terms seem less likely for example to transmute into the blandness of facilitator in that they retain auras of richness and respect that teacher has to some extent lost one might think also of the relation between wetenschappen in dutch and science where the latters contemporary connotations are still first and foremost with the physical sciences the german geisteswissenschaften has no straightforward english equivalent and to take a final example the english term apprenticeship which has a semitechnical meaning and which has gained a new influence in policy recently is narrow and restricted by contrast with the more everyday spanish term aprendizaje and its equivalents in romance languages so the general point here is that where the english term becomes current and where perhaps it is a mark of sophistication even simply of competence today for a nonnative speaker of the language to be adept in its use there is likely to be a surreptitious displacement of one set of connotations and associations in favour of another with the english expressions having the lions share of influence beyond such cases however there are grammatical differences between languages that encourage a different structuring of thought english lacks the ease with compound words of german and the middlevoiced verbs found for example in greek its familiar somewhat plodding subjectverbobject structure facilitates thought of a particular kind utitilitarianism arose in england against a background of industrial and demographic change where appalling social conditions demanded largescale systematic approaches but is it merely a coincidence that this occurred in an englishspeaking context are there features of the language that precipitated the kind of practicality that was called for there and then and does that insistent grammatical structure harden dichotomised subjectobject relations in a way that more middlevoiced grammars escape a further point to be made here is that the lingua franca of so much research is not exactly english but englishasasecondlanguage one characteristic of which is that for most of its speakers it is severed from the language of home and intimacy if there is a utilitarian technical bent to the anglophone construction of educational research this is likely to be accentuated where the language that is favoured and promoted in the international community is procedural and systematic especially where this is shared by speakers whose usage is cut off from those richer or more intimate counterbalances of thought a technical language after all presents fewer problems of translation these are problems but they also harbour opportunities nonnative speakers of english are in one respect at an advantage over nativespeakers in that they continually experience the space of judgement that is opened by translation crossing different conceptual fields and disparate grammatical forms this itself is an opening of thought to which the native speaker may be oblivious translation involves an exercise of judgement that is not governed by systematic procedures or definitive rules and where rigour will be achieved by sensitive attunement to context and to the significance of words hence it is to the benefit of educational research when attention is drawn thoughtfully to such difficulties in translation and this can be invaluable in holding back the deleterious technicising tendency described above if this puts native speakers of english at a disadvantage there may nevertheless be a gain for them in increased humility this might be ironic but it would not be before time conte and krafts remark illustrates how and why this might be done the path between subjectivism and foundationalism that bridges has sought may open more readily to languages where the idea of the human subject is not constituted within sclerotic dichotomous relations indeed a part of wittgensteins purpose has been said to be the finding of different and better ways of thinking of subjectobject relations as of subjectivity and objectivity such a direction of thought also characterises so much of poststructuralism especially insofar as those thinkers that are embraced by this term are committed to understanding the centrality of language in human life and the world such understanding undermines the notion of the sovereign subject and weakens the hold of the factvalue divide both of which have tended to dominate so much anglophone philosophy and to contribute to its nihilistic aspects and effects nietzsches remark that truth is a woman is an appeal to a feminine archetype its implication is that truth may be less amenable to thought that seeks to grasp directly the truth may require a more indirect way of thinking in which far from hastening to master things calculatively and assertively a practice of thought is developed that is more receptive and responsive a practice that allows the truth to be revealed there are no clearcut procedures for this which is certainly not to say that nothing can be taught here or that no progress can be made neither is there any system which is not to say that no discipline is required philosophy at its best embraces such possibilities of thought and in its absence the understanding of education through research will surely be the poorer v for example the statement that the internal angles of a triangle add up to 180 degrees is necessarily true this is part of what triangle means other statements such as that the english word true has four letters make fallibilism in this extreme form look implausible vi the 3 rd international conference on postdisciplinary approaches styles its purpose as follows the theme for our auckland gathering is knowledge as disobedience expression and creativity we welcome all types of presentations that address postdisciplinarity in a range of contexts including but not limited to epistemology and knowledge production practice and action ways of being and becoming and relational theory we particularly encourage nonwestern perspectives visàvis oral literature art and performance postdisciplinarity has been previously articulated as an invitation to different interpretations critical analysis and creative problem solving extending also to questioning conventional processes of knowledge making online at accessed 30 september 2018 vii rs peters was wont to use such phrases for discussion of the relation between the extremes of ideology and anything goes see john wilson and standish viii the term empiricism is being used here not in the technical sense found in epistemology where it contrasts with rationalism but in a pejorative sense the force of which the paragraph makes clear ix see gilles deleuze and félix guattari who write of such landmarks as drystone walls the substantial but porous nature of constructions of this kind makes them longlasting by enabling the wind to pass through them socrates speaks of the wind of thinking and this might license us to think not only of the flow of thought through the reading of such classic works but also of ideas that live and grow in their hollows and interstices

educational research is subject to orthodoxies of old and novel kinds the foundations approach risks becoming stuck in footnotes to received ideas while newfangled disciplines seek to legitimate themselves in jargon and deference to new authorities the critical deficit in both tendencies stands obstructs responsible enquiry i begin by sketching the weaknesses and the potential of the foundations approach and go on to identify a range of threats to this potential the first and major concern is the rise of empiricism understood as the view that it is only through empirical enquiry that research into education can take place a second concern is the dominance of english in educational research in relation not only to the inevitable unfairness this brings in opportunities for publication but also to the substance of thought and enquiry exploration of the key terms in david bridgess rigour discipline and the systematic in educational research and why they matter this issue frames the discussion raising questions of interand multidisciplinarity there is an internal relation between discipline rigour and coherence and these though not systematicity are requirements of argument the notion of disciplined thought is prised apart from distorted conceptions of rigour and overreliance on procedure we live in precarious times in which the status and meaning of truth are being challenged in new ways there are different truths my facts are different from your facts and donald trump is president of the united states of america while there has been a relatively recent exacerbation of this trend in politics it has been underway for some time in educational research the source of this is said to be postmodernism but this is an equivocal term at best sometimes it refers to a particular age perhaps better described as postmodernity and sometimes it is connected however questionably to strands in poststructuralist thought god is dead and truth nietzsche said is a woman i inaugurating a turn in thought that has sometimes been seen as the dislodging of the stone that led to the avalanche of postmodern undermining of truth and so to relativism in multiple forms in his introduction to an extended symposium held at the european conference in educational research in copenhagen 2017 with the title rigour discipline and the systematic in the european educational research community fetish or fundamental the products of which are collected in the present special issue david bridges draws attention to the post truth politics that surrounds us now and provides a spirited and welcome defence against its influence in educational research bridges 2017 he quotes approvingly kai horstemkes remark that the current climate is one in which truth facts and rationality are treated with disdain

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introduction demographic projections state that by 2050 for the first time in history the share of older persons in our population will match the share of younger persons in the more industrialized regions such as the eu or the united states the older population has already outnumbered the younger population 1 this demographic shift entails major challenges for our society and the healthcare system including more people who suffer from chronic diseases increasing healthcare costs a shortage of caregivers and a higher demand on family caregivers 12 aal technologies a new generation of assistive technologies known as ambient assisted living technologies could meet these challenges by facilitating active healthy and independent aging in place 3 this is also in the interest of the older adults who prefer to age in their own trusted home environment 4 aal technologies are developed in line with the ambient intelligence paradigm which aims to create digital environments which are unobtrusive adaptive and responsive to human needs 256 aal is an umbrella term for a variety of innovative technologies including smart homes robotics and ambient mobile and wearable sensors different algorithms and computational techniques such as activity recognition context modeling location identification planning and anomaly detection enable these technologies to monitor and improve the wellbeing of older adults 2 while some aal technologies focus on the older adults physical wellbeing by monitoring vital signs and activity patterns 7 providing reminders 8 and detecting falls 9 other aal technologies target the older adults emotional wellbeing by facilitating communication and interaction with peers and family members 1011 aal technologies have the potential to facilitate independent and healthy aging and therefore offer a promising solution to the challenges of our aging population however many of these technologies are still in the development phase and it is unclear if older adults are ready to adopt and use these technologies moreover compared to younger age groups older adults are a highly heterogeneous target group in terms of technology experience activity level level of social involvement and physical and mental wellbeing 1213 this translates into highly diverse needs and preferences making it challenging for developers to design a technology which appeals to the target user theories of user acceptance and aal technologies to successfully develop aal technologies for the older adults we need to understand which factors drive the acceptance process of these technologies some of the most influential models to explain the adoption and use of new technologies stem from information systems research 1314 unified theory of acceptance and use of technology 15 and media use research 1617 and social cognitive theory 18 although these models have their own focus they all incorporate the expectancyvalue principle 19 which has its origin in social psychology eg 20 in essence expectancyvalue theories suggest that future behavior is based on the expected outcomes of the behavior and the affect positive or negative attributed to these expected outcomes 21 thus the expected outcomes of using a technology seems to be an important predictor of technology adoption drawing the attention to tam and utaut both are very influential and widely applied models for investigating the adoption of new technologies however in tam and utaut expected outcomes are constructed rather onedimensional in terms of perceived usefulness and performance expectancy respectively originally created in an organizational context these constructs mainly reflect the instrumental value of a technology a similar notion was made by benbasat and barki 22 who stated with regard to tam that study after study has reiterated the importance of pu with very little research effort going into investigating what actually makes a system useful p 212 in our view tam and utaut are therefore not entirely appropriate to explain the expected outcomes of aal technologies those technologies consist of a wide array of different applications and can entail besides instrumental values also intrinsic values for the target group therefore we turn to a different approach social cognitive theory that acknowledges the multidimensional nature of expected outcomes social cognitive theory social cognitive theory 23 stems from the field of psychology and is an extension to social learning theory sct depicts human behavior as reciprocal causation of behavior cognition and other personal factors and environmental influences according to sct a large part of human behavior is purposive and regulated by forethought individuals use their forethought to plan actions set goals and anticipate potential consequences this means that people anticipate the outcome of their actions and adapt their behavior to achieve desired consequences beliefs about the expected outcomes can be either grounded in ones own direct experience or through observing others thus ones current beliefs about the expected outcomes of a certain behavior are an important motivator for implementing this behavior 2324 translating these principles to the context of the current study the expected outcomes of aal technology use will be a leading factor in the older adults adoption of these technologies in contrast to tam and utaut sct depicts expected outcomes as a multidimensional construct which are organized around six basic types of behavioral incentives social activity novel sensory status selfreactive and monetary 23 pp 232240 25 these incentives were initially theoretically constructed but have been validated to study the use of innovations such as the internet 2526 and social media 27 however these studies put the focus on media use which let us assume that not all of these incentives are equally relevant with regard to aal technologies for example other incentives such as selfpreservation incentives are very likely to be important in the context of aal technologies nevertheless sct is a broad theory of human behavior that was successfully applied to understand different types of behavioral processes therefore we regard sct as an adequate approach to get an insight in what could motivate older adults to adopt and use aal technologies the current research uses sct as theoretical approach to identify potential incentives for using aal technologies as perceived by the older adults thereby we also allow for additional incentives to surface from the data understanding which incentives older adults expect from the use of aal technologies can help developers in designing aal technologies which appeal to the needs and wishes of the user which in turn aids the likelihood of future adoption method to identify which incentives older adults perceive as important for the use of aal technologies we conducted a content analyses of published reports from projects funded by the ambient assistant living joint programme aal joint programme the ambient assistant living joint programme is a funding activity cofinanced by the european commission that aims to promote active and healthy aging in europe through the use of innovative information and communication technology their goal is to foster resultoriented research projects that deliver concrete solutions for independent aging in doing so aal jp seeks to strengthen the european market for ambient assisted living products and services and in the long term reduce costs regarding health and social care 3 so far six calls with 155 projects have been launched sample in june 2014 the aal jp launched a website containing all public deliverables from their funded projects 28 during the same month the website was accessed and all uploaded documents were screened applying the inclusion and exclusion criteria displayed in table 1 to be included in the sample deliverables had to contain results of the userrequirement analyses or the pilot testing with older adults directly involved in the testing of the aal application in the first round we included 64 documents from 22 projects based on their online availability and title after scanning the fulltext another 28 documents were removed from the selection leaving us with a selection of 35 document from 17 different aal projects this means that in the final sample some projects yielded multiple reports data extraction and coding to get an overview of the nature of the selected aal deliverables we extracted data about the project name call number of extracted documents technology category technology objective target user characteristics test countries and the used methodology from the fulltext reports prior to indepth coding to identify potential incentives for using aal technologies we used a mixedmethod approach in coding the fulltext reports with some of our codes developed apriori using the knowledge from the social cognitive theory and other codes emerging from the data 29 during the coding procedure we especially focused on online availability doubles the sections describing the users feedback and evaluation of the tested aal application hereby we included explicit statements from the involved endusers but also inferred statements from the researchers we applied a comparative method approach comparing new codes to previous assigned codes to ensure that codes remain valid 30 after several rounds of coding remaining inconsistencies were discussed between two researchers until consensus was reached 3 results general characteristics of the analyzed projects with one exception all of the analyzed project documents originated from the first and second aal call this was mainly due to the low online availability of documents originating from later calls the aal technologies in these projects were diverse in nature with eight social networks three daily life support systems two communication systems two robots and two game applications the technology objectives defined by the project members were also diverse social inclusion was mentioned in most projects as an objective followed by stimulate leisure activities support with activities of daily living safety health and care monitoring information selfconfidence physical fitness and improve intergenerational relations user studies were conducted in 13 different european countries with germany and spain being represented most often the applied methods were very diverse including observational methods surveys interviews focus groups and pilot studies in laboratory and natural settings the age of the older adults included as subjects in these projects ranged from 47 to 96 years most subjects still lived independently with some of them receiving care some of the analyzed projects specifically focused on subjects with cognitive impairments the ict experience among the subject varied from little to solid ict experience incentives for using aal technologies after thoroughly coding the data 13 incentives could be identified which were then clustered according to the categories identified by sct as expected a new category related to selfpreservation emerged which we labeled health and safety incentives however our data did not show support for outcome expectations in terms of monetary incentives in fact we noticed that in the majority of the analyzed projects older adults were afraid that the potential technology could be expensive and unaffordable to them suggesting that money is rather a disincentive in the context of aal technologies table 2 shows the number of assigned quotes per code as well as the number of source projects in which the codes appear social incentives social connectedness the most prevalent incentive for future use of aal technologies which surfaced from the data is social connectedness with a total quote count of n 351 and appearance in 16 of the 17 analyzed projects social connectedness can be understood in terms of connecting communicating and interacting with other individuals these can be either existing connections such as friends and family or new contacts developed with the help of the aal technology for example during the initial userrequirement assessment of the 3rdlife social network several older adults who were asked about desired features for 3rdlife stated that they would appreciate the opportunity to meet new people and talk to them 31 aal technologies were also viewed as a valuable tool to combat loneliness as one older adult indicated after watching a facilitator using the easyreach social network today in general elderly people are alone the system could be a key point for them it could help elderly people to socialize 32 p 34 in the domeo project which developed an assistive robot the technology itself was seen as a possible form of companionship 33 in sum older adults recognized that aal technologies could be an instrument to socialize feel closer to friends and family and combat loneliness involvement a second incentive in this category is involvement several projects showed that aal technologies were seen as a way to stay connected and involved with society and making new technologies accessible for older adults who feel more and more excluded through the increasing digitalization of our world one older adult described the easyreach social network as a window to the world 32 p 34 another participant stated easyreach is another chance for us elderly people it is an innovation and for the first time we are part of it i could feel part of the network of today 32 p 24 similar expectations were expressed by older adults in the fosible project that developed a tvbased communication system i think that it is to make the computer available to all 34 p 15 involvement as an incentive was somewhat less prevalent with a total quote count of n 28 divided among eight projects health and safety incentives health and safety besides social connectedness health and safety is the second most important incentive associated with the potential use of aal technologies the total quote count was n 103 with appearance in 15 of the 17 projects older adults perceived that aal technologies could benefit their physical and mental health for example by finding healthrelated information or providing games which train their abilities for instance in the 3rdlife project older adults said they would like the social network to include videogames with exercises for motor coordination and rehabilitation to maintain their functionality 31 another aspect was the increased feeling of safety if aal technologies would be present in their homes in the pilot phase of the hope system the majority of the endusers who tested this daily life support system that includes different functionalities for monitoring fall detection and communication in their homes agreed that it had increased their feeling of safety and security 35 support with daily activities another highly important incentive which was identified from the data is support with daily activities the older adults recognized that aal technologies had the potential to support them in their daily life for example with memory and reminder functions or administrative tasks for example in the domeo project reminders were regarded as a highly important feature for the tested assistive robot 33 aal technologies were also viewed as a tool for people that were physically limited as becomes clear by this statement of an older adult in the fosible project that developed a tvbased communication system it will be very useful for people with reduced mobility 34 p 19 the total quote count was n 111 extracted from 12 documents connect to care network the final incentive which fits this category is connect to care network older adults recognized that aal technologies could be useful to easily connect with their caregivers for instance in the easyreach project that developed a social network application one older adult said it would be helpful to connect easyreach to networks of home care 32 p 36 moreover older adults from different projects stated that aal technologies could provide some peace of mind to family caregivers however this incentive was less prevalent with a total citation count of n 8 divided among only five projects activity incentives leisure and personal interests the incentive leisure and personal interests was mentioned in 13 projects with a total quote count of n 110 the fact that aal technologies could stimulate leisure activities was highly appreciated by older adults they were very keen on the idea of personal interest forums or games they could play with other seniors via aal technologies for instance when prioritizing different features of the seniorengage social network application the most popular feature mentioned by the focus group participants was interest groups for hobbies or professions 36 enjoyment another incentive in this category is the feeling of enjoyment the first interaction with aal technology prototypes was often perceived as interesting fun and entertaining which in turn motivated future use for example one older adult from the connected vitality project said after testing the video communication feature of the system in the home we really really enjoyed it 37 p 15 the total quote count was n 51 divided among nine projects novel sensory incentives education common stereotypes suggest that older adults have neither the ability nor the motivation to learn new things however our data suggest otherwise education was another frequently mentioned incentive for the potential use of aal technologies with a total citation count of n 44 divided among 11 projects older adults were excited about potential educational features of aal technologies which would allow them to acquire new knowledge and skills for instance in the 3rdlife project participants found educational applications like lectures courses or elearning very attractive potential features for this social network application 31 older adults also indicated that they would like to expand their knowledge through the exchange with others for example in an online discussion group which could be facilitated via aal technologies information another incentive in this category is information older adults believed that aal technologies could provide them with information of their interest such as news weather or events in their neighborhood in the seniorengage project the tested social network application was perceived as a platform where older adults could find information and activities at a glance 36 p 32 this incentive was mentioned in more than half of the projects with a total quote count of n 51 status incentives selfexpression and selfworth the first and most important incentive in this category is selfexpression and selfworth this incentive was identified in 10 projects with a total quote count of n 58 older adults perceived aal technologies as a potential platform for selfexpression where they could share their values opinions experience and knowledge with others for instance through a discussion group feature the researchers of the fosible project concluded that for many participants the motivation to use the groups feature of the tvbased communication system is to display and share their knowledge with others 38 this in turn gives them the feeling of being capable being needed and being meaningful to society independence surprisingly independence was only mentioned in 4 of the 17 projects as an incentive for the use of aal technologies with a total quote count of n 9 this could be explained by the fact that independence is also implied by other incentives such as health and safety and support with daily activities therefore we still assume that independence is an important incentive for the use of aal technologies status the final incentive in this category is status some older adults were keen on using aal technologies in order to earn respect of others especially there family members as become clear by this statement of an older adult from the fosible project it is also about my grandchildren i want to impress them to make them proud perhaps 34 p 20 however status was only mentioned in two of the projects with a total quote count of n 6 thus we can conclude that status is not an important incentive for older adults to use aal technologies selfreactive incentives relieve boredom the least prevalent incentive was relieve boredom as it was only mentioned in 2 of the 17 projects with a total quote count of n 3 thus using aal technology just to pass time is not a major incentive for older adults conclusion and discussions in this study we conducted a content analyses of 35 aal project reports extracted from 17 projects to identify potential incentives for older adults to adopt and use aal technologies sct was used as a theoretical approach to identify and group the incentives emerging from the data however we also allowed for new categories to surface from the data in total 13 incentives could be identified which we grouped into six categories social incentives health and safety incentives activity incentives novel sensory incentives status incentives and selfreactive incentives except for health and safety incentives and monetary incentives these categories are identical to the incentive categories used in the sct this suggest that expected outcomes indeed should be considered as a multidimensional construct rather than as a onedimensional construct moreover these results show that the majority of the incentive categories identified by sct are also applicable in the context of aal technologies however banduras original approach 23 does not include a category for selfpreservation incentives yet our results showed that in many of the analyzed project health and safety were important incentives to use aal technologies therefore this was added as a new category banduras later work applied sct in the context of health promotion 39 within the context of health behavior one of the three essential outcome expectation categories is physical which is defined as pleasant sensory experiences and physical pleasures in the positive forms and aversive sensory experiences pain and physical discomfort in the negative forms 39 p 627 this supports our decision to add health and safety as an selfpreservation incentive category for aal technologies monetary incentives were not supported by the data but we assume that monetary matters rather form a disincentive earlier case studies of aal technologies support this assumption as older adults were often afraid that the tested aal application is unaffordable to them eg 4041 this is interesting as the vision of aal technologies is to reduce the costs of health and social care 42 however there seems to be a discrepancy between how aal is envisioned by the policy makers and how it is perceived by the older adults policy makers should therefore carefully think about the financing models and ensure that those technologies are affordable for all seniors looking more specifically at the incentives within a category thereby taking into account the number of different projects in which a code occurs as well as the total quote count social connectedness and health and safety are the most important incentives in the context of aal technologies this implies that older adults are likely to use aal technologies when they perceive that those technologies can help them to connect with others or when they benefit their health and safety this is in line with previous case studies of aal technologies that also found that health and safety eg 43 44 and social connectedness 4546 are important incentives of aal technologies other important incentives for the use of aal technologies include support with activities of daily living leisure and personal interest education and selfexpression and selfworth in contrast relieve boredom and status were the least important incentives this suggest that older adults are not likely to use aal technologies just to pass their time or to get respect from other individuals surprisingly the data showed that independence was also one of the least important incentives for the use of aal technologies we assume that this can be explained by the fact that the other incentives such as health and safety or support with daily activities also imply independence and the incentive independence can therefore be viewed as an umbrella term for these other incentives following this argumentation we still think that independence is a highly important incentive for aal technologies the previously described results should not be interpreted without taking into account several limitations first our documents were sampled from a single research framework which is eu based therefore generalizability is somewhat limited by the research focus and the geographical scope second the sample was affected by the online availability of the documents which were mostly sampled from the first and second call so important data sources might have been missed third we did not have access to the original transcripts of endusers evaluations therefore the available data already went through a filtering process which in turn could have affected our results future research should take into account more aal projects from a broader geographical scope various research frameworks and more recent calls in order to verify our results and give an outlook on the future trends and direction of the aal community second while this research describes several potential incentives for the use of aal technologies we cannot make valid predictions about their explanatory power thus future work should apply advanced statistical method to operationalize these incentives and verify their power in explaining aal technology adoption and use third in this research we specifically focused on potential incentives for using aal technologies however previous research 4748 also identified several barriers or disincentives which are likely to play a role in the decision to use aal technologies other potentially relevant factors include personal factors future research should distinguish between different types of older adults in terms of health status and technology experience and investigate how their perception of potential aal incentives might differ despite its limitations this study provides a comprehensive and theoretically grounded overview of incentives which are likely to motivate older adults to use aal technologies our findings can be used as a starting point by other researchers to further investigate the explanatory power of these incentives and help them to build an empirical model which can predict aal technology adoption developers policy makers and health care professional can use our insights to further shape the vision of aal and help them to design technologies which appeal to the need and wishes of the older adults

ambient assisted living aal technologies have the potential to target the challenges of our aging population however little is known about what motivates older adults to adopt these new technologies most research in this area relies on single cases with a specific aal application and a limited number of users to fill this gap a content analyses of 35 aal reports was conducted the aim was to provide a comprehensive overview of potential incentives for using aal technologies the data was coded using the social cognitive theory sct in total 13 incentives could be identified which were grouped into six categories 1 social incentives 2 health and safety incentives 3 activity incentives 4 novel sensory incentives 5 status incentives and 6 selfreactive incentives within these categories social connectedness and health and safety were the most important incentives these results provide a comprehensive and theoretically grounded understanding of what motivates older adults to adopt aal technologies

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for their work to develop young leaders who organize campaigns to promote social justice in their schools and communities research about youth organizing lends itself to interdisciplinary approaches that conceptualize change at multiple levels including youth development relationships and broader institutional and societal change although there tends to be agreement that youth organizing is compelling precisely because it strives for both individual and communitylevel change the balance of the empirical research has focused on individual outcomes such as civic efficacy empowerment educational attainment or civic engagement comparatively less attention has been placed on new strategies or theories that expand local campaigns to regional or national movements this is also an emerging priority for national networks of organizing groups such as the funders collaborative on youth organizing whileorganizers have had great success many are articulating limits to current organizing models in achieving their longterm vision of equity and justice for their communities these limits are related to the need for power to compel decision makers to make real transformative changes many youth organizing groups are already beginning to consider new power building strategies including increasing scale building new alliances experimenting with new models and increasing voter participation of young people of color achieving just and equitable communities requires the construction of real civic power now is a critical moment to support growing youth movements to under review not for citation or distribution develop strategies to do just that consistent with fcyos message in recent years we have seen youth organizers explore ways to strengthen their membership bases and shift towards more of a movement lens we use warren and supzsckas definition of movements as collective action on the part of oppressed or marginalized people on the basis of shared identity to build power to win changes in government policy and public attitudes that advance the cause of social justice movements link people across disparate locales shift the ideological terrain through public narrative and change power relations in this article we offer a case study of south africas equal education which is a movement for equality and quality in education for young black south africans 1 we explore how ee members developed and asserted collective action frames that connected them to the antiapartheid struggle and united young people from distinct locales and regions youth organizing limitations and new directions research on youth organizing which emerged in the late 1990s draws on frameworks and questions from a variety of disciplines 2 community psychologists for example study organizing because of its focus on empowerment and secondorder change which includes the transformation of settings and institutions according to the needs and demands of communities scholars in the positive youth development and learning sciences fields grew interested because of evidence that organizing provides a supportive developmental context or learning environment for youth particularly for youth contending with dispossession and structural racism youth organizing has gained traction with education policy scholars too who have under review not for citation or distribution written about the impact of organizing on policies such as school discipline and community schools there is much to applaud in the growth of interdisciplinary scholarship about youth organizing which is often carried out in partnership with community organizations as the field grows however it is useful to reflect on where more work is needed we see three limitations in contemporary youth organizing scholarship which motivate our focus in this article first when scholars and funders treat organizing primarily as an opportunity for youth development and learning it can become overly psychologized and out of touch with its transformative social change origins youth organizing is not just a developmental exercise it is powerful precisely because groups adopt a systems lens that interweaves personal relational and community change second the literature on youth organizing and activism suffers from a myopia common to fields that are dominated by research carried out in the united states although the literature centers the experiences of youth experiencing structural racism homophobia and xenophobia there are still qualities about usbased organizing that limits its generalizability to other contexts and therefore our collective imagination about what it can accomplish this parochialism can be addressed through studies of youth mobilizations in a variety of parts of the world including chile brazil egypt and south africa studies from these contexts for example have yielded more expansive definitions of the age of youth shown deeper connections between organized labor and university student unions and revealed how youth make explicit connections to revolutionary movements of the past under review not for citation or distribution a third limitation which is more nuanced stems from ambiguity in the literature about the relationship between organizing and movements early scholarship describing youth organizing in california in the 1990s described it synonymously with movementbuilding in their 2017 article earl et al describe youth organizing groups as social movement organizations similarly anyon discussed examples of youth organizing groups as evidence of a nascent movement for education justice although the growth of youth organizing groups may represent seeds of a movement we see value in distinguishing between organizing and movements the most selfevident distinction is one of scale youth organizing typically focuses on building young peoples political power to influence local policymakers or education agencies such as city councils or school boards although community organizing groups may be part of a larger network that shares an organizing model such as iaf or faith in action the focus is typically still on local goals a second and closely related feature of organizing is its emphasis on the longterm work of relationshipbuilding with and leadership development of voluntary members third in some sectors of community organizing there has been resistance to discussing ideology because of its potential to polarize or divide constituents movements on the other hand are distinguished by their national or international scale this geographic distinction between organizing and movements is important because particularly in the contemporary political economy the roots of problems that show up locally often have diffuse national and even global origins youth whose schools were shut down in chicago philadelphia and washington dc for example may take action against local under review not for citation or distribution school boards but such policy choices were developed and shaped by federal policies under the obama administration from this perspective the more ambitious social change aims of organizing will be frustrated if it stays local and cannot challenge some of the more diffuse origins of problems in addition to geographic scale movements also are distinct in the ways that they contest public narratives through framing problems and solutions movements bind actors together and have the potential to change the ideological terrain upon which policy decisions are made how youth activists conceptualize issues including moral narratives about rights and justice and attributions about causes and solutions creates new contexts for people to make demands on government the chilean student movement for example although spurred by immediate concerns about the costs of education articulated a broad critique of neoliberal privatization their defense of public goods enabled them to build alliances with those opposing privatization of chiles land and water movements also contest dominant worldviews by offering new identity categories that lend dignity meaning and power to participants and change public discourses about identity groups consider the dreamers movement for immigrant rights in the united states one of its defining features was a focus on building identity narratives that challenged the silence and stigma of being undocumented in summary although organizing and movements are interdependent and overlapping they are not the same phenomena we find it useful to distinguish them in order to examine how groups that start with local organizing might grow into movements that connect people by a shared narrative across geographic differences to build power it is under review not for citation or distribution especially valuable to study such processes in places where distinct histories and practices of movementbuilding broaden the fields understanding of what is possible drawing on ethnographic research over two years we explore aspects of movementbuilding with equal education in south africa a brief history of youth activism in south africa research and commentary about youth activism in south africa has a history of contentious debate on one hand youth are often lauded for their pivotal role in the fight against apartheid especially between 1976 and the early 1990s when they boycotted school classes staged numerous protests and fought street battles against armed security forces of the apartheid state on the other some accounts question or criticize tactics used by youth in fighting apartheid as brutal and rendering some areas ungovernable correspondingly the public imagination about youth leading up to the early 1990s was characterized by two competing discourses the young lion and the lost generation affectionate in orientation the young lion perspective was mostly advanced by antiapartheid activists and it depicted youth as courageous legitimate and honorable freedom fighters the lost generation perspective however framed youth as militant hooligans abusing the name of the struggle for selfish ends and thus posing a moral problem to social and political life in the mid 1990s with the transition of power from the apartheid state to the ancled government discourses about activism and youth shifted political parties and churches key institutions that played a big role in the early transitional phase failed to construct platforms for youth participation as everatt notes youth were politically demobilized but offered no under review not for citation or distribution alternate channels of expression or action mattess survey research reported that born frees the generation born after the end of apartheid were less committed to democracy than earlier generational cohorts this born free generation was depicted in public discourse as democratically inclined or materialistic between 2014 and 2019 there was a resurgence of youth activism in south africa signaled by interrelated movements such as rhodes must fall and fees must fall that sought to decolonize the university curriculum and ensure universities were accessible to all by the end of 2017 campus protests had morphed into a national movement that ended with government conceding to student demands by adopting a feefree policy for higher education we situate our study within this history of youth activism that has been central to political struggles in south africa and has seen cycles of decline and resurgence since 1994 methodology this article is based on data collected as part of a larger study of youth activism and organizing in four countries from 2012 through 2015 the research team conducted ethnographic research about youth organizing practices and learning trajectories in seven cities belfast cape town chicago denver dublin new orleans and san francisco for this article we focus exclusively on data from south africa equal education a brief background equal education was founded in 2008 in cape town by a group of students educators and an experienced hivaids activist through activities such as social audits grassroots organizing and media broadcasting ee describes itself as a movement of learners parents teachers and community under review not for citation or distribution members working for quality and equality in south african education through analysis and activism ee began by documenting conditions of infrastructural plunder and lack of resources in the township schools of khayelitsha as many historical accounts of apartheid have shown townships were systematically deprived of decent schools health infrastructure and social services because they were designated urban spaces for people of color years after the formal end of the segregationist system townships remain underresourced in relation to affluent communities and delivery of basic governmental services to such areas remains sporadic the fundamental node of ees organizing took place at the local level typically connected to secondary school enrollment ee ran afterschool clubs called youth groups which drew students from one to three schools within a given township there were several youth groups during the school term youth groups met weekly and were facilitated by roughly four posthigh school youth known as community leaders these community leaders were typically former high school members who guided younger peers to bring together different youth groups ee conducted trimonthly mass meetings for youth from the same province these mass meetings provided a platform for youth to meet share experiences and collectively set the upcoming provincial agenda they were also opportunities for ee staff to notify equalizers about updates on national campaign work revolving around the minimum norms and standards campaign which launched in 2011 and pressured the national government to adopt binding legislation to ensure a fair distribution of quality education across south africa since its formation in the western cape ee expanded to a selfdescribed movement that included members from across the country congruent with the ees democratic ideals in 2012 under review not for citation or distribution its form of governance shifted a nonprofit organization with an appointed board to an elected national council made up of representatives across the different members of the movement including equalizers this council also adopted a constitution that spelled out rights and responsibilities of members at the end of our data collection in 2015 ee was based in five different provinces and boasted a membership of several thousand high school learners called equalizers supported by provincial offices that ranged in size data collection fieldnotes interviews and organizational artifacts constitute our data sources most of these data were collected between 2013 and 2015 in the western cape by two ethnographers who lived in south africa and were familiar with the local history and sociocultural context of the area 3 ethnographers built relationships with program staff and youth members which fostered trust that enabled them to gain entry and observe organizational routines practices and actions we adopted a purposive sampling strategy that was based on proximity to where ethnographers lived and those youth groups to which we had the greatest access also because community leaders often met at ee headquarters in khayelitsha and they had more control over their time than high school students the majority of our sample of 32 semistructured interviews is made up of them some interviews were completed in xhosa by second author others were completed in english by first author or name in general the interviews sought to understand organizational processes and the experiences and meaningmaking of ees youth members we asked questions such as how did you get involved in ee how did this campaign topic get selected what kinds of things have you learned since you became involved we also interviewed several key staff people including the secretary general and leaders of the youth development department under review not for citation or distribution field notes augmented and triangulated interview data by describing activities talk and interaction in multiple settings including youth group meetings mass meetings public demonstrations and community leader classes field notes which totaled more than 71 hours of observations were written in accordance with emerson fretz and shaws guidelines which include lowinference narrative description jotting memos and observational notes in most situations notes were written by hand and then typed up later ethnographers spent additional time hanging out around the ee space getting to know members attending special events and gathering artifacts artifacts include photographs press releases news articles and reports produced by ee although our primary fieldwork took place in the western cape we drew on materials discussing ees work in other provinces and interviews with ee staff discussed work in those places as well data analysis phase 1 comparative case analysis comparative case analysis took place while data collection was underway through monthly meetings with ethnographers to discuss emergent findings and develop our codebook the codebook developed over two years categorized qualitative data in terms of youth outcomes and organizational practices a team of graduate student researchers worked in pairs to ensure shared code definitions and decisionrules and met routinely to resolve differences in code application consistent with interpretive ethnographic data analysis textual data were assigned codes using dedoose software each excerpted was coded by at least two people as an outcome of phase 1 the research team identified two aspects of organizing in ee that stood out as unique relative to the other cases in ireland northern ireland and the united states 1 under review not for citation or distribution frequent references to and invocations of historical context specifically the history of the antiapartheid struggle and 2 efforts to organize a national movement made up of chapters from multiple regions in contrast to locallybound organizing we observed in other countries phase 2 focused analysis of movementbuilding using the three faces of power the three authors of this article launched a deeper investigation of the qualities of ees organizing in response to the call for papers for this special issue this analytic process started by exploring in an inductive manner questions related to historical and national scales that had emerged in our first phase of analysis how did youth members talk about history in what ways did they make history relevant to their efforts at movement building what was the connection between the local work of youth groups and the national minimum norms and standards campaign we met biweekly to reflect debrief and discuss patterns and disconfirming evidence related to historical consciousness and movementbuilding between meetings each of us reviewed data to identify excerpts pertinent to a specific subquestion we then discussed each nominated excerpt to see if we agreed on its relevance and more importantly together identify what it meant or how it was related to the core research question during this time we broadened our textual data to also include visual examples through posters photographs and recordings of songs although these artifacts posed some challenges because they had not been coded in our database through intersubjective checks for interpretation we identified thematic connections to the textual data we pursued this cyclical process of discussion independent analysis and collective reflection in tandem with consideration of different theoretical lenses that would help us develop a coherent line of analysis in a first version of this paper we applied lukess three faces of power to data analysis and claims after critical reflection we concluded that this framework was misaligned to our data and claims primarily because it pointed us to the outcomes of movement under review not for citation or distribution building and evidence of power to influence policies nationally whereas our data spoke more to processes of movement building specifically how ee membership developed a unified movement among members phase 3 collective action frames our reassessment of historical narratives and campaign narratives led us to adopt a more focused analysis of how collective action frames contributed to ees movementbuilding framing gained ascendancy in the social movement literature in the 1990s when scholars drawing on symbolic interactionism made persuasive arguments about the role of meaningmaking as a key element of social movements frames condense reality into a shared schema that diagnoses the root causes of an issue and offers a collective way forward for movement actors as benford and snow summarize collective action frames are actionoriented sets of beliefs and meanings that inspire and legitimate the activities and campaigns of a social movement organization although framing has become a dominant paradigm in social movement literature there are few studies that examine the construction and negotiation of framing in youth movements with this more targeted lens we returned to our initial claims to ask what collective action frames and organizational practices enabled ee youth to develop a shared movement identity and aims across locales this called for a reanalysis of our initial claims and an audit of data excerpts to see what we had left out in our first draft following a similar process of data analysis involving independent analysis and group discussion we developed revised claims although these were closely linked to our earlier claims about the importance of historical meaningmaking we broadened the focus to analyze frames that linked geographic scales we became more explicit how specific kinds of frames enabled young people to assert legitimacy find inspiration and meaning and bridge locales collective action frames as resources for movementbuilding we identified two types of collective action frames that contributed to ees movement building efforts historical continuity frames and flexible problem frames with historical continuity frames members asserted meaning purpose and legitimacy in the present through connections to freedom struggles of the past flexible problem frames served a slightly different function which was to enable ee chapters to identify and work to solve locallyresonant education challenges while still being united under a national agenda that bridged locales consistent with an ecological approach trickett 2009visser 2007 we begin our analysis of each type of frame by describing relevant challenges in the sociopolitical context then move to claims about organizational framing practices and meaningmaking by individual members historical continuity frames references to and narratives about south african history especially the antiapartheid movement were ubiquitous in our data these references varied from ee workshops for youth leaders about the antiapartheid movement to art that evoked movement imagery to stories told by individual youth about the activism of 1976 such connections were not just textual or linguistic collective singing of struggle songs and disciplined civil disobedience embodied traditions of the antiapartheid movement we argue that these expressions of continuity with the past whether through organizational practices or in the stories told by individual members comprised a broad collective action frame that was integral to movement building which we call a historical continuity frame this frame asserted legitimacy and purpose for youth activists in a way that countered generational challenges to movementbuilding which we describe next under review not for citation or distribution generational challenges to movementbuilding ees core constituency was part of the bornfree generation of south african youth between the ages of 13 and 20 who unlike those who were born or came of age under apartheid did not grow up under the explicit institutionalized de jure forms of racialization discrimination and disenfranchisement that held prior to mandelas election the term marks not just a generational divide but creates a symbolic boundary between the earlier generations and the post1994 generations such that the moral authority of being part of the struggle was less available to the bornfrees this challenge was amplified by narratives in public discourse popular culture media and academic research about the bornfree generation as materialistic apathetic or unappreciative of democracy a related legitimacy challenge for south african youth pertained to the stature of the governing african national congress much of whose leadership had moral authority sometimes referred to as struggle credentials because of their role in the antiapartheid movement many ee members including parents were also members or supporters of the anc and yet the work of ee shed light on failures of the anc to deliver on the promise of the antiapartheid movement by showing the persistence of apartheid era inequities in education infrastructure and calling for changes at the national level these generational issues showed up in our data when people in positions of power challenged the legitimacy of ee former equalizers for example described how their school principals responded to their activism by challenging their right to organize and in some cases asserted that they were being manipulated by outside adults sometimes this assertion was laminated with an explicit racial frame such as what happened when ee filed a grievance with the court over delays in school repairs and organized simultaneous marches by thousands of under review not for citation or distribution young people and parents in pretoria and cape town two days later the national minister of education released a statement saying to suddenly see a group of white adults organizing black african children with halftruths can only be opportunistic patronizing and simply dishonest 4 in this sociopolitical climate where contestations of power involved competing claims to legitimacy and moral authority ee as an organizationand individual membersarticulated counternarratives about the born free generation that asserted historical continuity with the struggle ee members and leaders recruited and remixed historical narrative frames that linked the revolutionary struggles of the apartheid years to the present moment organizational framing practices artistic products and artifacts the use of art to reframe the bornfree generation was exemplified in ees slogan every generation has its struggle the slogan was affixed to posters and publications that were disseminated via social media and at campaign events posters included an illustration of raised fists familiar from revolutionary iconography grasping a ruler a pen and a calculator the word struggle referenced the antiapartheid years but remixed it for todays struggle education this artful combination of images and words showed that the activism of the bornfree generation carried on the legacy of the antiapartheid movement but for todays generation other ee educational infographics such as one that displayed differential percentages of school funding based on racial classifications during the apartheid years pointed to the historical roots of contemporary inequality other imagery placed a greater accent on the legitimacy of youth as fighters for education rights such as hoodies worn by equalizers that said our education our future or the video production program that ee ran called amazwi wethu under review not for citation or distribution insert figure 1 here struggle songs a key feature of ees movementbuilding work was the practice of singing struggle songs at meetings and public gatherings our field notes document the power of song at multiple events that were often well attended by youth and adults alike in fact some gathering included small groupings of 10 to 15 youth to hundreds of youth at public events these struggle songs highlighted youths power and voice and anchored their contemporary struggles for education in a long history of resistance and movementbuilding the following field note demonstrates the use of struggle songs in the context of a protest the young people sung songs with passion in their voices the students mainly sung in xhosa the lyrics came from the struggle songs from the antiapartheid and anticolonial movement in one of the struggle songs they replaced words that demanded the use of violence to win the revolution with education expressions of collective action through song and other forms of performance were similarly observed one year later as evidenced in this field note from a mass meeting amandla one of the prospective community leaders shouts the other youths respond in loud voices saying awethu while raising and clenching their right fists … both the call for amandla and the response of awethu are slogans accompanied by raising and subsequently shaking ones right hand whilst clenching the fist the symbolism of this action goes at the root of the fight against the apartheid regime thus the mood in the room although full of jubilation and excitement takes a serious note that is synonymous with political gatherings under review not for citation or distribution singing brought forth feelings of hope struggle and power which shaped the climate and sociopolitical context of events and meetings these emotions were rooted in an understanding of certain shared histories of disenfranchisement that caused pain and violence and which continue to maintain forms of injustice hence the expression amandla and awethu pays tribute to the past whilst affirming and giving hope for a present and future where power is taken and claimed another song recorded by 15 ee high school members for a cd called likhaya lam includes the refrain our education is very poor and painful and then concludes with a lone male voice crying for what was the struggle for what in building their movement ee youth leveraged cultural assets and resources like song and shared histories to raise consciousness and support for their cause karabo an ee organizer made this point clear in an interview that asked about the purpose of songs singing and performance in the context of organizing yeah i must say the songs that we sing trust me a song at equal education if youre in a mass meeting will always bring everyone togetherwe believe that the songs that were sayingback then when the people were fighting for education like when theyre fighting for freedom and everything we take those songs and we use them to actually unite ourselves and bring about the spirit that everyone here is fighting for something everyone here is fighting for a certain cause but in a very beautiful way through singing ee members took a collective practice tied to the antiapartheid movement and remixed the lyrics to apply to contemporary issues singing connected the present to a past and youth to older generations our field notes describe several meetings attended by parents and under review not for citation or distribution other community adults along with youth during these intergenerational singing struggle songs was a common practice organizing to bring about systemic change comes with many challenges and forms of physical emotional and mental taxation to organizers yet singing provided young organizers within ee an opportunity to express themselves most of all it enabled them to anchor their struggles in a long legacy of movement building activism and resistance to oppression ee utilized singing as a resource to support young organizers build solidarity or connection across generations and frame contemporary issues within a historical and sociopolitical context political education we observed many opportunities for community leaders and equalizers to engage in rigorous study of the antiapartheid movement and global movements these opportunities for political education supported youths critical understanding of the past in order to look with fresh eyes at the present the following excerpt from a political education class describes an activity where members reviewed the history of antiapartheid activism then turned close analysis of a primary source the instructor began the day in a quizstyle competition about various historical facts questions included what does fedsaw stand for what year did the defiance campaign start what year was the sharpeville massacre what were two policies challenged by the defiance campaign what was new about the defiance campaign there were marked differences in tactics what were the differences the instructor concluded the review which was just the opening activity by saying the goal is to deepen our understanding of the history too often we just hear that before 1993 anc was great they were heroes but todays factions have roots in 1969 under review not for citation or distribution the instructor then transitioned into a close reading of two primary sources nelson mandelas written explanation of the founding of the military faction of anc and chris hanis 1969 memorandum exposing corruption in the anc leadership the youth arranged themselves in a circle and took turns reading the hani memo aloud we share quotations from just one excerpt not to describe the discussion in full detail but to illustrate how they were making meaning of the text by asking questions about vocabulary sharing comments and connecting the example to their own situation community leader 1 this posh is it the type of car cl2 what is meant by harboring right wing designs cl3 i think i now get chris hanis concern he is not against the cause of the anc but he wanted people to be aware at first i thought he wanted money later cl4 he criticizes but is he part of anc or is he from the outside how is he complaining about the leadership cl5 he was a cl he said with a smile this last line he was a cl is a statement made to underscore that chris hani was a community leader which in our interpretation was akin to saying he was one of us and we are like him this example shows how political education went beyond merely learning historical facts it meant reflecting connecting and engaging with historical figures troubling their positionalities and reclaiming or reframing the issues at the heart of their movement this emphasis on historical study and discussion in ee we think contributed to an organizational context where young people constructed their own connections to the past and landed on specific milestones that resonated for them for example narratives about the soweto in this response the facilitator recognized his role in playing a part of that history and building a legacy for the next generation of youth two equalizers sizwe and sbu brought up 1976 when describing a school walkout they had led that involved an encounter with armed police sizwe we were ready to die at that particular moment sbu this was 1976 reinvented another interviewee yonela when asked how she would respond if the minister did not honor their demands for mns said if she dont deliver the minimum norms and standards by the late 29th of november 2016 i must try to engage with more youth to have more voice and be like 1976 youth who ignored everything but made sure that their voice was going to be heard and that one day discussion and school walkout youth were remixing these ideas in ways that gave them a sense of purpose and shared identity these were not mere slogans but active processes of meaningmaking that linked historical study collective practices and personal meaningmaking through these practices they also disrupted hegemonic narratives that might otherwise delegitimize their struggles or their claims to a more just and equitable education constructing frames that bridge local to national as noted in the literature review scholars have documented a central challenge of community organizing and movement building which is that problems experienced in everyday life can lose their power and urgency when abstracted to a national agenda and yet the root causes of or solutions to many local problems are not found at the local level in addition to this basic challenge here we report specific sociohistorical factors in south africa that influence movementbuilding efforts spatial challenges to movement building although an overwhelming majority of ee members selfidentified as black this racial identity encompasses various ethnic groups while there has been significant efforts to unify various ethnic groups along a shared national vision in the postapartheid era the country is still plagued by ethnictensions owing but not limited to the legacy of apartheid in south africa and its divide and rule tactics such tactics deepened existing ethnolinguistic differences by creating semiautonomous provincial system that gave each ethnic group autonomy for separate development these ethnolinguistic cleavages often pop up in everyday social and political life posing challenges to nationwide movement building efforts in addition the gains of the democratic transition ushered in by the mandelaled anc have been uneven across geographies and demographic indicators such as race gender and class under review not for citation or distribution despite efforts by successive postapartheid governments areas that were heavily affected by underdevelopment during apartheid such as rural areas and townships still lag behind metropolitan and suburban areas in terms of development and basic infrastructure this history of stateenforced ethnolinguistic separation and more recently uneven lines of development present challenges to ees organizing efforts that aimed to develop movements nationwide for instance although students in townships and rural areas both experienced school infrastructure challenges the severity was different ranging from broken windows or lack of computers in township schools to egregious cases of pit latrines or crumbling buildings in rural areas we observed more than one interaction where students from township schools expressed shock at the challenges faced by their rural counterparts during eeinitiated gatherings and positioned their own situation as privileged next to those in the eastern cape this contrast that township students drew with rural areas was emblematic of the ways that spatial apartheid influenced the political consciousness of township youth in both field notes and interviews we documented that ee youths from township schools reflected that they never knew that their school had infrastructural challenges until they went on a rare trip to see the model c schools in this way spatial boundaries function to limit how people living with them see and then challenge unequal systems here is themba a young equalizer making sense of these spatial boundaries and their impact on his consciousness i knew that i had challenges because at my younger age the school i was going to at my primary school was one of the best schools you could find in khayelitsha that time and we had some visitors that made me interested to want me to know more but its like i had boundaries around me at my primary because there was a room that was always under review not for citation or distribution locked and they had some few books and i think in grade seven i only realized that it was supposed to be a library and they called it a library but its not a library because it is not fully stocked and it does not have some good books it is just the books that are being put there and there is no librarian so i thought that oh okthis is one of my boundaries that made me want to be like this this young student was saying that if he had stayed within the confines of his school then he would not have realized the infrastructural challenges at his primary school indeed it was his experience at more highly resourced secondary school that enabled him to make sense of the injustice experienced by students at his former school a similar example can be observed in the experiences of thando a community leader who described her process of recognizing that the schools she attended were unacceptable she joined ee in 2009 and she said ee opened her mind to understand issues of inequality because she was a student who went to school and came back home without realizing any inequality these varied examples including ethnolinguistic diversity varied extents of school infrastructure deprivation and the bounded geographies of young peoples lives share a common theme related to the legacy of spatial apartheid in south africa they provide context for the kinds of frames that ee developed that unify people across diverse locales organizational framing practices flexible problem frames ee articulated flexible problem frames that allowed for a dynamic connection between local meaningmaking such as interrogation of schoolspecific problems and a national prognostic frame that linked disparate locales in a shared agenda these frames were flexible in that they allowed for the kinds of relational organizing that invites youth to identify issues that affect them directly consistent with under review not for citation or distribution community organizing while also weaving these local issues into a broader narrative that united youth across geographic distance and spatial separation local problem frames at the youth group level we observed how much of the work focused on understanding and naming infrastructure issues that youth experienced in their everyday lives young people came together to discuss their everyday experiences in their neighborhoods and schools and identify areas where they wanted to change or improvement part of this process involved questioning and looking critically at what might have become normalized about their school experience ee utilized many strategies for fostering awareness of inequities in education in addition to the field trips to model c schools described above another was for young people to engage in a social audit similar to participatory action research in tembisa for example a youth group counted the number of broken toilets in their schools which led to news articles and pressure on the ministry to fix the toilets sizwe an equalizer in cape town described his experience with a different social audit focused on broken windows in schools he said how initially he went for the songs the singingtheres food and theresfree hot dogs i was like wow there was girls around but he described a pivot eventually i got the message this is equal education these guys fighting for education in schools i was also involved in the learning first campaignthe broken windows so they gave us a task to go and photograph everything we see in school that we think is an inequality to us like anything that you see in your school that you think shouldnt be there wetook pictures of the bathrooms and things like broken windowsit is 500 broken windows in the school sothats where the first campaignthats when we started to campaign for the broken windows thats how i got involved… under review not for citation or distribution issues such as broken toilets or broken windows in some schools or the distance it took to travel to school in more rural areas represented local issues that ee members named and made visible to each other and broader community audiences unifying frames ee wove together a range of locally relevant problems with a national agenda for minimum norms and standards to foster the building of such frames ee performed a great deal of logistical and strategic work to forge a collective identity among disparate youth from places as different as cape town townships rural eastern cape rural kzn gauteng and limpopo from provincelevel gatherings such as mass meetings and lecture series to nationallevel variants such as teachins and youth camps the movement institutionalized spaces for contact and deliberation for youth from a diverse range of environments at these gatherings ee members brought data about challenges and campaigns at their respective schools and shared those experiences with fellow members from across the country consider this example from fieldnotes which describe first visit to a mass meeting held at a community center where multiple youth groups shared poster displays about problems they had investigated in their schools the excerpt shows how documentation of schoolspecific problems were accompanied by unifying practices and messages we entered the large gym with two basketball courts surrounded by bleachers and covered by a high roofwe stood looking over the scene lots of young people were standing around in clusters by uniform some of them clapping or chanting in tune with each other i estimated that by the end there were roughly 250300 people at the eventwhen i arrived at the gym floor the students had split into two big groups each group was being led in a chant and dance by youth leaderson the perimeter of the gym were displays from each school group about a problem at their schools some had blown under review not for citation or distribution up photos depicting broken doors broken ceilings holes in fences decrepit toilets many had pictures of trees with leaves representing symptoms of problems the trunk representing the issue and roots as causes this mass meeting included several elements that illustrate the flexible framing practices in ee on one hand the notes document a focus on local problems generated by students related to their experiences in schools the variety of root causes in the posters suggest that they were created separately by each youth group and not bound by a singular ideological frame on the other hand the meeting also reveals activities that linked young people across locales through physical movement and singing which offered an embodied way to experience a collective identity as activists also surrounding the gym were posters that unifying frames such as minimum norms and standards for school infrastructure now and equal education for a free and equal south africa these posters conveyed that although the specifics varied they were united by a shared set of policy goals this flexible problem framing was also illustrated in the way that one of the senior staff siyamthanda described the minimum norms and standards campaign at an implementation workshop in 2015 we mapped the issues that learners were facing in schools from thabiso group of equalizers we found out issues that learners faced in and out of school campaigns such as the late coming and broken windows campaign were the predecessors of the norms and standards campaign because they were responses to the issues that were emerging under review not for citation or distribution from our mapping exercise…as you know the education system in south africa is very unequal and your experience of it is largely shaped by where you attend school from her statement it is clear that although the mns was national in breadth it was also local in the way in which local youth made sense of the specifics of the campaign in instances where sanitation was important the local students described their vision of mns in terms of the sanitation challenges they were facing similarly youth confronted with a lack of electricity at their school would express their mns vision in terms of school electrification in this sense mns offered a flexible frame that resonated with multiple constituencies across varying locales the process of building a movement that connected nodes of youth equalizers from across provinces was not straightforward or conflictfree during a leadership meeting where student representatives from various schools talked about the focus of their local school campaigns connected to mns we observed debates about campaign objectives such as the merits of schools giving out condoms and whether to organize against corporal punishment the disagreement became heated enough that one of the senior ee staff stepped in to try to mediate the situation she reminded the group whilst every opinion is valid it is important to remember what our fight is about her reframing is an example of the active work by ee leaders and staff to forge a shared frame for their work tensions also emerged related to political tactics during the mns campaign at one point a debate emerged about how to respond to delays by the minister in implementing mns ee had to decide whether to grant the minister an extension or take her to court and ee membership disagreed about the best way forward although most rank and file equalizers voted to go to court ees elected national council which included equalizers decided to grant a onemonth extension although an unpopular decision with many under review not for citation or distribution members it did not fracture the movement and this may be in part because of ees democraticallyelected governance structure in summary ee adopted a flexible approach to framing that was expansive enough to encompass local work anchored in youths everyday lives while also connected to a broader agenda this broader agenda organized under the national minimum norms and standards campaign linked youth chapters across different provinces and cities discussion ee grew from a local effort to document inequalities in school infrastructure to a national movement made up of thousands of members united by the minimum norms and standards campaign we argue that the development and shared construction of collective action frames was a key element of this movementbuilding through historical continuity frames ee members found meaning and purpose as upholders of the past struggle and asserted legitimacy for their activism about contemporary issues we observed these frames in a variety of activities and media including political art struggle songs and political education in tandem with these historical narratives flexible problem frames offered a way to link localized issues which were identified and documented by young people with a national policy agenda one limitation of our study is our field notes and interviews were specific to ee activities in the western cape primarily khayelitsha it would be particularly valuable to hear from youth in rural areas such as the eastern cape in order to gain a fuller portrait of peoples meaningmaking in relation to the movement relatedly although ees growth as a movement included intergenerational coalitions with parents teachers and lawyers this analysis focused on the experiences and meaningmaking of youth another caveat we offer regarding implications for under review not for citation or distribution movementbuilding is the unique history and demography of south africa which calls for care when drawing implications for other nations and sociopolitical contexts despite these caveats we see contributions from this study for theories of framing and scholarship on youth organizing with regard to framing despite an emphasis on agency and the social construction of meaning in early theorizing the framing literature has been criticized for treating framing as instrumental and strategic more like a topdown activity than one constructed at the grassroots level tarlau for example writes in the framing perspective activist leaders assign meaning to movement activities in order to mobilize participation therefore framing makes the majority of movement actors the objects of the frame…theories of framing do not offer a language for analyzing how individuals and communities develop the consciousness and capacity they need to act collectively although framing can be presented as a calculated or topdown activity our data suggest a more organic process in which ee members developed action frames based on shared histories and collective practices we documented a variety of learning processes by which young people constructed their understanding of the past and made it relevant to the present learning happened in settings that were explicitly designed as workshops such as reading circles and lectures but also through intent participation in movement practices such as singing struggle songs along with parents and elders or marching on city streets documenting this interplay between organizational practices and individual agency in the development of action frames is especially important in youth movements because such movements lose their credibility if young people do not resonate with or actively construct those frames under review not for citation or distribution with regard to scholarship on youth organizing this study showed how collective action frames may offer a useful way to map how local organizing efforts grow into social movements accounts of youth organizing campaigns in the us often focus on influencing local policies such efforts to influence policymaking are necessary for social change but are only one piece of a broader effort to build power organizing groups led by youth of color after all contend with multiple constraints on their political power related to the intersection of age structural racism neoliberal ideologies and economic marginalization these complex circuits of dispossession call for collective action frames that can unit people across cities and borders to address causes of structural violence whether at the level of national policy multinational corporations or international trade agreements as hinson healey write without a larger framework that moves people from specific interests towards a critical analysis of social and power relations most people who get involved in a singleissue campaign will lose interest after the specific campaign is done they are less likely to see and feel the connections between their own issues and the struggles of others in their communities and in the larger world this comment resonates with findings our study in that youth found meaning and connection with ideological frames related to fairness in the distribution of resources and the meaning of the apartheid struggle collective action frames also enable young people to counter threats to their legitimacy as political actors one type of threat possibly unique to the south african context was the way in which the generation of bornfrees were discursively excluded from the moral authority of holding struggle credentials ee youth and organizational staff addressed this discursive challenge by asserting continuity with youth activists of the antiapartheid era they positioned under review not for citation or distribution themselves as historical actors who were carrying on a noble and unfinished struggle a second threat to the legitimacy of youth activists is to attribute their actions to the machinations of adults pulling the strings behind the scenes this threat poses a complex challenge for youth movements because it risks goading youth into accepting a false binary or framing their work in solely agebased terms sukarieh and tannock based on their analysis of youth protests and movements around the world argue that contemporary youth formations are often marginalized or marginalize themselves when they substitute an agebased lens for a structural one limiting the movement to a generational one can undermine ties to other constituencies such as organized labor or environmentalists and weaken movement infrastructure such as when experienced activists are regularly aging out we highlight these various complexities because they are unique to youth movements and deserve attention from social movement scholars in conclusion this study identified some of the key dimensions by which young people in south africa transformed their local struggles to a movement linking youth around a shared vision for equitable and high quality education this is an urgent moment for youth organizing groups to strengthen movementbuilding strategies given the injustices and precarity facing masses of young people globally we owe it to them to be ambitious in our theorizing and clear in drawing lessons that can be useful in the development of social justice youth movements which has been published in final form at jcop22405 this article may be used for noncommercial purposes in accordance with wiley terms and conditions for selfarchiving under review not for citation or distribution endnotes 1 racial terminology in south africa has a complicated history the vast majority of ee were youth came from schools that designated them as blackafrican consistent with south african census categories at the same time in social justice movement circles including equal education black includes a range of nonwhite peoples including those who identify as coloured and indian 2 although usbased youth organizing had its roots in civil rights activism and movements of the 1960s it emerged as a distinct phenomenon supported by nonprofit organizations and differentiated from adultled community organizing in the 1990s some of the first references to youth organizing as a distinct practice were in the early 2000s the emergence of youth organizing as a field can also be traced to the founding of the funders collaborative on youth organizing in 2000

the literature on contemporary youth organizing has documented psychological benefits associated with participation and some evidence of local political impact but how do local organizing campaigns transform into regional or national movements this is a practical question facing youth organizers and one that calls for attention from researchers in this article we draw on more than two years of ethnographic fieldwork with south africas equal education ee to analyze collective action frames that enabled ee youth to assert legitimacy and construct shared aims across locales our findings focus on how youth constructed historical continuity frames that lent them legitimacy as upholders of the south african freedom struggle and flexible problem frames that linked young peoples local struggles such as inadequate sanitation or broken windows at their schools to a national policy agenda we discuss connections to other youth movements and implications for the interdisciplinary youth organizing field

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introduction data is we imagine an immaterial thing or at least ethereal made of light and electricity processed at superhuman speed transmitted in real time the everyday world we move in seems dense and slow by comparison the landscape is slower again thick heavy and persistent 1 the mercurial nature of digital data described above can make it seem unpredictable and yet at the same time data can appear to be selfevident and unproblematic from an archaeological perspective data can be both material and immaterial objective but biased precise but inaccurate tangible but ephemeral detailed but generalized it can be big or small fast or slow quantitative or qualitative comprehensive yet selective it is open to misrepresentation misconception misunderstanding misreading and misinterpretation it can be distorted altered wrangled and reshaped into something entirely new used for different purposes and according to different agendas 2 despite its many perils and imperfections data is nevertheless the basis for archaeological interpretation and for determining what is and is not known about the past through its material remains indeed archaeologists are all too accustomed to the lacunae in their data whether viewed colourfully as a vast fiendish jigsaw invented by the devil as an instrument of tantalising torment missing an unknown number of pieces 3 or more prosaically as a discipline defined by the challenges of working with gaps and absences in its primary data 4 such characteristics are often considered to be key distinguishing features of archaeological data but this has not been broadly reflected in considerations of digital data beyond technical discussions of data handling and arguments supporting the importance of digital data archiving this paper seeks to redress this imbalance by considering the nature characteristics and implications of digital data for the construction of archaeological knowledge that data is so fundamental can be seen in the way that many of the revolutions or paradigm shifts experienced within archaeology are related to data whether they are new ways of approaching data the creation of new kinds of data a greater abundance of data or faster processing of data in larger quantities than before some revolutions are based on technological developments and adoptions for example the radiocarbon revolution of the 1950s and the quantitative revolution associated with the new archaeology while more recently kristiansen 67 has identified a new scientific revolution associated with the combination of dna and isotope studies with big data if anything there have been more turns than revolutions in archaeology for example sørensen 8 lists the linguistic turn the spatial turn the practice turn the material turn the affective turn and the ontological turn many of these have their origins outside archaeology derived from scientific and technological advances or theoretical developments in other disciplines but they nevertheless entail changes in approaches to datahow it is gathered analyzed processed and perceived as reflections of changes in wider society not just in archaeology the list may be extended further with the information age and the digital turn we may even be experiencing the second digital turn defined by carpo as a nonhuman postscientific method combining big data and artificial intelligence just as the digital revolution of the 1990s begot a new way of making todays computational revolution is begetting a new way of thinking 9 a data revolution is characterized by kitchin in terms of the profound datafication of our lives 10 and the extent to which data has come to govern our knowledge and experience these informational digital and data turns or revolutions are experienced within archaeology as much as elsewhere presenting both challenges and opportunities for the ways in which archaeological data is handled reproduced manipulated analyzed archived circulated and reused but the implications of these are as yet barely recognized introducing imaginaries terms such as revolution or turn carry connotations of abrupt dislocations or changes in direction these do not necessarily reflect the experience of technological methodological or theoretical changes within archaeology which often take place over extended periods of time and may be only identified in retrospect furthermore many of these developments are broadly contemporary with others rather than being succeeded or replaced and there may be a degree of interdependence involved an alternative which might better characterize the situation is the concept of the imaginary which is commonly applied in anthropology and science and technology studies and seems appropriate in the context of an inquiry into digital data strauss 14 outlines a complex range of origins for the term derived from cornelius castoriadiss concept of the imaginary as the shared unifying core conceptions of a group 14 jacques lacans view of the imaginary as an illusion or fantasy created in response to a psychological need 14 and the imaginaries of benedict anderson and charles taylor consisting of communities of people sharing concerns and practices 14 as strauss suggests the imaginary goes beyond simply shared facts or knowledge and covers a spectrum between indisputable knowledge and ignorance including explicit knowledge of imagined facts implicit cultural beliefs and dissociated repressed and fantasized knowledge 14 so for example marcus 17 sees the possibilities of a technoscientific imaginary associated with scientific practice and potentially ranging across reflective visionary and innovative scientific thought and the imagination of science fiction writers 17 before narrowing it down to the social and culturally embedded imaginaries of scientists tied more closely to their current positionings practices and ambiguous locations in which the varied kinds of science they do are possible at all 17 similarly jasanoff and kim 18 the idea of the imaginary emphasises that political agendas are driven by culturally specific belief and value systems that produce different forms of technopolitical order and invites a close reading of the various expectations and concerns the diverse norms mores and ideologies that help these imaginaries to form stabilise proliferate and endure 20 like jasanoff ruppert sees imaginaries as something enacted rather than determined which can lead to unintended or unexpected consequences she suggests that some of the most powerful sociotechnical imaginaries concern digital technologies and big data 21 these imaginaries not only shape what is thinkable but also the practices through which actors perform them they are taken up in practices through which new paradigms or ways of thinking are propagated 21 in buchers study of facebook for instance she introduces the concept of the algorithmic imaginary which does not merely describe the mental models that people construct about algorithms but also the productive and affective power that these imaginings have 22 she highlights the way in which algorithms are experienced and encountered as part of the force relations that give people a reason to react and the consequent feedback loop through which the algorithm is moulded in turn 22 the fact that these algorithms operate on data together with the very ubiquity of data means that data imaginaries have also been characterized by several authors for example beer defines the data imaginary as part of how people imagine data and its existence as well as how it is imagined to fit with norms expectations social processes transformations and ordering the data imaginary is about how data are imagined in the social world and how they intervene in the connections between people and between people and organisations nation states media and their material environment 23 beer emphasizes how the data imaginary like buchers algorithmic imaginary operates in a feedback loop with the imaginary shaped by data practices and those practices in turn shaped by the visions of the imaginary leading to an intensification of data analytics for example 23 in her discussion of the use of data in response to the coronavirus pandemic leonelli also highlights the importance of the vision entailed in data imaginaries this is a vision of the technical human institutional and data resources that can be developed and combined to address a problem without assuming those resources necessarily exist yet hence the choice of the term imaginaries rather than just collections of ideas these are ways in which data science is routinely imagined and performed by researchers policymakers and various publics and stakeholders they typically do not amount to a coherent plan or a systematic philosophy of data use they are also not necessarily stable and can rapidly adapt to changing research conditions 24 elsewhere data ideology is employed as a term in much the same way as data imaginary for example poirier et al define data ideology as constituted through the complex cultural and institutional forces that shape particular yet always collective ideas and values about data sharing and data infrastructure design 25 similarly dourish and gómez cruz suggest their data narrativesnarratives in from and of databroadly parallel data ideologies 26 alternatively gray uses the notion of data worlds as a means of exploring the performative capacities of data infrastructures what they do and could do differently and how they are done and could be done differently to consider how data infrastructures may be involved in not just the representation but also the articulation of collective life while at the same time being the products of social and institutional work themselves 27 data imaginaries data ideologies or data worlds all provide ways of conceptualizing the assumptions practices and consequences surrounding data for example jasanoff argues that the value of studying imaginaries is the way in which it allows at its best a deep meditation on the basis of a technological societys particular forms of sightedness and blindness and the tradeoffs that inevitably accompany attempts to build a shared normative order 28 nor are they exclusive categories multiple imaginaries or worlds may coexist and interact for example leonelli explores five data imaginaries related to covid19 studies linked to surveillance predictive modelling causal explanation logistical decisionmaking and socioenvironmental needs 24 similarly gray characterizes three overlapping aspects of data worlds the worldmaking capacities of data infrastructures the collective identities of those making and using data and the transnational scope of data infrastructures 27 suggests the data imaginary is a component of the broader sociotechnical imaginary in the same way a data imaginary may itself consist of a subset of imaginaries each focused on a different intervention or characteristic for example poirier et al identify four data ideologies at work within cultural anthropology what they call all or nothingism ethicopolitical sensitivities institutionally reinforced individualism and interpretive exceptionalism 25 underlying all four ideologies or imaginaries is the question of sharing and reusing data the archaeological data imaginary understood in this light the archaeological data imaginary can be conceived as consisting of several interlinked imaginaries these include imaginaries connected to open research to research infrastructures to big data and algorithmic analysis and to the nature of archaeological data itself separately and jointly they carry implications for approaches to archaeological data the open data imaginary archaeology has a longstanding relationship with the concept of open data although how it is operationalized has varied considerably in terms of digital data archaeology is in certain respects wellserved with free access to data provided by a range of national institutions and other organizations however different degrees of openness may be encountered ranging from open to viewonly through a limited ability to download data to full download access limited only by the requirement to cite the source 30 although there may be a general perception within the subject at least that archaeology is relatively open in terms of a willingness to share data the reality often falls some way short as rights over data are frequently retained this is embedded in some professional codes through the right of primacy for example the chartered institute for archaeologists specifies that a member has up to ten years within which to publish data during which time they retain nearexclusive rights 31 similarly the european association of archaeologists specifies a tenyear period within which an archaeologist may have prior rights and while they are expected to make results as accessible as possible during this period it is only after ten years that records should be freely available to others 32 consequently archaeologists traditionally treat their datasets as proprietary to a degree given their investment in collecting them in the first place 33 to some extent such a position was easily defensible given traditional practices which made datasharing cumbersome and awkward at best but the growth in digital data removes this physical limitation marwick et al observe that this dataownership mindset should become obsolete in favour of datastewardship recognizing that data are collected and shared on behalf of the broader community 33 a view expressed more robustly by kansa 34 for example the challenge to archaeological practice cannot be underestimated for example a permissive definition of openness is summarized in the open definition knowledge is open if anyone is free to access use modify and share itsubject at most to measures that preserve provenance and openness 35 a more recent characterization of openness is encapsulated within the fair principles data that is findable accessible interoperable and reusable in the open definition the means by which openness is achieved is not specified whereas the fair principles outline how openness might be accomplished while maintaining that the barrier to entry that these methods represent is set deliberately low 36 the emphasis of the fair principles is on more rigorous management and stewardship of data 36 and is described as the culmination of years of agreements and actions by publishers repositories funding agencies and others 37 which may lie behind its greater appearance of institutionalization as in other disciplines the fair acronym has become something of a buzzword in discussions of open archaeological data providing a model against which data provision can be measured and assessed although its generic nature may not be altogether helpful 39 it also embeds a series of expectations surrounding the standardization of data and metadata in part required in order to allow for the automated discovery and integration of datasets this goes beyond standardized digital communications protocols and persistent identifiers to include shared languages for knowledge representation and common vocabularies for instance these ontologies highlevel classes of information and associated standards are not widely discussed in archaeology 40 and recent studies demonstrate that the structures created with such tools do not necessarily capture the nuances of archaeological data consequently the kinds of cultural changes required to develop open approaches in archaeology and beyond via stronger data mandates from funders incentivization of open data practices and appropriate funding for data infrastructures are not the whole story the opendata imaginary risks fetishizing data sharing without fully considering the implications of what is shared how and for whom the data infrastructure imaginary a key feature of development in archaeology over the past twenty years or so has been the development of digital infrastructures designed to support data management data access data sharing and data preservation in addition to making data findable accessible interoperable and reusable these digital infrastructures provide data integration features using structured data to support interdisciplinary research they can be described as scholarly ecosystems supporting scholarly development and the use of research resources tools and methods and the outputs they enable 47 in this way archaeological practice is increasingly embedded in digital infrastructures in much the same way as communication infrastructures have become fundamental to supporting activities in the modern world and largely disappear into the background it is only when such infrastructures break down or behave unexpectedly that they become foregrounded and the degree of dependence on them becomes apparent for example historic environment scotlands archaeological digital collections including canmore and pastmap the national collection of aerial photography britain from above and the buildings at risk register were taken offline for a month from december 2021 to january 2022 in order to resolve the apache log4j critical vulnerability in their internet services such a significant downtime even over a holiday period underlined the extent to which these services were relied upon for deskbased assessments in commercial archaeology as well as for general research as evidenced in social media queries and responses around that time it is when such tools are demonstrated to be central and indispensable components of regular practice that they can be revealed as imaginaries in terms of what they enable in practice such infrastructural data imaginaries organize and promote certain practices over others and therefore act as technological gatekeepers through the ways in which they provide and control access to information for example day 49 argues that such sociotechnical infrastructures mediate their access by hiding the assumptions that underlie them a simple way of demonstrating this in practice is by comparing search tools used by national and transnational archaeological infrastructures canmore maintained by historic environment scotland provides access to records for ancient and historic monuments and allied resources across scotland searching for the site classification motte and bailey a term offered by the canmore search interface returns 43 the two additional sites returned by the ariadne portal are actually in england and a consequence of border changes between england and scotland as they also appear in historic englands heritage gateway records but not in canmore the difference between 43 and 345 records is more problematic however on inspection it appears that archsearch is using a fuzzy search returning sites that are mottes alongside the motte and baileys that were specifically requested in contrast canmore uses an exact search as expected indeed adding a search for mottes to a search for motte and baileys in canmore returns a total of 346 records this is not to suggest that either of these wellestablished data tools is wrong as such however at first sight the two generate very different results from the same data because the underlying search implementation is different and in neither case can this be seen or controlled by the end user in short they control access to digital data in nontransparent ways underlining their function as an imaginary and emphasizing that the choices made by those who control such infrastructures determine what data in what form and which other resources are made available in the future 50 as okune et al observe it is critical to reflect on who is included and excluded in the design and use of these infrastructures and they argue for what they call inclusive knowledge infrastructures which are mindful of the diversity of human needs identities abilities experiences and forms of knowing 51 the big data imaginary archaeology has seen significant growth in the quantity and availability of digital data in recent years for example the archaeology data services annual report for 20202021 indicates that its archive holds over 36 million files in 308 file formats totalling 2528 tb of data 52 these are spread across 4087 collections including databases of artefacts burials coins building surveys fieldwork archives and reports scientific datasets and sites and monuments records 52 over 14 million metadata records are catalogued and searchable via archsearch and their unpublished fieldwork library currently contains over 64000 reports elsewhere historic environment scotlands canmore passed 1 million digital objects in 2020 53 while the portable antiquities scheme for england and wales has just over 1 million records relating to more than 15 million objects 54 in the usa the digital archaeological record was reported in 2019 to contain over 395000 documents 21000 images and 1700 databases documenting around 1100 archaeological projects 55 turning from national collections to single archaeological projects for example a network analysis of connections between sites in southwestern usa employed a database of over 43 million ceramic artefacts from more than 700 sites and more than 4800 obsidian artefacts from 140 sites 56 similarly a project examining changing distributions of settlements cemeteries field systems and finds across england from c1500bc to ad1086 employed a database of over 900000 records collated from a wide variety of different sources including regional historic environment records and the portable antiquities scheme 57 constituting over 3 gb of data and over 100 gb of gis data 58 these examples certainly represent large datasets in archaeological terms and the availability and accessibility of increasing quantities of archaeological data through digital infrastructures has made a significant difference to research and deskbased assessments as well as to archaeological practice more generally as a result there has been some debate within archaeology in reaction to the growth in use of large if not big datasets in archaeological analysis another example of concepts and associated technologies borrowed from beyond the immediate discipline big data has become more than a buzzword as in the wider world it can be seen as representing a mythology in which data are framed as raw materials to be mined alongside a corresponding shift in theory and methodology for example holdaway et al warned that one attraction of big data is to make archaeology appear more scientific and more suited to predictive and probabilistic inference 59 it is also closely associated with the resurgence of artificial intelligence and the expanding use of neural networks and deep learning technologies which are dependent upon large datasets and can be seen in part as a rebranding of big data the narrative of big data claimed that comprehensive coverage of a topic was possible due to the quantities of data available making sampling unnecessary in turn such quantities meant that biases were removed and errors compensated for in the data and analyses focused on the search for correlations within the data famously characterized by andersons declaration of the end of theory 62 whether archaeological data truly constitutes big data is open to debate but ruppert argues that the force of the big data imaginary is in the adoption of new mindsets and paradigms and the way in which data practices are reconfigured they not only shape what is thinkable but also the practices through which actors perform them so while some commentators declare big data as hype these pronouncements underestimate the material and political effects of imaginaries as they are taken up in practices through which new ways of thinking are propagated 63 while there have been warnings in archaeology about the risk of gathering larger and larger quantities of data in the assumption that masses of data enable it to largely speak for itself the technologies themselves are embedded with a bigdata datadriven ethos and consequently influence approaches to data and analysis for example a common feature of digital imaginaries is the perception that the technology provides a neutral means to an end but this overlooks the potential drawbacks and theoreticalmethodological implications that lie beyond in archaeology for instance as long as geographical information systems were primarily used as a means of mapping data they were seen to present few problems and many advantages however the analytical tools provided by gis presented greater challenges in terms of embedded theory and methods and required a more critical approach in the same way the idea of big data as being little more than a capacity to search aggregate and crossreference large datasets may imply that big data practice is simply a case of doing the same thing as before only with more however the imaginary of big data reveals that the underlying changes are more radical and more broadly affect the attitudes and methodologies applied to data which offers profound challenges to established methods as well as potential new opportunities for archaeological practice 60 the datacapta imaginary how data is perceived in archaeology has fluctuated and changed for many years in part these changes mirror distinctions drawn between the sciences and humanities and since archaeology sits on the cusp of both it might reasonably be expected that archaeological approaches to data would be complicated as a result at various times archaeology has taken a more scientific or a more humanistic position towards data and currently both approaches to data are in use for instance sørensen warns of challenges to data that he identifies with the scientific turn the unhelpful return to the ethos of letting data speak for itself becauseas the popular legend goesfacts do not lie and thus become associated with truth quite often leading to a liberal even careless use of scientific data 8 one challenge is that the nature of what is meant by data in archaeology can appear at times to be selfevident and is infrequently discussed the idea of data is often subsumed within higherlevel discussions of the archaeological record and associated issues surrounding the deposition survival and preservation of material evidence while remaining largely silent on the meaning of data itself the terms facts and data are often used interchangeably even as in data see facts 70 however the etymology of the terms is different the origin of data is in the latin verb dare to give while fact is derived from the latin facere that which was done occurred or exists 72 73 74 in the 17th and early 18th centuries data referred to truths or to claims that were accepted for the sake of argumentmatters of faith or belief evennot discovered through experiment or investigation during the 18th century rosenberg identifies a shift in which data came to evoke a particular sort of representational entity upon which one could operate through systems of calculation classification and communication while holding the question of referential truth in abeyance 73 data and facts could increasingly be substituted for each other 74 by the end of the 18th century references to data had expanded from primarily mathematics and theology to medicine economics natural history and geography and its meaning had shifted to facts in evidence determined by experiment experience or collection with data becoming the result of an investigation rather than its premise 72 as rosenberg describes it data went from being reflexively associated with those things that are outside of any possible process of discovery to being the very paradigm of what one seeks through experiment and observation 72 data subtly shifted from being given from being beyond argument to being something that is captured or extracted through observation and computation although rosenbergs characterization has received some criticism the meaning of data has changed over time and the shift he identifies from data as given to data as captured finds an echo in chippindales contention that archaeological data are not data at all for they are practically never given to us by the archaeological record they are actually capta things that we have ventured forth in search of and captured with all that the idea of capture implies hunting is a dangerous and uncertain business in the rugged country of archaeological material 76 although there was no subsequent published discussion following chippindales forum piece in american antiquity the idea of data as capta was later developed by drucker who argued that humanistic enquiries should acknowledge the situated partial and constitutive character of knowledge production the recognition that knowledge is constructed taken not simply given as a natural representation of preexisting fact 77 she concluded that data are capta taken not given constructed as an interpretation of the phenomenal world not inherent in it 77 the fact that the term data is still used in preference to capta might suggest that archaeologistsand humanists more broadlyrecognize data as capta but continue to use data to avoid confusion 75 in reality this serves to disguise different attitudes to data and to theory in general for instance realist positivist or modernist versus constructivist phenomenologist or postmodernist approaches 78 the importance of the concept of capta in relation to data lies in its interpretative character hence drucker describes it as situated observer codependent and partial its variables are in theory infinite but they are always present in some degree or measure by virtue of the performative and participatory character of interpretative information interpretation depends upon and is an expression of an individual reading in a particular set of circumstances and never presumes to completeness or observer independence 77 this resonates with approaches to data in archaeology for instance in their discussion of excavation strategy andrews et al argued that obviously all observations involve interpretation simply because observations become comprehensible when they confront the preexpectations which are held by the observer 79 similarly wylie argued that what archaeologists recognize as data and what they infer to be its evidentiary significance are necessarily functions of the preunderstandings they bring to bear 4 this sets up what wylie identifies as an epistemic anxiety that archaeological data are of value only if they can be used as evidence but those same data only exist because they conform to the preexpectations and conventions of archaeological practice in what she describes as a vicious circularity leonelli sees this as a paradox namely that despite their epistemic value as given data are clearly made they are the results of complex processes of interaction between researchers and the world which typically happen with the help of interfaces such as observational techniques registration and measurement devices and the rescaling and manipulation of objects of inquiry for the purposes of making them amenable to investigation 80 likewise buccellati identifies an archaeological paradox in which data only come into existence through observation rather than being given 81 to put it simply therefore two distinct approaches to data in archaeology can be broadly identified on the one hand data are seen to be empirical and unarguable while on the other data are seen to be interpretative negotiable the first perspective sees data as relatively straightforward raw pieces of information about the world so that where instruments are used to capture the data what they capture is representative of preexisting characteristics and they do so in a neutral objective manner independently of any philosophical thought the role of the archaeologist is to use the most representative means of capturing the data and as far as possible creating as complete a record as is feasible at the same time minimizing any errors or biases in the data these data provide the groundwork for subsequent interpretation and understanding which is therefore more reliable and consistent the second perspective sees things rather differently data do not exist independent of the archaeologist they are brought into being through archaeological practice the research agenda available techniques and technologies physical and temporal constraints conventions learned behaviors etc all make a difference to what data are created giving rise to multiple possible datasets for instance the same measurement can be captured by different instruments in different ways giving rise to different resolutions in the outcomes the archaeologist still seeks to work in a consistent rigorous professional and objective manner but is limited by choices restrictions requirements and resources this means that data are situated contextually culturally socially politically technologically and spatially in reality however the boundaries between these two positions are blurred giving rise to the paradox that leonelli identifies that data are treated as preexisting givens whilst at the same time being a consequence of human action in archaeology therefore data are seen as primarily interpretive rather than being purely empirical 79 while at the same time essentially descriptive data are treated as objective empirical data in the process an interpretive archaeology is transformed into a objective more scientific archaeology and the valueladen theoryladen processladen selection and organization of data is largely set aside chippindale associates this reversion of capta to data with the advantages of digital data as the manipulation of data becomes easier so it also becomes easier to treat the data as given things rather than to enquire after just what these given things are just where they come from just what uncertainties assumptions classifications and concepts their created existence depends upon 76 this is a consequence of sørensens scientific turnor more specifically a computational turn in which data are processed as symbols and numbers as is frequently seen in big datastyle analyses in the process data are treated as a neutral and objective reflection of the archaeological record the distant data imaginary a particular characteristic of digital data is a distancing effect the heady combination of the availability accessibility and quantities of data making data more available as it paradoxically becomes more remote as a consequence increasing access to increasing amounts of data has to be set against greater distance from that data and a growing disconnect between the data and knowledge about that data 30 ellul for example observed how proximity to technology can replace knowledge of the primary elements from which things are made occasioning profound mental and psychic transformations which cannot yet be assessed 85 and the deskilling alienation and distancing effects of technology has been a common critique in recent years for instance ingold argues that the project of technology has been to capture the skills of craftsmen or artisans and reconfigure their practice as the application of rational principles whose specification has no regard for human experience and sensibility 86 for example the interface in a digital environment mediates the range of negotiations between investigator and data drucker observes that no single innovation has transformed communication as radically in the last half century as the gui in a very real practical sense we carry on most of our personal and professional business through interfaces knowing how interface structures our relation to knowledge and behaviour is essential 87 this interface operates both at the physical level and at a more metaphysical level and can easily resemble a device of capture as a journey is plotted out through which mechanisms are triggered and set off that reduce autonomy into zones of nonknowledge 88 this can promote a push button approach in which complex routines can be easily applied with little understanding of their background operation or consequences 90 this distancing can be visualized in several ways for example consider archaeological field data increasingly commonplace in digital archives it is often considered that such data starts with the material evidence in the ground for instance buccellati argues for the primordially atomic nature of the archaeological record in which we do not fragment an observed whole nor do we impose an analytical fragmentation 81 however from a capta perspective such data are not the start of the process but a consequence of multiple decisions predeterminations and perspectives which precede the moment of capture and impose constraints on the observations recorded as data for example carvers field research procedure characterizes the sequence of reconnaissance evaluation and project design that come before and define and structure the nature of the investigation itself each of these prior stages themselves entail data creation and data analysis for instance evaluation may include desktop assessment the creation of a deposit model and the creation of a research agenda that will then influence the project design which in turn establishes the strategies for data acquisition in the field these field data are consequently enmeshed in a web of other data decisions and determinations and cannot be seen as truly primordial the field data are themselves influenced by a combination of cultural and taphonomic processes and the observer articulates their knowledge based on experience research objectives professional expectations customary actions commercial and temporal constraints and so on in order to identify select and categorize the data once recorded those data records are then drawn together through a process of interpretation and analysis into a datastructures report or its equivalent which in turn provides the basis for a site report this may subsequently be incorporated into a synthetic volumea period or regionalbased study for instance it is easy to see how the report is much more remote from the original site data than say the context record however consider what happens when other interventions occur for instance the synthetic work is incorporated into other studies or the grey literature report is referred to in another project or another synthetic work these are still further removed from the original site data often building on interpretations of those data rather than the data themselves additionally of course it is becoming increasingly common to deal with data at second or third hand rather than going back to the primary data which themselves are only a proxy for the original material evidence which is long gone another way of visualizing this distancing is to consider the relationship between archaeological practice and the data it generates this model illustrates the transitioning of archaeology from a craft practice into a more automated computerized form 95 the model tries to show that the different categories or elements of practice overlap with each other and that practice may operate at one or more stages depending on factors such as the resources available experiences and preferences of the practitioners and professional expectations from a digital perspective there are also chains of dependencythe automation of a particular task requires there to be systematization and standardization for instance additionally there are questions of the changing relationships between practitioner and the digitalwhere the balance of agency between the two is different across the model however there are also implications for the perception and handling of data in this model for example at the craft level there is close physical proximity to the datadirect personal observations made in the encounter with the material evidence standardization introduces a degree of distance from the data through a closer definition of what is of interest and how it should be captured and hence it can be perceived to be in tension with craft practice systematization sees the introduction of another way of visualizing this distancing is to consider the relationship between archaeological practice and the data it generates this model illustrates the transitioning of archaeology from a craft practice into a more automated computerized form 95 the model tries to show that the different categories or elements of practice overlap with each other and that practice may operate at one or more stages depending on factors such as the resources available experiences and preferences of the practitioners and professional expectations from a digital perspective there are also chains of dependencythe automation of a particular task requires there to be systematization and standardization for instance additionally there are questions of the changing relationships between practitioner and the digitalwhere the balance of agency between the two is different across the model however there are also implications for the perception and handling of data in this model for example at the craft level there is close physical proximity to the datadirect personal observations made in the encounter with the material evidence standardization introduces a degree of distance from the data through a closer definition of what is of interest and how it should be captured and hence it can be perceived to be in tension with craft practice systematization sees the introduction of tools that increase distance againfor example using photogrammetry rather than manual drawing to capture sections and surfaces finally automation introduces still further distance with technological devices performing the encounter with the archaeology and capturing data about it the intervention of technology can therefore introduce distance into the data capture process for instance there is a growing trend for the use of digital photogrammetry as a replacement for traditional section drawing and planning in which imagery and 3d models produced through digital photogrammetry are used in the field to draw the contexts and to record the textual and graphical information describing the context in the database the aide mémoire project 99 has begun to look at the implications of digital versus handdrawing for archaeological understanding and their initial survey results speak to a sense of distance introduced by the digital application for example respondents commented that i find its much easier in my experience to simply switch off and fall into the mechanical clickclick of photogrammetry and drawing a context is like reading a page in a book photographing is like photocopying that page 99 another respondent said if drawing starts to be seen as more akin to transcription than to translation as a result of digital tools i think we will lose perspective on our own processes of knowledge generation and finally were never capturing reality at least hand drawings are unfailingly honest about that 99 such perspectives capture a clear sense of an armslength relationship through technology which fosters distance or remoteness from the data the many characters of data these instances of data imaginaries combine in different ways and in different situations to contribute to the archaeological data imaginary in the process they underline the inherent diversity and complexity of archaeological data in different contexts ranging from the empiricalinterpretative nature of data attitudes and approaches to data proximity to data and ultimately the construction of infrastructures that enable subsequent access to and reuse of data huvila 100 characterized the idiosyncratic nature of archaeological information arguing that the heterogeneity and fragmentary nature of archaeological information destructive nature of archaeological work coexistence of multiple epistemologies and standards of information work and representation of information and long temporal time span of the archaeological subject matter and archaeology itself all impede effective and efficient management of archaeological information the intervention of technology can therefore introduce distance into the data capture process for instance there is a growing trend for the use of digital photogrammetry as a replacement for traditional section drawing and planning in which imagery and 3d models produced through digital photogrammetry are used in the field to draw the contexts and to record the textual and graphical information describing the context in the database the aide mémoire project 99 has begun to look at the implications of digital versus handdrawing for archaeological understanding and their initial survey results speak to a sense of distance introduced by the digital application for example respondents commented that i find its much easier in my experience to simply switch off and fall into the mechanical clickclick of photogrammetry and drawing a context is like reading a page in a book photographing is like photocopying that page 99 another respondent said if drawing starts to be seen as more akin to transcription than to translation as a result of digital tools i think we will lose perspective on our own processes of knowledge generation and finally were never capturing reality at least hand drawings are unfailingly honest about that 99 such perspectives capture a clear sense of an armslength relationship through technology which fosters distance or remoteness from the data the many characters of data these instances of data imaginaries combine in different ways and in different situations to contribute to the archaeological data imaginary in the process they underline the inherent diversity and complexity of archaeological data in different contexts ranging from the empiricalinterpretative nature of data attitudes and approaches to data proximity to data and ultimately the construction of infrastructures that enable subsequent access to and reuse of data huvila 100 characterized the idiosyncratic nature of archaeological information arguing that the heterogeneity and fragmentary nature of archaeological information destructive nature of archaeological work coexistence of multiple epistemologies and standards of information work and representation of information and long temporal time span of the archaeological subject matter and archaeology itself all impede effective and efficient management of archaeological information 100 the survey of digital archaeological repositories reported by geser et al 39 underlines some of the challenges associated with the management of such diverse data however it is possible to see archaeological data as more exceptional in character than it really is for example the uniqueness of archaeological data derived from the excavation is destruction trope is frequently employed as a justification for the preservation of remains or intervention in the field it has also played a crucial role in calls on funding agencies to support digital archival infrastructures given the added fragility of digital data and the need to actively curate it yet although great play is made of the distinctiveness of archaeological data and the unrepeatability of its data collection process it is not alone in this regard and other disciplines might make equal claim for instance a musicologist could point to the uniqueness of a live performance or an ethnographer to the interview event occurring at a single place and time similarly the range of epistemologies and data standards in archaeology is not an exceptional feature amongst humanities disciplines nor is their frequent conflict with the generic digital systems and infrastructures which are built upon formalized data descriptions to support data sharing for example the long temporal scope of archaeological data is also not in itself an exclusive characteristic nor is the fragmentary nature of archaeological data and its inherent biases as parallels for both can be found in other disciplines what does make archaeological data unique however is the way in which it is used as a proxy for past human behavior or as huvila puts it the fact that archaeological data is seldom directly informative about matters of archaeological interest 100 data recovered by archaeologists stands as proxy for the complexities of human social and economic activities in the past for example quantitative measures may stand for qualitative aspects such as gis distance measures as proxy for a sense of place or knowledge about a landscape or friction calculations as proxy for accessibility within a landscape elsewhere material remains act as proxies the presenceabsence of artefacts as indicators of trading networks the substitution of one characteristic artefact with another associated with population replacement the style and decoration on artefacts used as signifiers of social or group identity and so on proxies are also extensively used within more scientific approaches in archaeology with for example environmental change through time assessed through proxies including pollen data tree rings and sediment analysis for instance multiple proxies are frequently used in conjunction with each other such as in gis studies network analyses and indeed in big data analyses with their search for correlations however the interpretation of the outcomes of such proxy data investigations is highly influenced by the nature of those same data to the extent that it may never be possible to dispense with controlled conjecture 104 because of the fragmentary partial and temporal aspects of the data which means it is both representation and sample collins 105 for example identified what he called a sequence of contingencies which intervene between past human action and the archaeologists perception of that action and which emphasize the incompleteness of archaeological data the consequence of the range of cultural taphonomic and archaeological factors mean that much is unrepresented unrecognized and unknown and hence archaeological data is haunted by absences 69 shadowy 4 and characterized by ignorance and silences 106 as chippendale describes it archaeology is plagued in many an instance with poorly defined variables drawn from illunderstood populations and with uncertain articulations between the entities whose logical relations we seek to understand 76 the sequence of contingencies that constitute archaeological data is compounded with the recognition that in different situations and at different times the character of data itself may take on a range of different forms and potentials sometimes simultaneously and even contradictorily for example kitchin identifies a range of technical categories of data which influence their subsequent use 10 and within this may be nominal ordinal interval or ratio data or qualitative data may also be structured semistructured or unstructured data may also be captured directly through observation or survey for instance or indirectly as a byproduct of another function or purpose data may be primary secondary or tertiary there may be indexical data attribute data and metadata metadata itself falls into several categories descriptive structural administrative and process metadata or paradata other categorizations of data are also possible for instance marwick and birch identify four different types of archaeological data although they emphasize that their list is the sequence of contingencies that constitute archaeological data is compounded with the recognition that in different situations and at different times the character of data itself may take on a range of different forms and potentials sometimes simultaneously and even contradictorily for example kitchin identifies a range of technical categories of data which influence their subsequent use 10 and within this may be nominal ordinal interval or ratio data or qualitative data may also be structured semistructured or unstructured data may also be captured directly through observation or survey for instance or indirectly as a byproduct of another function or purpose data may be primary secondary or tertiary there may be indexical data attribute data and metadata metadata itself falls into several categories descriptive structural administrative and process metadata or paradata other categorizations of data are also possible for instance marwick and birch identify four different types of archaeological data although they emphasize that their list is not comprehensive 42 observational data includes site and artefact descriptions and measurements computational data includes the outputs of simulations and computer models experimental data includes results from laboratory procedures and field experiments and records are largely concerned with textual documentation elsewhere for example purdam and elliot 107 define an eightpart typology of data for social scientists based on the way data are generated which overlaps in certain respects with the categories identified by marwick and birch then of course there is the classic division into raw and derived data leaving aside the observation that the concept of raw data is an oxymoron and that all data are cooked in some way 108 109 this seeks to distinguish between data in its most basic unprocessed form and data that has been manipulated cleaned and processed into what might otherwise be called information suggests the term raw attempts to get back to an origin point where data is least processed although it might be expected that the unprocessed data would be where the true value of the data lies it is often the subsequent processing of the data that is seen to add value even to the extent that the processed data becomes perceived as the more important product and the raw data is set aside in its favor furthermore digital data can be categorized according to its format for instance xml files or word processor formats containing textual and semior unstructured data various database formats commaseparated values or delimited text files containing structured data shapefiles geography markup language or georeferenced tif files containing spatial data and jpeg or uncompressed tif files containing photographic or image data each format carries its own implications requirements and constraints for example data tables in the form of commaseparated values files will require separate documentation to describe the relationships between tables that were originally incorporated within the proprietary database formats other filetypes comprise multiple filesfor example a shapefile consists of three mandatory and up to seven optional datafiles all of which must be present for the data to be usable without problems some file types may also contain information about their character and origin for instance gis geoprocessing tools may update associated metadata with details of the processing applied to the data while exif metadata is captured in digital photographs containing information about shutter speed focal length exposure time date and so on what these characterizations highlight is that digital data only exists as a relatively simple conceptual entity at a very high level of abstraction drill down into the character of data and it becomes apparent that far from being a thing it is at once many things consisting of a rich and complex set of characteristics which are combined and recombined in many ways during its lifetime manovich for example highlights the variability of digital media which can exist in different potentially infinite versions and the way that it can be transcoded or translated into different formats 83 together with the host of datacleansing techniques which transform data in often poorly documented ways data in proprietary file formats is translated into open formats for archival purposes which preserves the data but may lose relationships or other characteristics in the conversion requiring accompanying documentation to fill the gap semistructured or unstructured data may be incorporated within a structured data model in the process smoothing out variability or omitting aspects considered to be unimportant for the study at hand or which simply do not fit within the schema the provision of directly captured data typically from instruments may be set aside in favor of processed datasets although not in all cases the distinctions between primary secondary and tertiary data highlight the transitioning of data from what was originally collected and what is subsequently processed and interpreted incorporating a range of data transformations in the process add to this volatile mix the sequence of contingencies classically associated with archaeological data together with the fact that the same data entities may be evidence for multiple phenomena 50 along with the fact that what is perceived to be data will depend on the context of use and the preconceptions of the users and the result is a highly complex highly unstable and highly unpredictable product data travels and frictions this modeand mediumswitching capacity of digital data can be seen as a strength as well as a weakness as leonelli has argued what makes data so powerful as sources of evidence is their mutability the multiple ways in which they are transformed and modified to fit different uses as they travel across space time and social situations 114 their mobility and capacity for adaptation is what makes it possible for data to be reused reanalyzed and recycled in different contexts data acquire or shed components merge with other data shift shape and labels change vehicles and companions and such transformations prove essential to their usability by different audiences and purposes 114 this contrasts with latours perspective of data as defined by their mobility while their power is derived from their immutability or unchanging nature to latour data are immutable mobiles 115 which circulate without substantive change in themselves instead the potentiality of dataor the idea of data as prospective evidence 116 means that its value as data at any point in time or place is not certain or fixed that what actually counts as data can change at any stage and it may only become clear at some unspecified future point all of which makes the initial capture of data its subsequent curation and continued accessibility crucial interventions for future knowledge creation indeed leonelli proposes that digital repositories do not actually preserve data but objects which may or may not be used as data as soon as the effort is made to use such objects as data or acquire data from them they are at least minimally modified to fit the everevolving physical environments and research cultures within which they are valued and interpreted 114 the metaphor of data journeys has been developed in relation to the movement of data from their site of production to other sites of subsequent use within and beyond the same field of research 116 an archaeological analysis may typically employ data created by the analysts themselves data created by other archaeologists and data that travels into archaeology from other specializations and disciplines for instance leonelli defines three stages through which data traveldecontextualization and reformatting recontextualization and reuse 120 each of which entails packaging and repackaging of the data although this may simply imply shifting file formats data conversion and standardization may be complicated by the risk of data loss or misinterpretation recontextualization enables the data to be used within a new quite possibly unanticipated context and requires knowledge about the origins of the data the procedures used in its collection and any subsequent modifications in order to evaluate the data and determine whether they are appropriate for the present use 120 that is supposedly provided through the accompanying metadata this data journey model is not without its problems when applied to the archaeological situation and in certain respects has higher expectations of data than is often the case for instance most archaeological metadata associated with datasets in support of their reuse typically focus on data discovery rather than how the data originated although paradata may be seen as incorporating documentation about equipment expertise protocols and procedures if present at all it currently tends to focus primarily on the means by which the data have been processed rather than the preunderstandings and constraints behind their original capture and processing 106 this introduces a remoteness from the data through a detachment from and consequent loss of the implicit tacit knowledge concerning prior decisions and limitations these may also be lost during the decontextualization as the data and metadata are classified and characterized which is not a neutral process accordingly a perception may arise that the data is more objective more reliable and more complete than may be the case a useful metaphor related to the idea of data journeys is the concept of data friction originally characterized by edwards 122 in the context of climatology and subsequently applied to other fields data friction describes what happens at the interfaces between data surfaces the points where data move between people substrates organizations or machinesfrom one lab to another from one discipline to another from a sensor to a computer or from one data format to another every movement of data across an interface comes at some cost in time energy and human attention 123 edwards also characterized computational friction the struggle involved in transforming data into information and knowledge 119 and related to data friction consequently friction can be seen to be encountered across the range of different technologies standards and practices associated with the creation processing curation and reuse of data often drawn from different contexts during its travels although edwardss definition of data friction typically casts it as associated with the movement of data friction may equally arise within the immediate context of data creation and use before it travels into different settings in archaeology for instance data friction arises through human agency in terms of both the original deposition and eventual materialization of what might become data as well as through the range of nonhuman agencies that determine what might survive as potential data for example edgeworth describes the affordances and constraints experienced during the act of excavation which influence the archaeological encounter 93124 and which may be seen as resulting in friction in the recognition and capture of data in the field collinss sequence of contingencies can therefore be viewed through a different lens as data friction in action long before recorded data moves beyond its creators for use by others common data practices during archaeological data capture can also be seen as attempts to reduce friction for example standardization across proforma recording systems and the use of recording templates seeks to normalize data from within a specific site to ensure that defined characteristics are captured and subsequently eases the movement of data from different sites into centralized organizational recording systems and potentially thereafter into largescale curatorial infrastructures data friction is also experienced in the translation of datasets whether salvaging old data or repurposing data for instance huvila has observed the conditioning of archaeological information work by paperbased norms 127 which gives rise to friction through its digitization similarly harrison describes the ways in which steps to clean and standardize an old dataset masks inconsistencies and gaps in the data in order to increase interoperability and access she argues that transparency about methods of data cleaning and manipulation builds confidence in the data 126 and thereby helps to reduce data friction interfaces to data also introduce friction in both initial recording and subsequent reprocessing and in the integration of data with other data through the ways in which they constrain and structure as much as they facilitate access framing interactions and representations data friction may also be characterized in sociopolitical terms arising between people organizations and infrastructures in the form of conflicts frustrations with processes variations and disagreements over practices and so on 128 for example kansa 129 describes a range of issues affecting archaeological infrastructures such as the ethical legal and practical challenges of data ownership power inequities and the consequences of dependencies on both commercial infrastructures and opensource software libraries all of which might also be seen as contributing to data friction many of the archaeological responses to digital agency may also be linked to friction including the subversion of recording systems failures to streamline recording methods and delays introduced in primary recording practice for instance 95 friction is generally presented as a negative problematic characteristic to be resolved with benefits accruing from its resolution however as borgman 50 points out ontologies taxonomies thesauri metadata structures and the like are developed to facilitate interoperability and hence reduce friction but at the same time these systems may create friction in terms of incompatibilities between schema conflicting standards variability in data sharing arrangements and emphasize boundaries between different communities and domains the mental and labor costs involved in the creation handling and management of metadata is itself a form of frictionmetadata friction 123 and the same can equally be extended to the development and maintenance of thesauri wordlists ontologies etc which may disincentivize their use in overcoming frictions similarly the kinds of challenges identified by kansa 126 in relation to the archaeological use of commercial data infrastructures and opensource software underlines this conflicting aspect they may overcome friction and introduce valueformoney in terms of what they enable but at the same time they may reintroduce friction through the constraints and risks which they bring from other perspectives however friction can be seen in positive terms rather than something that is necessarily required to be overcome for example carahers characterization of a slow archaeology 131132 emphasizing the humanity of archaeological data over their complexity is supported by others who highlight slow approaches to field methodologies for instance or to the design of interfaces which encourage slower more reflective engagements with data friction in these terms is seen to slow down processes with beneficial results allowing time and energy to reflect and engage with data effectively as a response to the data imaginary slow approaches to data help to reveal the forgotten or overlooked aspects of data to expand knowledge of the data to reflect on the value of data and the practices that generated them to engage with the collaborative aspects of data to participate in the thoughtful reworking of data and its evolution and transformation and to create narratives about the data 13 case study journeys and frictions in grey literature archaeological data have typically journeyed from their original identification through to their recording processing reporting and ultimate incorporation within a larger infrastructure awaiting their rediscovery in light of the data frictions experienced en route are data still capable of being reused in full knowledge of their origination their strategies of recovery the procedures applied the constraints experienced and any modifications applied edwards 122 uses the term infrastructural inversion to describe this process of inspecting the original data on which subsequent analyses have been based so that confidence in the data can be gained through an understanding of the character of the data including any inconsistencies and variability data arent data until you have turned the infrastructure upside down to find out how it works 122 for instance one of the transformational bodies of data increasingly used within uk archaeology is the collection of unpublished archaeological site reports which have become important as a reference source for new archaeological investigations including predevelopment assessments they also provide a resource for regional and national synthetic studies and increasingly for automated data mining to extract information about periods of sites locations of sites types of evidence and so on despite this archaeological grey literature itself has not been closely evaluated as a resource for the creation of new archaeological knowledge such reports on their own would typically be considered to represent secondary archaeological data inserting a degree of distance between the descriptive discussion in the report and the original observations in the field however access to the site records behind the report should reduce this distance by enabling the discussion presented in the report to be evaluated to a greater extent for instance by tracking where uncertainties in the primary record have been transformed into assertions in the report the archaeology data service based in the uk currently holds over 64000 unpublished archaeological reports in its digital library covering a wide range of archaeological interventions including schemes of investigations for archaeological work deskbased assessments watching briefs evaluations excavations geophysical surveys environmental assessments and artefact reports for example it should be emphasized that this collection of grey literature held by the ads is in a state of nearconstant flux with over 1400 registered organizations and individuals 138 adding data and reports to the collection via the oasis information system which was developed to report investigations to regional and national historic environment records and for subsequent deposit with the ads the collection therefore continues to grow rapidly in scale and scope with hundreds of records added or edited each week 138 this means that a considerable investment in time and effort is required by the ads to ensure that the various generations of reports and associated datasets are interlinked and crossreferenced a process which may not necessarily be carried out at the time of deposit one means of assessing the nature of the data journeys and frictions experienced by such reports is to evaluate the extent to which the data embedded within them is capable of being reused in full knowledge of its origination the strategies of recovery and any constraints which may have applied in advance during and after its collection and analysis the grey literature report essentially packages the data collected through interventions and its data journey can be unpacked by reviewing the original data in order to understand the travels and the frictions the data has experienced in its repackaging as a report for this investigation a small sample of unpublished reports that were accompanied by site archives was extracted consisting of 15 cases produced in 2021 relating to two watching briefs seven evaluations and six excavations eight archaeological commercial organizations were represented in this sample three appearing more than once data friction was experienced from the outset since it transpired that the tool used to extract the sample did not retrieve records from the full collection of 64000 reports or from the set of 34288 grey literature reports indicated as a separate resource in the ads archsearch browser but from an unspecified sample somewhere in between because of a variety of complex issues currently being resolved consequently the sample is more random than anticipated yet at the same time limited by a range of lessthanrandom data issues dependent on a range of factors all of which are presently hidden behind the interface for the purposes of the present investigation this is not an issue but clearly a largerscale study could not have complete confidence in the data as currently constituted this conveniently illustrates the challenges associated with handling data from multiple origins multiple authors multiple depositors and deposited at different times and the frictions associated with their data journeys the guide to good practice for archiving excavation and fieldwork data produced by the archaeology data service 139 recognizes that different scales of archaeological intervention require different levels of digital archives an indexlevel archive derived from a deskbased assessment andor evaluation or watching brief primarily consists of narrative reports together with tabulated lists of contexts artefacts etc 139 beyond this the assessmentlevel archive was defined for where work proceeded beyond an initial evaluation 139 the context database and the location of all interventions the researchlevel archive is reserved for significant excavations and consists of a more extensive and complex archive 139 on this basis it might be expected that the archives associated with the reports in the current selected sample would be situated at the index or assessment level depending on whether the intervention was a watching brief evaluation or excavation at face value few of the cases conformed to the definition of an indexlevel archive since all were missing one or more elements insofar as can be judged by eye all reports in the sample incorporated digitally created location maps site plans and featuresection drawings alongside the report text details of contexts artefacts etc were generally provided in summary tables in the reports but were omitted in one instance all the site archives accompanying the reports contained photographic image data primarily of excavated features although in 8 of the 15 cases these photographs were the sole category of data included in the archive other than the report itself the remaining seven cases consisting of watching briefs evaluations and excavations included scanned original context sheets and cataloguesregisters of drawings artefacts etc alongside the images only one included a fullcontext database as a set of commaseparated files with an accompanying entity relationship diagram five of the seven cases with scanned context sheets or a database also included cad data while a sixth provided zipped gis shapefiles rather than cad data since all the cases appeared to have used cadgis to create the various maps and plans in the reports their absence from almost twothirds of the site archives in the sample is notable this may be because more data remains to be added to the archives in the future and in relation to site location maps it may be a result of the use of copyright ordnance survey map data which was not licensed for reuse however in their current condition data which was evidently available to the authors of the reports in this sample was not included in the accompanying archive in six cases the scheme of investigation was either included as an appendix to the report or provided separately in the site archive prior reports were often referenced in the report text but in most cases these have not been deposited in the wider ads library although this may change with time although in general the reports themselves conformed to templates specific to each originating organization the same is not true of the site archives there was no clear pattern of inclusionexclusion relating to authorship scale of investigation or depositing organization these results broadly confirm observations elsewhere for example in 2017 richards 140 reviewed the state of archiving at the assessment level and concluded that few projects met those minimum standards with stratigraphic matrices rarely preserved and specialist spreadsheets of finds and animal bones not regarded as part of the core archive instead project archives more often consisted of a text report and a collection of photographs of trenches and features 140 as is the case with the examples examined here richards suspected that more digital data was likely available but was not included partly as a consequence of cost and concluded that the definition and enforcement of a minimum standard for an adequate archive was one of the greatest challenges facing archaeological curators and repositories 140 the present sample would seem to support this argument as presently constituted there remains variability amongst the site archives for similar investigations of a similar scale and similar variability even within deposits made by the same organization although as noted earlier this may change as records are added and updated in many respects therefore archaeological grey literature and its associated site archives form another data imaginary consisting of the expectations and realities of data alongside the social practices professional standards and institutional requirements associated with its creation archiving and subsequent potential for reuse although the case study is small there is considerable variability in terms of the journeys and frictions experienced by the data most of which are largely tacit at best even when the data providers are the same people or organizations a variety of significant frictions are evident and the journeys represented by the individual cases vary to a considerable degree for example the study highlights evidence for hidden decisions taken surrounding the inclusion of data without revealing the reasons behind those decisions it also demonstrates how aspects of the data might be obscured behind opaque interfaces or omitted from the archive altogether restricting understanding of the specific data context and increasing the risk of misuse or misrepresentation the presence of grey literature reports without site archives and the variability of those archives where present makes it very difficult to trace the data journeys involved in those archaeological interventions in a very real sense the ultimate data friction is when that data is absent where reports of earlier evaluations deskbased assessments surveys and evaluations were also absent a full understanding of the contextual and situated nature of the data becomes even more difficult although the standardized format of the reports means that they include aims and objectives of the work it is difficult to trace how these may have changed over the duration of the archaeological inquiries where those earlier reports are missing from the archive uncertainties about the nature of the data journeys or the data frictions experienced means that the range of entanglements present in the data may remain largely obscure and the analytical selectivity contained within the reports is unable to be as easily evaluated as might be desirable the inability at present to have clear knowledge about the data journeys and the presence of often tacit data frictions makes it difficult to be confident about the subsequent use of the grey data in grey literature and its incorporation into the kind of larger amalgamated datasets typically used in more remote even automated analyses discussion markham describes data as the material result of a series of choices made at critical junctures 141 she emphasizes that data is a consequence of lived experience the practices skills conversations and categorizations which combine in the effort to capture the essence or meaning of the object of study in the same way archaeological data are a consequence of the lived experiences of excavators surveyors supervisors finds specialists illustrators site directors heritage managers academics archivists and a host of others who engage with and influence archaeological data through its data journeys however archaeological data go beyond this in the sense that the lived experience is not limited to the present or the future but also includes past encounters archaeological data are the detritus of past lives as well as the analytical objects of investigators past present and future the sequence of contingencies of archaeological data underlines that engagements with data take place within situated contexts in place and time which influence what data survive are recognized and are considered important or relevant to capture and what data are set aside obscured or otherwise forgotten the archaeological data imaginary is interwoven with encounters such as these which influence how archaeology manages the issues surrounding open data the design and construction of digital infrastructures the treatment and handling of data in analytical contexts and broader philosophical and conceptual approaches to data what is also clear is that many of these incorporate internal contradictions solutions which seek to resolve perceived problems or action desired outcomes but which introduce new sets of challenges and often unforeseen consequences so for instance we might recognize the importance of not treating archaeological data as givens as unproblematic or as selfevident not expecting the data to speak for themselves even if that makes the task more difficult and more time consuming however how can the creative or performative nature of data be represented additionally how might this be operationalized documentation is the traditional means by which the range of syntactic semantic and coverage anomalies in the data ought to be resolved so that a subsequent user can fully understand the decisions and methods that the data have undergone however documentation and its digital surrogate metadata place significant demands on time and energy acquiring the historical chain of events and actions back to the origins of the data is a nontrivial task and attempting to reduce the labor demands of doing so by introducing automatic or at least semiautomatic methods is a largely unsolved problem it also overlooks that much of this information is primarily tacit rarely articulated and in some cases impossible to be consciously represented there is a long tradition of archaeologists using unstructured recording methods during fieldwork or laboratory work such as the use of diaries and notebooks which record their thoughts ideas theories mistakes decisions and actions often alongside the more formalized proforma methods however such methods often sit uncomfortably within a commercial environment and where they exist such reflexive records tend to be reserved for the physical rather than the digital archive some digital recording systems have been designed with less structured recording in mind for instance data records in the federated archaeological information system are associated with annotation fields which are said to mimic the handwritten marginalia in proforma sheets 142 however such approaches tend to take a limited perspective by focusing on the more easily recognized and codified forms of tacit knowledge 106 similar issues arise at the infrastructural level where the potential distance from data is perhaps at its greatest and consequently the need for data about the data is crucial digital archives operate differently to traditional material archives not only in the sense that they are not subject to the same physical constraints or costs but in several uniquely digital respects for instance blom identifies a fundamental shift between traditional archives where content is distinct from infrastructure and digital archives where once the archive is based on networked data circulation its emphatic form dissolves into the coding and protocol layer into electronic circuits or data flow 143 this dematerialization is what enables the collapse of time and space that supports remote access but at the same time it constrains access through the systems and algorithms used to manage and reveal data furthermore the digital content is frequently recontextualized as part of its data journey which means that the archive is dynamic and constantly changing 144 to which the data are put 145 perhaps inevitably therefore infrastructural metadata largely focusses on the support of the fair principles and is subject to its limitations the handling of archived digital data is also unique in comparison to traditional archives digital data is preserved by a combination of refreshing and migration consequently digital preservation is concerned with ensuring the authenticity of copies of the original data whereas in a traditional archive the emphasis is placed on preservation of the physical media the original digital data only exist as long as they remain accessible through their original technology but ultimately it is copies of data which persist through multiple migrations and translations so that the original lives on only in reproductions as digital archivists emphasize this means that digital data does not lend itself to benign neglect and yet the costs and efforts entailed in archiving the quantities of archaeological data can make it difficult to do more than store the data in the hope that a demonstrable demand for its reuse makes it feasible to properly document and archive them in the end this is what lies behind the idea that the best way to preserve archaeological data is to reuse it and yet the ability to reuse it is critically dependent on the documentation efforts required to make it accessible moreover the ability simply to access data is not sufficient in itself since data are prepared in specific contexts with specific questions in mind and using specific sets of criteria and tools they may not easily be retasked for different purposes this makes it important to be able to track back to the origins of the data in order to properly understand the full data journey through to the present rather than simply reusing highlevel precooked data conclusions what is currently lacking in archaeology is a detailed understanding of the journeys and frictions experienced by data considerable efforts have been expended in debating the nature of the archaeological record but substantially less attention has been paid to the basis of that record the character of the data themselves the concept of data journeys could be used as a framework from which to evaluate the use of data developing the small case study here into a largescale analysis of grey literature and associated site archives over time and incorporating questionnaires and interviews with data depositors similarly data friction could provide a mechanism with which to investigate the range of issues surrounding the creation manipulation archiving and subsequent reuse of data such studies would usefully sit alongside calls for similar ethnographicstyle studies to examine the construction of the ontologies used in archaeology 40 and to investigate the emphasis on structured data and structuring mechanisms 41 for instance operating within the archaeology data imaginary clearly presents a host of challenges by no means all of these are unique to the discipline and many can be seen as features of any disciplinary and interdisciplinary data relations however while archaeology can undoubtedly learn from the lessons of others and adopt and adapt methodologies from elsewhere many of the solutions and approaches need to arise out of the recognition of the particularities of the archaeological imaginary and respond to the specifically archaeological encounters with data thinking about archaeological data provides the basis for rethinking our engagement with it from its initial recognition and capture through to its subsequent incorporation into analyses at all levels in the end an appropriately critical approach to our data can only make the archaeological knowledge we create with it more robust reviewers for their constructive and helpful feedback as ever any errors or misconceptions are my own data availability statement the grey literature reports and archives used in the case study are openly available from the archaeology data service appendix a lists the reports and archives used with associated dois appendix a reports used in the grey literature case study sample were extracted from the archaeology data service archive using the search tool and filtered to return reports for the year 2021 which also had site archives watching briefs evaluations and excavations were selected from the resulting set setting aside the historic building surveys geophysical surveys artefact and environmental reports that were also returned the final sample therefore consisted of the following cases

archaeology operates in an increasingly datamediated world in which data drive knowledge and actions about people and things famously data has been characterized as the new oil underpinning modern economies and at the root of many technological transformations in society at large even assuming a nearreligious power over thought and action as the call for this special issue recognizes archaeological research is socially and historically situated and consequently influenced by these same broader developments in archaeology as in the wider world data is the foundation for knowledge but its capacity is rarely reflected upon this paper offers just such a reflection a meditation on the nature of archaeological digital data and the challenges for its re use it asks what we understand by data its etymology and comprehension its exceptionality and mutability its constructs and infrastructures and its origins and consequences the concept of the archaeological data imaginary is introduced to better understand approaches to the collection and use of archaeological data and a case study examines how knowledge is mediated and remediated through the data embedded in grey literature appreciating the volatility and unpredictability of digital data is key in understanding its potential for use and reuse in the creation of archaeological knowledge